CASE REPORT – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 19 (2014) 166–168 doi:10.1093/icvts/ivu056 Advance Access publication 30 March 2014
Simultaneous cusp-sparing aortic root replacement and coarctectomy with total arch replacement from the midline incision Yutaka Okitaa,*, Shuichiro Takanashib and Yoshiaki Fukumurac a b c
Division of Cardiovascular Surgery, Kobe University, Kobe, Japan Sakakibara Heart Institute, Tokyo, Japan Tokushima Red Cross Hospital, Tokushima, Japan
* Corresponding author. Division of Cardiovascular, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Tel: +81-78-3825942; fax: +81-78-3825959; e-mail: [email protected] (Y. Okita). Received 6 November 2013; received in revised form 18 December 2013; accepted 26 December 2013
Abstract Four cases of simultaneous surgery for aortic root aneurysm with aortic regurgitation and coarctation of the aorta were presented. Age at surgery ranged from 18 to 37 years and all were male. All had annuloaortic ectasia and dilatation of the ascending aorta, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative grade of aortic regurgitation was trivial in 1, moderate in 2 and severe in 1. Three had aortic valve-sparing root replacement with reimplantation technique and 1 had plication of the sinotubular junction. All patients had total arch replacement, coarctectomy and orthogonal anastomosis to the descending aorta. Antegrade cerebral perfusion was used for brain protection. All patients survived and postoperative pressure difference between the upper and lower extremities disappeared. Postoperative aortogram was satisfactory. Keywords: Annuloaortic ectasia • Aortic coarctation • Midline approach • Total arch replacement
Aortic coarctation sometimes is found in adulthood with significant blood pressure difference between the upper and lower extremities. In the 2011 annual report of the Japanese Association for Thoracic Surgery [1], there were 12 adult (age over 18 years) coarctation patients who underwent surgery, which was 6.1% of all coarctation patients. Coarctation is rarely accompanied with aortic root disease such as annuloaortic ectasia, including congenital aortic bicuspid valve. Surgery has been focused on the coarctation and reconstruction of the aortic arch usually performed through left thoracotomy except for complex congenital heart disease. In this report, we present 4 patients who underwent simultaneous surgery for aortic root aneurysm and total arch replacement with coarctectomy.
Cases Age at surgery ranged from 18 to 37 years and all were male (Table 1 and Fig. 1). All had annuloaortic ectasia, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative diameter of the Valsalva sinus or ascending aorta was 35–56 mm, and aortic regurgitation ranged from trivial, moderate to severe. Preoperative peak pressure gradient between the aortic arch and the femoral artery was 29–35 mmHg. The ankle brachial pressure index was 0.65–0.78. The diameter of the distal aortic arch was normal or rather hypoplastic. All had mid-sternotomy, aortic coarctectomy and total arch replacement. Arterial perfusion was provided through both cannulae in the ascending aorta and the femoral artery. Three had aortic valve-sparing root replacement with the reimplantation technique
and 1 had plication of the sinotubular junction. Three patients had additional aortic cusp repair, including central plication technique and free margin reinforcement. Aortic arch vessels were reconstructed as an aortic cuff in 3 and individual reconstruction with small grafts in 1. The Valsalva graft (Gelweave Valsalva™, Vascutek Terumo, UK) size for aortic root replacement was 22, 26 and 28 mm. The graft size for aortic arch was 22, 24 and 26 mm. The distal anastomosis was made to the descending aorta beyond the coarctation. An additional smaller graft was used for distal anastomosis to incorporate the diameter of the descending aorta during circulatory arrest of the lower body or total circulatory arrest, and the size of the graft was 20 and 22 mm. Total cardiopulmonary bypass time ranged from 187 to 333 min, cardiac ischaemic time was from 147 to 259 min. Antegrade cerebral perfusion was used for brain protection in all patients and its duration ranged from 42 to 124 min. The duration of the circulatory arrest in the lower body ranged from 51 to 76 min. The lowest tympanic temperature was 18.1–20.3°C, and the rectal temperature was 26–27°C. All patients survived and postoperative clinical course was eventless. No patient demonstrated spinal cord ischaemia and hoarseness. Postoperative ankle brachial pressure index was 0.98–1.02. Aortogram was satisfactory and all patients returned to normal life.
DISCUSSION Although coarctation of the aorta sometimes is accompanied with a congenitally bicuspid aortic valve, few cases of uncorrected aortic coarctation associated with cardiac pathology in adults have
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Y. Okita et al. / Interactive CardioVascular and Thoracic Surgery
167
Table 1: Patients’ characteristics and operative data Case
Age (years)
Sex
AAE
BAV
AR
Others
Pre-PG (mmHg)
Root
Aortic diameter (mm)
1 2 3 4
37 18 27 30
Male Male Male Male
Yes Yes Yes Yes
Yes No Yes Yes
Trivial Moderate Severe Severe
Acute AD
35 29 31 35
VSO VSO STJ VSO
56 45 35 51
Case
Aortic cusp repair
ECC (min)
Cardiac ischaemia (min)
CA (min)
FA perfusion
SACP
Rectal temperature (°C)
Post-ABPI
Post-AR
1 2 3 4
No Yes Yes Yes
333 331 187 275
259 249 147 227
51 76 66 54
Yes No No Yes
Yes Yes Yes Yes
26 27 27 26
0.9 0.9 1.2 1.1
Trivial None Trivial Trivial
AAE: annuloaortic ectasia; BAV: bicuspid aortic valve; AR: aortic regurgitation; Pre-PG: preoperative peak pressure gradient between aortic arch and femoral artery; ECC: extracorporeal circulation; CA: circulatory arrest of the lower body; FA: femoral artery; SACP: selective antegrade cerebral perfusion; ABPI: ankle brachial pressure index; AD: aortic dissection; VSO: valve-sparing operation; STJ: sinotubular junction.
been reported [2]. The other associated pathologies included coronary artery disease, aortic dissection, ascending aortic aneurysm, annuloaortic ectasia, aortic valve stenosis and insufficiency. As a staged strategy, Sampath et al. [2] advocated the initial repair of the coarctation to relieve proximal hypertension, thereby decreasing the chance of progressive dissection or rupture. Different approaches have also been reported [3]. Regarding the use of stent-grafting, we consider that, in young patients, direct open repair is optimal. Replacement of the ascending aorta was first performed, and repair of the coarctation was done as the second
procedure because repair of acute aortic dissection was necessary for survival. There are a few reports of single-stage surgical repair of this combination. Others reported cases of insertion of both composite valve grafts for the ascending aorta and extra-anatomical bypass grafts from the ascending aorta to the descending aorta or the abdominal aorta. Paparella et al. [3] described a case of total arch graft replacement resecting the segment of the coarctation through median sternotomy and left thoracotomy. We were able to perform a one-stage repair of aortic root disease and coarctation through a median sternotomy. The one stage surgery through
CASE REPORT
Figure 1: Preoperative (upper) and postoperative (lower) computed tomography of case 1 (A, A-2), 2 (B, B-2), 3 (C, C-2), and 4 (D, D-2).
168
Y. Okita et al. / Interactive CardioVascular and Thoracic Surgery
the mid-sternotomy approach is rarely adopted in the adult patient because deep distal suture line beyond coarctation from the midline and replacement of a normal-sized aortic arch. However, with the use of antegrade cerebral perfusion, total arch replacement is a safe procedure in this age group, and the patient does not have to undergo multiple surgeries. This approach has some advantages compared with left thoracotomy because numerous collateral vessels, which may be important for blood supply, sometimes preclude access to the coarctation. We have selected patients very carefully for this extensive surgery. Usually, patients are young and without any comorbidities. We have another 8 adult patients (mean age 63.8 years at surgery) with aortic coarctation. Five patients had extra-anatomical bypass from the ascending aorta to the abdominal aorta, and 3 had coractectomy and graft replacement of the descending aorta from the left thoracotomy. One had combined Bentall operation and extra-anatomical bypass from the midline approach. No patient had staged operation. Several bypass techniques have been reported. Heinemann et al. [4] described 17 patients with complex aortic coarctation who had undergone ascending aorta–descending aorta, ascending aorta– abdominal aorta, descending aorta–abdominal aorta, descending aorta–descending aorta or left subclavian artery–descending aorta bypass. On the other hand, Rokkas et al. [5] reported usefulness of deep hypothermia to protect brain and spinal cord during reconstruction of complicated adult aortic coarctation. Exposure of the coarctation from the midline is facilitated by using deep hypothermic circulatory arrest of the lower body, sometimes total body circulatory arrest because of rich collateral blood supply to the lower body. In this technique, the aortic arch of normal calibre necessitated to be replaced with a prosthetic graft. We usually apply antegrade cerebral perfusion at the rectal temperature of 30°C; also cardiac arrest was required during coarctectomy, and anastomosis to the descending aorta. In 2 cases, perfusion from the femoral artery as well as the ascending aorta was applied to have uniform cooling of the lower body.
Technically, anastomosing a separate smaller graft (20–22 mm in diameter) to the descending aorta first and then connecting it to the arch graft facilitated exposure of the distal anastomosis in the narrow space. This is a rather technically demanding procedure. We had to use additional graft anastomosis (step-wise anastomosis) between the distal anastomosis and the arch graft. Our 4 patients had excellent recovery and showed no residual stenosis or no anastomotic aneurysm. Valve-sparing aortic replacement for aortic root aneurysm with a morphologically intact valve has become a common procedure with acceptable results. Plication of the sinotubular junction is also reported to be effective to alleviate aortic regurgitation in patients with a dilated ascending aorta. Also many reports have demonstrated acceptable early and mid-term results of valve-sparing root replacement in patients with a bicuspid valve. Conflict of interest: none declared.
REFERENCES [1] Amano J, Kuwano H, Yokomise H. Thoracic and cardiovascular surgery in Japan during 2011: Annual report by The Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg 2013;61:578–607. [2] Sampath R, O’Connor WN, Noonan JA, Todd EP. Management of ascending aortic aneurysm complicating coarctation of the aorta. Ann Thorac Surg 1982;34:125–31. [3] Paparella D, Schena S, Schinosa LLT, Vitale N. One step surgical repair of type 2 acute aortic dissection and aortic coarctation. Eur J Cardiothorac Surg 1999;16:584–6. [4] Heinemann MK, Ziemer G, Wahlers T, Kohler A, Borst HG. Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur J Cardiothorac Surg 1997;11:169–75. [5] Rokkas CK, Murphy SF, Kouchoukos NT. Aortic coarctation in the adult: management of complications and coexisting arterial abnormalities with hypothermic cardiopulmonary bypass and circulatory arrest. J Thorac Cardiovasc Surg 2002;124:155–61.
Interactive CardioVascular and Thoracic Surgery 19 (2014) 166–168 doi:10.1093/icvts/ivu056 Advance Access publication 30 March 2014
Simultaneous cusp-sparing aortic root replacement and coarctectomy with total arch replacement from the midline incision Yutaka Okitaa,*, Shuichiro Takanashib and Yoshiaki Fukumurac a b c
Division of Cardiovascular Surgery, Kobe University, Kobe, Japan Sakakibara Heart Institute, Tokyo, Japan Tokushima Red Cross Hospital, Tokushima, Japan
* Corresponding author. Division of Cardiovascular, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan. Tel: +81-78-3825942; fax: +81-78-3825959; e-mail: [email protected] (Y. Okita). Received 6 November 2013; received in revised form 18 December 2013; accepted 26 December 2013
Abstract Four cases of simultaneous surgery for aortic root aneurysm with aortic regurgitation and coarctation of the aorta were presented. Age at surgery ranged from 18 to 37 years and all were male. All had annuloaortic ectasia and dilatation of the ascending aorta, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative grade of aortic regurgitation was trivial in 1, moderate in 2 and severe in 1. Three had aortic valve-sparing root replacement with reimplantation technique and 1 had plication of the sinotubular junction. All patients had total arch replacement, coarctectomy and orthogonal anastomosis to the descending aorta. Antegrade cerebral perfusion was used for brain protection. All patients survived and postoperative pressure difference between the upper and lower extremities disappeared. Postoperative aortogram was satisfactory. Keywords: Annuloaortic ectasia • Aortic coarctation • Midline approach • Total arch replacement
Aortic coarctation sometimes is found in adulthood with significant blood pressure difference between the upper and lower extremities. In the 2011 annual report of the Japanese Association for Thoracic Surgery [1], there were 12 adult (age over 18 years) coarctation patients who underwent surgery, which was 6.1% of all coarctation patients. Coarctation is rarely accompanied with aortic root disease such as annuloaortic ectasia, including congenital aortic bicuspid valve. Surgery has been focused on the coarctation and reconstruction of the aortic arch usually performed through left thoracotomy except for complex congenital heart disease. In this report, we present 4 patients who underwent simultaneous surgery for aortic root aneurysm and total arch replacement with coarctectomy.
Cases Age at surgery ranged from 18 to 37 years and all were male (Table 1 and Fig. 1). All had annuloaortic ectasia, 3 had bicuspid aortic valve and 1 had acute localized aortic dissection. Preoperative diameter of the Valsalva sinus or ascending aorta was 35–56 mm, and aortic regurgitation ranged from trivial, moderate to severe. Preoperative peak pressure gradient between the aortic arch and the femoral artery was 29–35 mmHg. The ankle brachial pressure index was 0.65–0.78. The diameter of the distal aortic arch was normal or rather hypoplastic. All had mid-sternotomy, aortic coarctectomy and total arch replacement. Arterial perfusion was provided through both cannulae in the ascending aorta and the femoral artery. Three had aortic valve-sparing root replacement with the reimplantation technique
and 1 had plication of the sinotubular junction. Three patients had additional aortic cusp repair, including central plication technique and free margin reinforcement. Aortic arch vessels were reconstructed as an aortic cuff in 3 and individual reconstruction with small grafts in 1. The Valsalva graft (Gelweave Valsalva™, Vascutek Terumo, UK) size for aortic root replacement was 22, 26 and 28 mm. The graft size for aortic arch was 22, 24 and 26 mm. The distal anastomosis was made to the descending aorta beyond the coarctation. An additional smaller graft was used for distal anastomosis to incorporate the diameter of the descending aorta during circulatory arrest of the lower body or total circulatory arrest, and the size of the graft was 20 and 22 mm. Total cardiopulmonary bypass time ranged from 187 to 333 min, cardiac ischaemic time was from 147 to 259 min. Antegrade cerebral perfusion was used for brain protection in all patients and its duration ranged from 42 to 124 min. The duration of the circulatory arrest in the lower body ranged from 51 to 76 min. The lowest tympanic temperature was 18.1–20.3°C, and the rectal temperature was 26–27°C. All patients survived and postoperative clinical course was eventless. No patient demonstrated spinal cord ischaemia and hoarseness. Postoperative ankle brachial pressure index was 0.98–1.02. Aortogram was satisfactory and all patients returned to normal life.
DISCUSSION Although coarctation of the aorta sometimes is accompanied with a congenitally bicuspid aortic valve, few cases of uncorrected aortic coarctation associated with cardiac pathology in adults have
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Y. Okita et al. / Interactive CardioVascular and Thoracic Surgery
167
Table 1: Patients’ characteristics and operative data Case
Age (years)
Sex
AAE
BAV
AR
Others
Pre-PG (mmHg)
Root
Aortic diameter (mm)
1 2 3 4
37 18 27 30
Male Male Male Male
Yes Yes Yes Yes
Yes No Yes Yes
Trivial Moderate Severe Severe
Acute AD
35 29 31 35
VSO VSO STJ VSO
56 45 35 51
Case
Aortic cusp repair
ECC (min)
Cardiac ischaemia (min)
CA (min)
FA perfusion
SACP
Rectal temperature (°C)
Post-ABPI
Post-AR
1 2 3 4
No Yes Yes Yes
333 331 187 275
259 249 147 227
51 76 66 54
Yes No No Yes
Yes Yes Yes Yes
26 27 27 26
0.9 0.9 1.2 1.1
Trivial None Trivial Trivial
AAE: annuloaortic ectasia; BAV: bicuspid aortic valve; AR: aortic regurgitation; Pre-PG: preoperative peak pressure gradient between aortic arch and femoral artery; ECC: extracorporeal circulation; CA: circulatory arrest of the lower body; FA: femoral artery; SACP: selective antegrade cerebral perfusion; ABPI: ankle brachial pressure index; AD: aortic dissection; VSO: valve-sparing operation; STJ: sinotubular junction.
been reported [2]. The other associated pathologies included coronary artery disease, aortic dissection, ascending aortic aneurysm, annuloaortic ectasia, aortic valve stenosis and insufficiency. As a staged strategy, Sampath et al. [2] advocated the initial repair of the coarctation to relieve proximal hypertension, thereby decreasing the chance of progressive dissection or rupture. Different approaches have also been reported [3]. Regarding the use of stent-grafting, we consider that, in young patients, direct open repair is optimal. Replacement of the ascending aorta was first performed, and repair of the coarctation was done as the second
procedure because repair of acute aortic dissection was necessary for survival. There are a few reports of single-stage surgical repair of this combination. Others reported cases of insertion of both composite valve grafts for the ascending aorta and extra-anatomical bypass grafts from the ascending aorta to the descending aorta or the abdominal aorta. Paparella et al. [3] described a case of total arch graft replacement resecting the segment of the coarctation through median sternotomy and left thoracotomy. We were able to perform a one-stage repair of aortic root disease and coarctation through a median sternotomy. The one stage surgery through
CASE REPORT
Figure 1: Preoperative (upper) and postoperative (lower) computed tomography of case 1 (A, A-2), 2 (B, B-2), 3 (C, C-2), and 4 (D, D-2).
168
Y. Okita et al. / Interactive CardioVascular and Thoracic Surgery
the mid-sternotomy approach is rarely adopted in the adult patient because deep distal suture line beyond coarctation from the midline and replacement of a normal-sized aortic arch. However, with the use of antegrade cerebral perfusion, total arch replacement is a safe procedure in this age group, and the patient does not have to undergo multiple surgeries. This approach has some advantages compared with left thoracotomy because numerous collateral vessels, which may be important for blood supply, sometimes preclude access to the coarctation. We have selected patients very carefully for this extensive surgery. Usually, patients are young and without any comorbidities. We have another 8 adult patients (mean age 63.8 years at surgery) with aortic coarctation. Five patients had extra-anatomical bypass from the ascending aorta to the abdominal aorta, and 3 had coractectomy and graft replacement of the descending aorta from the left thoracotomy. One had combined Bentall operation and extra-anatomical bypass from the midline approach. No patient had staged operation. Several bypass techniques have been reported. Heinemann et al. [4] described 17 patients with complex aortic coarctation who had undergone ascending aorta–descending aorta, ascending aorta– abdominal aorta, descending aorta–abdominal aorta, descending aorta–descending aorta or left subclavian artery–descending aorta bypass. On the other hand, Rokkas et al. [5] reported usefulness of deep hypothermia to protect brain and spinal cord during reconstruction of complicated adult aortic coarctation. Exposure of the coarctation from the midline is facilitated by using deep hypothermic circulatory arrest of the lower body, sometimes total body circulatory arrest because of rich collateral blood supply to the lower body. In this technique, the aortic arch of normal calibre necessitated to be replaced with a prosthetic graft. We usually apply antegrade cerebral perfusion at the rectal temperature of 30°C; also cardiac arrest was required during coarctectomy, and anastomosis to the descending aorta. In 2 cases, perfusion from the femoral artery as well as the ascending aorta was applied to have uniform cooling of the lower body.
Technically, anastomosing a separate smaller graft (20–22 mm in diameter) to the descending aorta first and then connecting it to the arch graft facilitated exposure of the distal anastomosis in the narrow space. This is a rather technically demanding procedure. We had to use additional graft anastomosis (step-wise anastomosis) between the distal anastomosis and the arch graft. Our 4 patients had excellent recovery and showed no residual stenosis or no anastomotic aneurysm. Valve-sparing aortic replacement for aortic root aneurysm with a morphologically intact valve has become a common procedure with acceptable results. Plication of the sinotubular junction is also reported to be effective to alleviate aortic regurgitation in patients with a dilated ascending aorta. Also many reports have demonstrated acceptable early and mid-term results of valve-sparing root replacement in patients with a bicuspid valve. Conflict of interest: none declared.
REFERENCES [1] Amano J, Kuwano H, Yokomise H. Thoracic and cardiovascular surgery in Japan during 2011: Annual report by The Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg 2013;61:578–607. [2] Sampath R, O’Connor WN, Noonan JA, Todd EP. Management of ascending aortic aneurysm complicating coarctation of the aorta. Ann Thorac Surg 1982;34:125–31. [3] Paparella D, Schena S, Schinosa LLT, Vitale N. One step surgical repair of type 2 acute aortic dissection and aortic coarctation. Eur J Cardiothorac Surg 1999;16:584–6. [4] Heinemann MK, Ziemer G, Wahlers T, Kohler A, Borst HG. Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results. Eur J Cardiothorac Surg 1997;11:169–75. [5] Rokkas CK, Murphy SF, Kouchoukos NT. Aortic coarctation in the adult: management of complications and coexisting arterial abnormalities with hypothermic cardiopulmonary bypass and circulatory arrest. J Thorac Cardiovasc Surg 2002;124:155–61.
