CASE REPORTS
Simultaneous Treatment of Aortic Stenosis and Coarctation by Left Thoracotomy with Apical Aortic Conduit John W. Brown, M.D., Jeffrey M. Dunn, M.D., James F. Brymer, M.D., a n d Marvin M. Kirsh, M.D. ABSTRACT The simultaneous treatment of aortic stenosis and coarctation by left thoracotomy with apical aortic conduit is described.
Bicuspid aortic valve is one of the more common congenital heart anomalies and is estimated to occur in 2% of the population. It frequently occurs in association with other congenital cardiovascular anomalies, especially, coarctation of the aorta. When both lesions produce major obstruction, the usual treatment has been to relieve the most life threatening obstruction first and then repair the other lesion as a separate operation. On occasion both lesions have been repaired during one operation through two separate incisions. Because of the morbidity associated with simultaneous repair, this approach has been used infrequently [9, 111. Apicoaortic anastomosis is being used more frequently in a variety of patients with aortic stenosis whose obstruction cannot be relieved by conventional surgical techniques. In patients with both severe aortic stenosis and coarctation of the aorta, the combination of apicoaorticanastomosis and patch angioplasty of the coarctation enables one to relieve both obstructions simultaneously through a single incision. We have recently encountered an adult patient with both severe aortic stenosis and coarctation of the aorta who was successfully treated with this method. The patient, a 33-year-old man, had been noted to have a heart murmur in childhood, but he had no symptoms until 12 months prior to admission. At that time he began to experience From the Department of Surgery, Section of Thoracic Surgery, and the Department of Internal Medicine, Section of Cardiology, The University of Michigan Medical Center, Ann Arbor, MI. Accepted for publication Sept 14, 1977. Address reprint requests to Dr. Kirsh, C7175 University Hospital, Ann Arbor, MI 48109.
exertional dizziness and tired easily. He denied angina, syncope, or symptoms of congestive heart failure. Physical examination revealed a healthy appearing obese man weighing 87 kg. Blood pressure in the right arm was 130/85with a regular pulse of 98 per minute. There was a delayed carotid upstroke and bilateral carotid bruits. A harsh 3/6 systolic ejection murmur was heard at the base of the neck and radiated into the neck. A soft-blowing2/6 diastolicmurmur could be heard along the left sternal border. There were no palpable femoral pulses. The chest roentgenogram revealed the heart to be moderately enlarged. No rib notching was evident. The electrocardiogram disclosed sinus tachycardia with first-degree atrioventricular block and left ventricular hypertrophy with secondary S-T segment and T wave changes. Preoperative cardiac catheterization data are summarized in the Table. Angiocardiography showed a dilated left ventricle with mild to moderate left ventricular hypokinesia. The aortic valve was heavily calcified. The coarctation was just distal to the left subclavian artery, and the aortogram showed little collateral circulation. Mild aortic regurgitation was seen in the supravalvular aortogram. The patient was placed on partial cardiopulmonary bypass (femoral artery-femoral vein), and a modified commercially available 22 mm Hancock Model 100 prosthesis was inserted, as shown in Figures 1 and 2A, B. The coarctation was repaired by means of the patch graft aortoplasty technique (Fig 3). The patient’s postoperative course was essentially uncomplicated, and he was discharged on the eighteenth postoperative day. He was evaluated six months postoperatively and was asymptomatic. Postoperative catheterization data are summarized in the Table. A pullback pressure measurement revealed no gradient across the coarctation. Left ventricular cineangiography
364 0003-4975/78/0025-0415$1.00 @ 1978 by John W. Brown
365 Case Report: Brown et al: Treatment of Aortic Stenosis and Coarctation of Aorta
Preoperative and Six-Month-Postoperative Catheterization Data
Determination
PAP (mm Hg) PAP, wedge (mm Hg) LVP (mm Hg) Prox. AoP (mm Hg) Dist. AoP (mm Hg) LVEDP (mm Hg) EF CI (Llmidm')
6 Months
Postoperative operative
Pre-
70138
38
220120 135180 80165 40 0.33 4.3
42/15 13 16010 130180 130180 13 0.69 3.75
PAP = pulmonary artery pressure; LVP = left ventricular pressure; AoP = aortic pressure; LVEDP = left ventricular end-diastolic pressure; EF = ejection fraction; CI = cardiac index.
showed marked improvement in left ventricular contractility, as shown by improvement of the ejection fraction from 0.31 to 0.61 and by the decrease in left ventricular end-diastolic pressure. Contrast medium injected into the left ventricle was ejected through both outflow tracts. A chest roentgenogram obtained six months postoperatively revealed decreased cardiomegaly. Since a heterograft was used in Fig I. The upioaortic prosthesis.
the conduit, the patient was not given anticoagulants. Prosthesis The prosthesis that was utilized in our patient was developed after extensive laboratory investigation [4] (see Fig 1).The cloth-covered, wirereinforced segmented polyurethane elbow stent is designed to project 5 mm into the left ventricular cavity and prevent collapse of the conduit during ventricular systole. The cloth covering promotes a good seal between myocardium and prosthesis and at the same time promotes tissue ingrowth and thus lessens the chance for thrombus formation around the intraventricular lip of the stent. The stent has a sewing ring for attachment to the left ventricular apex with pledgeted mattress sutures placed at equidistant points about the left ventriculotomy. The rigid rightangled turn in the stent facilitates attachment to the descending thoracic or suprarenal abdominal aorta without kinking the conduit. The Hancock Model 100 valved conduit has been experimentally shown to withstand left heart pressures for periods of up to two years, and currently it is the preferred valved conduit for apicoaortic anastomosis [4-61. The advantages of our prosthesis are that (1)
366 The Annals of Thoracic Surgery Vol 25 No 4 April 1978
Fig 2 . (A) End-to-side aortic anastomosis using tiny intraaortic pledgets. ( B ) An obturator is passed through the left atrial appendage and into the apex of the left ventricle. Counterpressure is exerted on the obturator while a circular piece of myocardium is excised with a cork bore. The obturator occludes the ventriculotomy while the left ventricular stent is placed over the tip of the obturator. Both obturator and stent are drawn back into the left ventricle. The stent is held in place with pledgeted sutures placed at equidistant points about the ventriculotomy and through the sewing ring of the stent while the obturator is removed from the left atrial appendage.
the external surface of the stent is cloth covered, and the likelihood of thrombus formation about the interventricular lip is thereby decreased; (2) the stent extends into the left ventricular cavity far enough to prevent muscular obstruction of the stent at the endocardium but does not interfere with papillary muscle function; and (3) the rigid angled contour of the stent facilitates anastomosis to the descending thoracic or supraceliac abdominal aorta without kinking the conduit.
Comment The association of bicuspid aortic valve and coarctation of the thoracic aorta is well known. Congenital bicuspid aortic valve has been found postmortem in 85% of patients with coarctation of the aorta [B], but only 2.2% of these patients had significant aortic stenosis [l]. However, the percentage of patients with coarctation of the aorta and bicuspid aortic valve eventually requiring repair or replacement is unknown.* The fact that there are only isolated reports in the literature of patients who have had both lesions repaired indicates how infrequently aortic valve repair or replacement is performed in patients with coarctation of the aorta. The majority of these patients underwent staged operations. Aortic valvotomy or aortic valve replacement was carried out first, since congestive heart failure has been reported to occur when the coarctaFig3. Completion of conduit insertion and patch angioplasty repair of the coarctation.
‘Edwards JE: Personal communication, 1977.
367 Case Report: Brown et a1 Treatment of Aortic Stenosis and Coarctation of Aorta
tion is repaired initially [9, 111. A few patients underwent simultaneous repair through two separate incisions. The disadvantages of a staged procedure or a simultaneous repair through two separate incisions point out the advantages of repairing both lesions simultaneously through one incision in selected patients. The use of an apicoaortic anastomosis in conjunction with patch aortoplasty enables one to relieve both obstructions simultaneously through one incision with minimal morbidity. An additional advantage of this technique is that it allows for insertion of a relatively large prosthesis in a patient who has a small aortic root, as ours did. The concept of apicoaortic anastomosis is not new. However, despite extensive laboratory investigation [3, 4, 7, 101 the method has not been widely used clinically. In 1962 Templeton used the technique in 5 patients with severe aortic stenosis and employed a rigid lucite tube containing a Hufnagel valve.*Two patients survived long term, 1 patient living thirteen years. No further use of this technique was reported until 1975, when Bernhard and associates [23 inserted a rigid apicoaortic prosthesis into a patient with a tunnel aortic stenosis. The prosthesis consisted of a stainless steel tube covered with flocked Dacron fibrils. A porcine xenograft glutaraldehyde-treated tissue valve was mounted in a tube graft and interposed between the rigid prosthesis, which had been inserted into the left ventricle, and the thoracic aorta. In 1976 Dembitsky and Weldon [6] reported their successful experience with 2 patients in whom a polyester woven prosthesis bearing a glutaraldehyde-treated porcine aortic valve was inserted between the apex of the left ventricle and the infrarenal abdominal aorta. The inlet tube was a cloth-covered straight metal cylinder. Also in 1976, Cooley and associates [5] reported their experience with 9 patients who underwent surgical relief of left ventricular outflow tract obstruction with an apicoaortic valve conduit. The prosthesis consisted of a straight, rigid stent of Pyrolite carbon attached to a Teflon sewing ring and a Dacron fabric graft containing a glutaraldehyde-preserved porcine valve. The distal anastomosis was to the abdominal aorta above the level of the celiac artery. Postoperative *Templeton JY: Personal communication, 1974.
catheterization in the patients reported by Cooley and associates showed that these grafts reduced the aortic valve gradient by approximately or an average of 100 mm Hg. A similar favorable hemodynamic response occurred in our patient and other reported patients. The simultaneous repair of aortic stenosis and coarctation of the aorta by apicoaortic anastomosis and patch aortoplasty allows correction of both aortic stenosis and coarctation of the aorta through a single incision, a left thoracotomy. We recommend this method as an alternative approach in adult patients with this combination of lesions or in children in whom it is not possible to perform an aortic valvoplasty.
References 1. Bailey CP: O n the surgical treatment of coarctation of the aorta (Report of the Section on Cardiovascular Surgery, American College of Chest Physicians). Dis Chest 31:468, 1957 2. Bemhard WF, Poirier V, LaFarge CG: Relief of congenital obstruction to left ventricular outflow with a ventricular-aortic prosthesis. J Thorac Cardiovasc Surg 69:223, 1975 3. Brown JW, Myerowitz I'D, Cann MS, et al: Apical-aortic anastomosis: a method for relief of diffuse left ventricular outflow obstruction. Surg Forum 25:147, 1974 4. Brown JW, Myerowitz PD, Roberts AE, et al: Apicoaortic anastomosis for left ventricular outflow obstruction: prosthetic design, operative technique and laboratory evaluation. Surgery (in press) 5. Cooley DA, Norman JC, Reul GJ, et al: Surgical treatment of left ventricular outflow tract obstruction with apicoaortic valved conduit. Surgery 80:674, 1976 6. Dembitsky WP, Weldon CS: Clinical experience with a valve-bearing conduit to construct a second left ventricular outflow tract in cases of unresectable intraventricular obstruction. Ann Surg 184:317, 1976 7. Detmer DE, Johnson EH, Braunwald NS: Left ventricular apex-to-thoracic aorta shunts using aortic valve allografts in calves. Ann Thorac Surg 11:417, 1971 8. Edwards JE, Carey LS, Neufeld HN, et al: Congenital Heart Disease. Philadelphia, Saunders, 1965, vol 2, p 677 9. PontiusRG: Discussion of Schusterand Gross [ l l ] 10. Sarnoff SJ, Donovan TJ, Case RB: The surgical relief of aortic stenosis by means of apical-aortic valvular anastomosis. Circulation 11:564, 1955 11. Schuster SR, Gross RE: Surgery for coarctation of the aorta. J Thorac Cardiovasc Surg 43:54, 1962
Simultaneous Treatment of Aortic Stenosis and Coarctation by Left Thoracotomy with Apical Aortic Conduit John W. Brown, M.D., Jeffrey M. Dunn, M.D., James F. Brymer, M.D., a n d Marvin M. Kirsh, M.D. ABSTRACT The simultaneous treatment of aortic stenosis and coarctation by left thoracotomy with apical aortic conduit is described.
Bicuspid aortic valve is one of the more common congenital heart anomalies and is estimated to occur in 2% of the population. It frequently occurs in association with other congenital cardiovascular anomalies, especially, coarctation of the aorta. When both lesions produce major obstruction, the usual treatment has been to relieve the most life threatening obstruction first and then repair the other lesion as a separate operation. On occasion both lesions have been repaired during one operation through two separate incisions. Because of the morbidity associated with simultaneous repair, this approach has been used infrequently [9, 111. Apicoaortic anastomosis is being used more frequently in a variety of patients with aortic stenosis whose obstruction cannot be relieved by conventional surgical techniques. In patients with both severe aortic stenosis and coarctation of the aorta, the combination of apicoaorticanastomosis and patch angioplasty of the coarctation enables one to relieve both obstructions simultaneously through a single incision. We have recently encountered an adult patient with both severe aortic stenosis and coarctation of the aorta who was successfully treated with this method. The patient, a 33-year-old man, had been noted to have a heart murmur in childhood, but he had no symptoms until 12 months prior to admission. At that time he began to experience From the Department of Surgery, Section of Thoracic Surgery, and the Department of Internal Medicine, Section of Cardiology, The University of Michigan Medical Center, Ann Arbor, MI. Accepted for publication Sept 14, 1977. Address reprint requests to Dr. Kirsh, C7175 University Hospital, Ann Arbor, MI 48109.
exertional dizziness and tired easily. He denied angina, syncope, or symptoms of congestive heart failure. Physical examination revealed a healthy appearing obese man weighing 87 kg. Blood pressure in the right arm was 130/85with a regular pulse of 98 per minute. There was a delayed carotid upstroke and bilateral carotid bruits. A harsh 3/6 systolic ejection murmur was heard at the base of the neck and radiated into the neck. A soft-blowing2/6 diastolicmurmur could be heard along the left sternal border. There were no palpable femoral pulses. The chest roentgenogram revealed the heart to be moderately enlarged. No rib notching was evident. The electrocardiogram disclosed sinus tachycardia with first-degree atrioventricular block and left ventricular hypertrophy with secondary S-T segment and T wave changes. Preoperative cardiac catheterization data are summarized in the Table. Angiocardiography showed a dilated left ventricle with mild to moderate left ventricular hypokinesia. The aortic valve was heavily calcified. The coarctation was just distal to the left subclavian artery, and the aortogram showed little collateral circulation. Mild aortic regurgitation was seen in the supravalvular aortogram. The patient was placed on partial cardiopulmonary bypass (femoral artery-femoral vein), and a modified commercially available 22 mm Hancock Model 100 prosthesis was inserted, as shown in Figures 1 and 2A, B. The coarctation was repaired by means of the patch graft aortoplasty technique (Fig 3). The patient’s postoperative course was essentially uncomplicated, and he was discharged on the eighteenth postoperative day. He was evaluated six months postoperatively and was asymptomatic. Postoperative catheterization data are summarized in the Table. A pullback pressure measurement revealed no gradient across the coarctation. Left ventricular cineangiography
364 0003-4975/78/0025-0415$1.00 @ 1978 by John W. Brown
365 Case Report: Brown et al: Treatment of Aortic Stenosis and Coarctation of Aorta
Preoperative and Six-Month-Postoperative Catheterization Data
Determination
PAP (mm Hg) PAP, wedge (mm Hg) LVP (mm Hg) Prox. AoP (mm Hg) Dist. AoP (mm Hg) LVEDP (mm Hg) EF CI (Llmidm')
6 Months
Postoperative operative
Pre-
70138
38
220120 135180 80165 40 0.33 4.3
42/15 13 16010 130180 130180 13 0.69 3.75
PAP = pulmonary artery pressure; LVP = left ventricular pressure; AoP = aortic pressure; LVEDP = left ventricular end-diastolic pressure; EF = ejection fraction; CI = cardiac index.
showed marked improvement in left ventricular contractility, as shown by improvement of the ejection fraction from 0.31 to 0.61 and by the decrease in left ventricular end-diastolic pressure. Contrast medium injected into the left ventricle was ejected through both outflow tracts. A chest roentgenogram obtained six months postoperatively revealed decreased cardiomegaly. Since a heterograft was used in Fig I. The upioaortic prosthesis.
the conduit, the patient was not given anticoagulants. Prosthesis The prosthesis that was utilized in our patient was developed after extensive laboratory investigation [4] (see Fig 1).The cloth-covered, wirereinforced segmented polyurethane elbow stent is designed to project 5 mm into the left ventricular cavity and prevent collapse of the conduit during ventricular systole. The cloth covering promotes a good seal between myocardium and prosthesis and at the same time promotes tissue ingrowth and thus lessens the chance for thrombus formation around the intraventricular lip of the stent. The stent has a sewing ring for attachment to the left ventricular apex with pledgeted mattress sutures placed at equidistant points about the left ventriculotomy. The rigid rightangled turn in the stent facilitates attachment to the descending thoracic or suprarenal abdominal aorta without kinking the conduit. The Hancock Model 100 valved conduit has been experimentally shown to withstand left heart pressures for periods of up to two years, and currently it is the preferred valved conduit for apicoaortic anastomosis [4-61. The advantages of our prosthesis are that (1)
366 The Annals of Thoracic Surgery Vol 25 No 4 April 1978
Fig 2 . (A) End-to-side aortic anastomosis using tiny intraaortic pledgets. ( B ) An obturator is passed through the left atrial appendage and into the apex of the left ventricle. Counterpressure is exerted on the obturator while a circular piece of myocardium is excised with a cork bore. The obturator occludes the ventriculotomy while the left ventricular stent is placed over the tip of the obturator. Both obturator and stent are drawn back into the left ventricle. The stent is held in place with pledgeted sutures placed at equidistant points about the ventriculotomy and through the sewing ring of the stent while the obturator is removed from the left atrial appendage.
the external surface of the stent is cloth covered, and the likelihood of thrombus formation about the interventricular lip is thereby decreased; (2) the stent extends into the left ventricular cavity far enough to prevent muscular obstruction of the stent at the endocardium but does not interfere with papillary muscle function; and (3) the rigid angled contour of the stent facilitates anastomosis to the descending thoracic or supraceliac abdominal aorta without kinking the conduit.
Comment The association of bicuspid aortic valve and coarctation of the thoracic aorta is well known. Congenital bicuspid aortic valve has been found postmortem in 85% of patients with coarctation of the aorta [B], but only 2.2% of these patients had significant aortic stenosis [l]. However, the percentage of patients with coarctation of the aorta and bicuspid aortic valve eventually requiring repair or replacement is unknown.* The fact that there are only isolated reports in the literature of patients who have had both lesions repaired indicates how infrequently aortic valve repair or replacement is performed in patients with coarctation of the aorta. The majority of these patients underwent staged operations. Aortic valvotomy or aortic valve replacement was carried out first, since congestive heart failure has been reported to occur when the coarctaFig3. Completion of conduit insertion and patch angioplasty repair of the coarctation.
‘Edwards JE: Personal communication, 1977.
367 Case Report: Brown et a1 Treatment of Aortic Stenosis and Coarctation of Aorta
tion is repaired initially [9, 111. A few patients underwent simultaneous repair through two separate incisions. The disadvantages of a staged procedure or a simultaneous repair through two separate incisions point out the advantages of repairing both lesions simultaneously through one incision in selected patients. The use of an apicoaortic anastomosis in conjunction with patch aortoplasty enables one to relieve both obstructions simultaneously through one incision with minimal morbidity. An additional advantage of this technique is that it allows for insertion of a relatively large prosthesis in a patient who has a small aortic root, as ours did. The concept of apicoaortic anastomosis is not new. However, despite extensive laboratory investigation [3, 4, 7, 101 the method has not been widely used clinically. In 1962 Templeton used the technique in 5 patients with severe aortic stenosis and employed a rigid lucite tube containing a Hufnagel valve.*Two patients survived long term, 1 patient living thirteen years. No further use of this technique was reported until 1975, when Bernhard and associates [23 inserted a rigid apicoaortic prosthesis into a patient with a tunnel aortic stenosis. The prosthesis consisted of a stainless steel tube covered with flocked Dacron fibrils. A porcine xenograft glutaraldehyde-treated tissue valve was mounted in a tube graft and interposed between the rigid prosthesis, which had been inserted into the left ventricle, and the thoracic aorta. In 1976 Dembitsky and Weldon [6] reported their successful experience with 2 patients in whom a polyester woven prosthesis bearing a glutaraldehyde-treated porcine aortic valve was inserted between the apex of the left ventricle and the infrarenal abdominal aorta. The inlet tube was a cloth-covered straight metal cylinder. Also in 1976, Cooley and associates [5] reported their experience with 9 patients who underwent surgical relief of left ventricular outflow tract obstruction with an apicoaortic valve conduit. The prosthesis consisted of a straight, rigid stent of Pyrolite carbon attached to a Teflon sewing ring and a Dacron fabric graft containing a glutaraldehyde-preserved porcine valve. The distal anastomosis was to the abdominal aorta above the level of the celiac artery. Postoperative *Templeton JY: Personal communication, 1974.
catheterization in the patients reported by Cooley and associates showed that these grafts reduced the aortic valve gradient by approximately or an average of 100 mm Hg. A similar favorable hemodynamic response occurred in our patient and other reported patients. The simultaneous repair of aortic stenosis and coarctation of the aorta by apicoaortic anastomosis and patch aortoplasty allows correction of both aortic stenosis and coarctation of the aorta through a single incision, a left thoracotomy. We recommend this method as an alternative approach in adult patients with this combination of lesions or in children in whom it is not possible to perform an aortic valvoplasty.
References 1. Bailey CP: O n the surgical treatment of coarctation of the aorta (Report of the Section on Cardiovascular Surgery, American College of Chest Physicians). Dis Chest 31:468, 1957 2. Bemhard WF, Poirier V, LaFarge CG: Relief of congenital obstruction to left ventricular outflow with a ventricular-aortic prosthesis. J Thorac Cardiovasc Surg 69:223, 1975 3. Brown JW, Myerowitz I'D, Cann MS, et al: Apical-aortic anastomosis: a method for relief of diffuse left ventricular outflow obstruction. Surg Forum 25:147, 1974 4. Brown JW, Myerowitz PD, Roberts AE, et al: Apicoaortic anastomosis for left ventricular outflow obstruction: prosthetic design, operative technique and laboratory evaluation. Surgery (in press) 5. Cooley DA, Norman JC, Reul GJ, et al: Surgical treatment of left ventricular outflow tract obstruction with apicoaortic valved conduit. Surgery 80:674, 1976 6. Dembitsky WP, Weldon CS: Clinical experience with a valve-bearing conduit to construct a second left ventricular outflow tract in cases of unresectable intraventricular obstruction. Ann Surg 184:317, 1976 7. Detmer DE, Johnson EH, Braunwald NS: Left ventricular apex-to-thoracic aorta shunts using aortic valve allografts in calves. Ann Thorac Surg 11:417, 1971 8. Edwards JE, Carey LS, Neufeld HN, et al: Congenital Heart Disease. Philadelphia, Saunders, 1965, vol 2, p 677 9. PontiusRG: Discussion of Schusterand Gross [ l l ] 10. Sarnoff SJ, Donovan TJ, Case RB: The surgical relief of aortic stenosis by means of apical-aortic valvular anastomosis. Circulation 11:564, 1955 11. Schuster SR, Gross RE: Surgery for coarctation of the aorta. J Thorac Cardiovasc Surg 43:54, 1962
