Interdigitating Technique for Repair of Aortic Coarctation and Arch Hypoplasia in a Neonate

The patient was a two-day-old, 3.6 kilogram neonate who was diagnosed prenatally with aortic coarctation. After birth, a prostaglandins infusion was initiated, and a transthoracic echocardiogram showed critical aortic coarctation with arch hypoplasia. There was also an atrial level shunt across a patent foramen ovale, as well as a large ductus arteriosus. The left heart structures appeared hypoplastic with possible parachute mitral valve.

A computed tomography scan confirmed the arch hypoplasia, and the decision was made to proceed with repair.

Through a median sternotomy, the thymus gland was resected, and a pericardial well was created. The ductus arteriosus was dissected and encircled with a 5-0 Prolene suture. Heparin (100 units/kg) was administered systemically, and a side-biting clamp was placed on the innominate artery. Next, an end-to-side anastomosis was constructed between a 3.5 millimeter Gore-Tex graft and the innominate artery, which was then used for the arterial inflow from the cardiopulmonary bypass (CPB) machine. The arterial cannula (8 Fr) was placed inside the graft and secured.

The remaining dose of heparin was then administered. The arch branches were dissected and encircled with vessel loops. Next, a single-stage venous cannula was placed through the right atrial appendage. Once activated clotting time (ACT) was confirmed, CPB was initiated and the core temperature was gradually brought down to 28 degrees Celsius.

Next, the ductus arteriosus was doubly ligated and divided. The proximal descending aorta was then thoroughly mobilized, taking care not to injure the recurrent laryngeal nerve.

Once the desired temperature was reached, the aortic cross-clamp was applied and antegrade cardioplegic arrest was achieved. The left subclavian and left common carotid arteries were temporarily clipped, and a second cross-clamp was placed at the base of the innominate artery, thus initiating antegrade selective cerebral perfusion. A side-biting clamp was then applied at the mid-descending thoracic aorta.

The ductus arteriosus was resected and all ductal tissues were excised. The aortic arch was then opened on its undersurface and all the way back to the distal ascending aorta. Two longitudinal incisions were then made on opposing sides of the proximal descending aorta. The distal arch was then interdigitated into the proximal descending aorta with running 7-0 Prolene sutures. Next, an appropriately sized decellularized cryopreserved pulmonary homograft patch was used to augment the proximal descending aorta, and the aortic arch was secured using running 7-0 Prolene sutures.

The proximal descending aortic clamp was then removed, and the anastomosis was de-aired, followed by removal of the arch clamps. The heart was subsequently de-aired and the aortic cross-clamp was removed. The patient regained his normal sinus rhythm and was then rewarmed back to normothermia.

Once at normothermia, the patient was ventilated and weaned off CPB without difficulty. Epicardial echocardiogram showed a widely patent aortic arch and a good abdominal flow signal. There was no gradient between the right radial and femoral arterial lines.

The patient was then decannulated, heparin was reversed, and hemostasis was achieved. The chest was closed in the standard fashion, and the patient was extubated in the operating room.
The remaining postoperative course was uneventful, and the patient was discharged almost two weeks later.

References

1. Burkhart HM, Ashburn DA, Konstantinov IE, DeOliveira NC, Benson L, Williams WG, Van Arsdell GA. Interdigitating arch reconstruction eliminates recurrent coarctation after the Norwood procedure. J Thorac Cardiovasc Surg 2005; 130(1): 61-5
2. Zhang H, Cheng P, Hou J, Li L, Liu H, Liu R, Ji B, Luo Y. Regional cerebral perfusion for surgical correction of neonatal aortic arch obstruction. Perfusion. 2009 May;24(3):185-9
3. Rajasinghe HA, Reddy VM, van Son JA, Black MD, McElhinney DB, Brook MM, Hanley FL. Coarctation repair using end-to-side anastomosis of descending aorta to proximal aortic arch. Ann Thorac Surg. 1996 Mar;61(3):840-4.
4. Tworetzky W, McElhinney DB, Burch GH, Teitel DF, Moore P. Balloon arterioplasty of recurrent coarctation after the modified Norwood procedure in infants. Catheter Cardiovasc Interv. 2000; 50: 54-58

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The author, Sameh Said, is a consultant for Artivion, Stryker, and Abbott.

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