Download Posterior Pericardial Ascending-to-Descending Aortic

Posterior Pericardial Ascending-to-Descending
Aortic Bypass
An Alternative Surgical Approach for Complex Coarctation of the Aorta
Heidi M. Connolly, MD; Hartzell V. Schaff, MD; Uzi Izhar, MD; Joseph A. Dearani, MD;
Carole A. Warnes, MD; Thomas A. Orszulak, MD
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Background—Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders
that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic
bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative
approach for the patient with complex coarctation.
Methods and Results—Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43⫾13 years) with
coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart
Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous
cardiovascular operations had been performed in 12 patients (67%); 10 patients had ⱖ1 prior coarctation repair. Two
patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%)
included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and
septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure,
and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA
bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke
or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery.
Conclusions—CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although
management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent
single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.
(Circulation. 2001;104[suppl 1]:I-133-I-137.)
Key Words: heart defects, congenital 䡲 coarctation 䡲 bypass 䡲 aorta 䡲 surgery
C
reviews indications, techniques, and results of the posterior
pericardial approach to the descending aorta in 18 consecutive patients with coarctation of the aorta.
oarctation of the aorta is commonly associated with
congenital and acquired cardiac pathology that may
require surgical intervention.1,2 In addition, 5% to 30% of
patients with previous coarctation repair have recoarctation
and require reintervention.3–5 Adult patients with native or
recurrent coarctation with or without associated intracardiac
disease pose a surgical challenge. There is no consensus on
the optimal approach for these patients. Several extraanatomic bypass grafting techniques have been described,
including methods in which the distal anastomosis is performed on the descending thoracic aorta, supraceliac abdominal aorta, or the infrarenal abdominal aorta.3,4,6 –9
In 1980, Vijayanagar et al10 described exposure of the
descending thoracic aorta through a median sternotomy and
posterior pericardium. This procedure allowed bypass of
coarctation with concomitant aortic valve replacement. Additional reports detail modifications of this procedure for
complex forms of aortic coarctation.4,11,12 The present study
Methods
We reviewed the clinical, surgical, and follow-up records of 18
patients with coarctation of the aorta who underwent extra-anatomic
ascending-to-descending aortic bypass grafting through a median
sternotomy between December 1985 and December 2000. Clinical
characteristics are outlined in Table 1. The ages of the 13 males and
5 females ranged from 15 to 66 (mean 43⫾13) years. All patients
underwent preoperative transthoracic echocardiography. Additional
imaging studies included aortography in 11 patients, coronary
angiography in 10 patients, and MRI of the descending thoracic aorta
in 6 patients. Twelve of the 18 patients (67%) had previously
undergone cardiac or thoracic aortic operations (Table 2). Concomitant cardiovascular procedures were performed in 14 patients (78%)
(Table 3). Six patients had no prior cardiovascular surgery.
From the Division of Cardiovascular Diseases (H.M.C., C.A.W.) and the Division of Cardiovascular Surgery (H.V.S., U.I., J.A.D., T.A.O.), Mayo
Clinic, Rochester, Minn. Dr Izhar is now at Hebrew University Hadassah Medical Center, Jerusalem, Israel.
Reprint requests to Dr Heidi M. Connolly, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail
[email protected]
© 2001 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
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Circulation
September 18, 2001
TABLE 1.
Demographic Characteristics of the Study Group
Characteristic
No. of Patients or Value
Mean age (range), y
TABLE 2.
%
Operation
43 (15–66)
Female
Previous operation
10
Aortic valvotomy
1*
13
72
AVR
1*
5
28
CABG
1
12
67
SubAS resection
1†
PDA ligation
1†
Cardiac
3*
Thoracic
10*
Hypertension
15
83
3
17
I
6
33
II
8
44
III
3
17
IV
1
6
CAD
No. of Patients
Repair of coarctation
Sex
Male
Previous Cardiac or Thoracic Operations
AVR indicates aortic valve replacement; SubAS, subaortic stenosis; and PDA,
patent ductus arteriosus.
*Same patient.
†Same patient.
Preoperative NYHA class
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CAD indicates coronary artery disease; NYHA, New York Heart Association.
*Two patients had ⬎1 operation.
Indications for Extra-Anatomic Aortic
Bypass Grafting
Extra-anatomic aortic bypass grafting was performed for 2 indications in this series. The first indication was coarctation or recoarctation and associated cardiac problems that required repair through
median sternotomy (group 1, patients 1 to 4, 6, 8, 10 to 12, 14 to 18;
Table 3). The second indication was complex coarctation or recoarctation, for which extra-anatomic bypass grafting was chosen
because of the anticipated difficulties with direct anatomic repair
(group 2, patients 5, 7, 9, and 13; Table 3). Complex coarctation was
defined as a long coarctation or recoarctation segment, a pseudoaneurysm at a previous aortic isthmus suture line, or concomitant
hypoplasia of the aortic arch.
TABLE 3.
Patient
The preoperative diagnoses among patients in group 1 included
recurrent coarctation of the aorta (n⫽7) and coarctation of the aorta
(n⫽6). Associated cardiovascular problems included aortic valve
stenosis (n⫽5), aortic valve regurgitation (n⫽4), coronary artery
disease (n⫽3), mitral valve regurgitation (n⫽3), ascending aortic
dilation (n⫽2), subaortic stenosis (n⫽2), ventricular septal defect
(n⫽1), and hypertrophic obstructive cardiomyopathy (n⫽1). The
preoperative diagnoses among patients in group 2 included recoarctation of the aorta (n⫽2), hypoplastic transverse aorta associated
with coarctation (n⫽1), and pseudoaneurysm formation after 2
previous coarctation repairs (n⫽1).
Operative Technique
The surgical approach used in all patients was the median sternotomy. After aortic and right atrial or bicaval cannulation, hypothermic
(16°C to 34°C) cardiopulmonary bypass (mean time 118⫾51 minutes, range 18 to 217 minutes) was established. Arterial cannulation
was accomplished by using the ascending aorta in all but 1 patient,
in whom femoral artery cannulation was used. Cephalad retraction of
the heart and longitudinal pericardial incision directly over the
descending thoracic aorta allowed exposure of the aorta through the
posterior pericardium in all patients. The aorta was dissected to allow
Preoperative Diagnosis and Concomitant Procedures
Age, y
Diagnosis
Additional Procedure
AVR
1
47
Recoarctation, aortic stenosis
2
39
Recoarctation, aortic regurgitation
AVR
3
15
Recoarctation, mitral regurgitation
MVRe
4
59
Recoarctation, CAD
CABG
5
50
Recoarctation
6
66
Recoarctation, aortic stenosis, mitral regurgitation, HCM
AVR, MVR, septal myectomy
7
46
False aneurysm, status postrepair coarctation ⫻2
LCCA-LSCA bypass graft
8
41
Recoarctation, aortic regurgitation
AVR
9
31
Recoarctation
10
49
Recoarctation, aortic stenosis, CAD
AVR, CABG
11
48
Coarctation, VSD
VSD closure
12
28
Coarctation, subaortic stenosis, aortic regurgitation
Subaortic stenosis resection, AVR
13
44
Coarctation, hypoplasia of transverse arch
14
55
Interrupted arch, ascending aneurysm, aortic regurgitation
Aortic root replacement, AVR
15
40
Coarctation, subaortic stenosis
Subaortic stenosis resection
16
44
Coarctation, mitral regurgitation
MVR
17
25
Coarctation, prosthetic aortic stenosis
AVR
18
55
Coarctation, CAD
CABG
HCM indicates hypertrophic cardiomyopathy; VSD, ventricular septal defect; MVRe, mitral valve replacement; MVR, mitral valve
repair; LCCA, left common carotid artery; and LSCA, left subclavian artery.
Connolly et al
Coarctation of the Aorta
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Figure 2. Postoperative MRI of patent ascending-to-descending
aortic bypass graft (patient 7, Table 3). S indicates superior; I,
inferior; R, right; and L, left.
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(patient 7, Table 3). The proximal anastomosis was completed after
the cardiac operation.
Results
Figure 1. Drawing of ascending (ASC)-to-descending (DESC)
aortic bypass via posterior pericardium (patient 10, Table 3). Simultaneous aortic valve replacement and CABG was performed.
RA indicates right atrium; IVC, inferior vena cava; L. IMA, left
internal mammary artery; LAD, left anterior descending coronary
artery; Coarct, coarctation; SVG, saphenons vein graft; and
DIAG, diagonal coronary artery.
placement of a partially occluding vascular clamp. This was used to
control the descending aorta, and the end-to-side Dacron graft-toaorta anastomosis was made with continuous 4-0 polypropylene
suture. Unnecessary dissection in the region of the esophagus was
avoided. The graft was directed anterior to the esophagus and routed
posterior to the inferior vena cava but anterior to the right inferior
pulmonary vein (Figure 1). The graft was led around the right atrium
and anastomosed to the right lateral aspect of the ascending aorta by
using a side-biting clamp. Bypass graft sizes were 20, 22, or 24 mm
in 16 patients; 2 patients (patients 3 and 13, Table 3) with small
descending aortas received a 16- and 18-mm graft, respectively.
Cardiopulmonary bypass was used in all patients in this series.
Concomitant intracardiac procedures or CABG were accomplished
after performing the distal anastomosis of the graft to the descending
aorta and after introduction of cardiac arrest with antegrade coldblood cardioplegia and aortic cross clamping. The mean cross-clamp
time was 52⫾29 (range 23 to 128) minutes. Deep hypothermia and
total circulatory arrest (mean 20⫾9 minutes, range 14 to 34 minutes;
temperature 18°C to 20°C) was used in 4 patients. This was required
to facilitate exposure and construction of the distal anastomosis to
the descending aorta in 3 patients (patients 1, 3, and 13; Table 3) and
to exclude a false aneurysm of the aortic isthmus in 1 patient (patient
7, Table 3). The diseased segment of the descending thoracic aorta
was excluded from circulation in the patient with a false aneurysm
No early or late deaths occurred. Early postoperative morbidity included reexploration for control of bleeding from an
intercostal artery in 1 patient, transient atrial fibrillation in 2
patients, and permanent pacemaker implantation in the patient who underwent ventricular septal defect closure. There
were no instances of postoperative paraplegia, and there were
no permanent abnormalities in the neurological examination.
The mean hospital stay was 8⫾3 (range 5 to 17) days.
Follow-up was 100% complete and extended to a maximum of 13 years (mean 45⫾48 months). Reoperation was
required in 1 patient for a perivalvular leak 8 months after
mitral valve replacement and coarctation bypass (patient 3,
Table 3). No late graft-related complications or reoperations
occurred. At follow-up, echocardiography demonstrated patency of all grafts. Additional postoperative imaging studies
demonstrated graft patency in 4 patients, magnetic resonance
angiography in 1 (patient 7, Table 3, Figure 2), and computerized tomography in 3 (patients 8, 10, and 14; Table 3).
Systolic blood pressure decreased after surgery
(158 mm Hg for average preoperative blood pressure versus
125 mm Hg for average postoperative blood pressure). Overall, left ventricular ejection fraction did not change after
surgery but did improve substantially in 2 patients (patients 4
and 10, Table 3) who had severe left ventricular dysfunction
before surgery (from 21% to 58% and from 35% to 59%,
respectively).
Discussion
Complex forms of coarctation have been surgically approached by using anatomic repair and extra-anatomic bypass
grafting.3,4,6 –10,13 Anatomic repair may be complicated by the
need for extensive mobilization of the aorta, control of
collateral blood vessels, the possibility of parenchymal lung
injury, damage to the recurrent laryngeal or phrenic nerves,
chylothorax, and spinal cord ischemia.14 The most feared
complication of aortic surgery is paraplegia and risk of spinal
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September 18, 2001
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cord injury. The risk of these complications increase with
prolonged aortic cross-clamp time and older age.14 Nonsurgical interventional procedures are possible for native or
recurrent coarctation; however, these procedures are not
feasible or desirable in all patients,15 and long-term outcome
data are not available. The best management for patients with
coarctation and recoarctation remains uncertain.
Several reports6,16 describe the outcome of ascending
aorta–to– descending aorta bypass grafting through combined
left thoracotomy and median sternotomy. Sweeney et al4
described 16 patients who had a bypass graft placed for
recoarctation; in 4, the graft from the ascending to the
descending aorta was placed through a median sternotomy.
The 2 surgical approaches for patients with coarctation of
the aorta and associated cardiac defects that require repair
include a 1-stage simultaneous correction of both lesions
through a median sternotomy4,9,10,14,17–19 and a 2-stage repair
through median sternotomy and lateral thoracotomy.20,21 In
1980, Vijayanagar et al10 described an adult patient with
coarctation of the aorta and severe aortic valve regurgitation.
Ascending aorta–to– descending aorta bypass was performed
by exposing the descending thoracic aorta through the posterior pericardium and placing the graft around the left
margin of the heart. The proximal anastomosis was made to
the left lateral aspect of the ascending aorta. Powell et al22
described a modification of this technique, which routed the
graft around the right margin of the heart. In this modification, the proximal anastomosis was made to the right lateral
aspect of the ascending aorta.
Since these initial descriptions, additional investigators
have used the posterior pericardial approach to the descending aorta.4,9 –12,14,17–19 A recent report by Izhar et al23 from our
institution included 10 of the coarctation patients reported in
the present series but also included 7 patients with aortic
disorders unrelated to coarctation.
In the present series, the posterior pericardial approach was
used in 18 consecutive adolescent and adult patients presenting with coarctation or recoarctation with or without
associated cardiac disorders. The incidence of recurrent
coarctation of the aorta is between 5% and 30%,3–5 and no
single surgical method is applicable to all patients.3,4,8,13
When coarctation or recoarctation is associated with cardiac
defects that require repair, a 1-stage approach using cardiopulmonary bypass and coarctation bypass grafting through
the posterior pericardium is a safe surgical alternative. This
combined approach avoids the potential complications of
anatomic repair and reoperation and allows a concomitant
procedure through the same incision. The graft is placed
between the inferior vena cava and the right inferior pulmonary vein, a route that keeps the graft in a posterior location
avoiding compression of the right atrium and, thus, may
protect the prosthesis if sternal reentry is necessary.
Paraplegia is rarely encountered when using the extraanatomic coarctation bypass technique. A side-biting aortic
clamp allows continuation of blood flow to the posterior wall
of the aorta. This allows continuation of blood flow to the
intercostal arteries and, in turn, reduces the risk of paraplegia.
We have encountered no serious complications with this
technique; importantly, there have been no episodes of spinal
cord ischemia.
Cardiopulmonary bypass was used in all patients in this
series because of the presence of additional cardiovascular
disorders or because of difficulty with exposure of the
descending aorta. The ascending aorta was used for arterial
cannulation in all but 1 patient included in this series in an
effort to optimize cerebral blood during manipulation and
clamping of the descending thoracic aorta.
In 1996, Pethig et al24 reported hemodynamic instability in
2 patients early after aortic valve replacement and extraanatomic bypass of aortic coarctation. This complication was
believed to be due to myocardial ischemia related to low
diastolic perfusion pressure in severely hypertrophied hearts.
We have not observed this phenomenon in our series of
patients. Alternative treatment options include the 2-stage
repair of adult coarctation associated with valve or coronary
disease20 or surgical intervention of valve disease associated
with catheter-based coarctation intervention.15
There are few long-term reports of bypass grafting for
coarctation or recoarctation. Potential long-term complications include graft narrowing with thrombus and neointimal
formation. Polytetrafluoroethylene ringed grafts are used for
this procedure by some groups in an effort to reduce the
potential complications of graft kinking and narrowing.
Additional potential late complications include infection,
development of false aneurysms, and anastomotic dehiscence
with pseudoaneurysm formation in patients who have considerable somatic growth after repair. None of the patients
that we have reported required reoperation for graft-related
complications at a mean follow-up of 3.7 years. We have
been hesitant to use this method in preadolescent children
because of the risk of anastomotic dehiscence related to
somatic growth.12
The surgical management of patients with complex coarctation or recoarctation with or without associated cardiac
disorders must be individualized. Extra-anatomic coarctation
bypass appears to be a safe flexible method that is particularly
useful in adult patients when simultaneous intracardiac repair
is required.
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Posterior Pericardial Ascending-to-Descending Aortic Bypass: An Alternative Surgical
Approach for Complex Coarctation of the Aorta
Heidi M. Connolly, Hartzell V. Schaff, Uzi Izhar, Joseph A. Dearani, Carole A. Warnes and
Thomas A. Orszulak
Downloaded from http://circ.ahajournals.org/ by guest on June 12, 2017
Circulation. 2001;104:I-133-I-137
doi: 10.1161/hc37t1.094897
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
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