A Case of Extra-Anatomical Bypass for Aortic Coarctation: An On Pump Beating Heart Procedure

Aortic coarctation is one of the most common congenital anomalies. The incidence of coarctation of the aorta is 4 in 10,000 live births, accounting for 5–8% of the children with congenital heart defects (1). During adult life, the presentation of coarctation mostly represents re-coarctation following previous therapy or missed cases of native coarctation. Patients who have not had surgery are at risk of developing severe hypertension, stroke, aortic dissection, and congestive heart failure. Mean life expectancy when untreated is 35 years, and 90% of those patients die before the age of 50. There are different methods employed for the treatment of coarctation in adults, including surgical or percutaneous balloon angioplasty with or without stent placement, and medical therapy.

The authors present a case of a 62-year-old woman with no known prior cardiac disease other than hypertension. During a workup for a neurological tumor, the diagnosis of an aortic coarctation was made. Surgery was needed for the neurological tumor, but the neurosurgeons refused to operate with the presence of coarctation because of possible hypoperfusion of the abdominal organs during surgery. Computed tomography (CT) scan of the aorta showed a coarctation with residual lumen of 3 mm and post-stenotic dilation and calcification of the descending aorta. The authors decided to do an extra-anatomical bypass via sternotomy because of faster recovery and less perioperative risks, and a percutaneous approach was deemed not feasible.

The authors monitored a radial and a femoral artery line to evaluate pressure proximally and distally from the coarctation. They measured 180/80 mmHg radial and 100/50 mmHg femoral pressure. A classic sternotomy was performed. For arterial cannulation they used a split configuration with an Eopa 20 Fr cannula in the aorta and a second arteria 16 Fr cannula in the femoral artery placed percutaneously. A ProGlide™ system was put into place. This way, the abdominal organs could remain perfused at all times. Upon declamping the arterial lines, the authors could see an equalization of radial and femoral arterial pressure. They performed a bicaval venous cannulation to assess the anatomy optimally for positioning the bypass.

The heart was luxated out of the pericardium using an apical suction device. The pericardial fold was opened and dissection of the descending aorta was performed. The esophagus was identified by moving the TEE probe up and down. After achieving good exposure, a side-clamp was positioned and a size 20 graft was sewn into the descending aorta using prolene 4.0. After thorough inspection for leakage, the pericardial fold was closed with a few stitches and the heart was put back in place. The graft naturally fell to the ventricular side. To measure the length of the graft, the heart was filled up to normal size. A side-clamp was placed on the ascending aorta and the proximal anastomosis was made using prolene 4.0. Patency of both anastomosises was checked and dissection was ruled out with perioperative TEE. After weening the patient from cardiopulmonary bypass, both arterial pressures were equal and the sternum was closed, leaving two chest drains. The patient was discharged six days postoperatively and had no perioperative complications.

References

1. Agarwala BN, Bacha E, QiLing C, Ziyad MH. Clinical manifestations and diagnosis of coarctation of the aorta.2009.
2. Anagnaostopoulos–Tzifa A. Management of aortic coarctation in adults: endovascular versus surgical therapy. Hellenic J Cardiol. 2007;48(5):290–295.