正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形

目的总结正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形的外科治疗经验,以提高手术疗效。方法1997年7月至2008年7月,采用正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形31例,其中男20例,女11例;年龄31．9±11．7岁。合并的心脏畸形包括：主动脉瓣狭窄或关闭不全22例,二尖瓣狭窄或关闭不全9例,动脉导管未闭5例,升主动脉瘤4例,室间隔缺损3例,冠心病2例。解剖外旁路移植术包括升主动脉-腹主动脉旁路移植术22例,升主动脉-心包后降主动脉旁路移植术9例。同期手术包括主动脉瓣置换术16例,主动脉根部置换术6例,二尖瓣成形或置换术9例,升主动脉置换或成形术4例,动脉导管未闭缝合术5例,室间隔缺损修补术3例,冠状动脉旁路移植术2例。结果住院死亡1例（3．2％）,术后39d死于感染性中毒性休克。术后上、下肢收缩压压差较术前明显下降（13．7±10．2mmHg vs．64．2±25．3mmHg,P〈0．05）。随访27例,随访时间4～73个月,无晚期死亡、与人工血管相关的并发症和再次手术患者。结论正中切口解剖外旁路移植术是一期治疗成人及青少年主动脉缩窄合并心脏畸形的一种安全有效的手术方法。升主动脉腹主动脉旁路移植术及升主动脉-心包后降主动脉旁路移植术均可获得满意疗效。     

Aneurysm of the ascending aorta in its coarctation

In long-term period after resection of aorta coarctation, 9-14% patients developed aortic aneurysms, one third of them localized in the ascending aorta. From 146 patients operated on for aneurysm of the ascending aorta, 3 had aortic coarctation. In 2 patients aneurysms of the ascending aorta formed late after resection of the coarctation, the third patient was hospitalized with clinical picture of cardiac insufficiency at terminal stage due to coarctation of the aorta and a giant aneurysm of the ascending aorta with significant aortic insufficiency. The patients underwent successful surgeries: 1) ascending aorta grafting; 2) aortic valve and ascending aorta grafting by Bentallo de Bono method; 3) aortic valve and ascending aorta grafting by Bentallo de Bono method with bypass of descending aorta from the conduit. Cystic medianecrosis and two-volume aortic valve were revealed in all the patients. It is concluded that patients after surgery for coarctation of the aorta require long-term follow-up to defect cardiovascular complications early.     

Posterior pericardial ascending-to-descending aortic bypass through median sternotomy

Abstract   Background and Aim: Adult patients with complex forms of descending aortic disease remain a surgical challenge and have a high risk of postoperative mortality and morbidity. Surgical management may be complicated when there is an associated cardiac defect, necessitating repair, or a hostile anatomy exists. We present our experience with extra-anatomic bypass through posterior pericardial route at the same stage with intracardiac/ascending aortic aneurysm repair. Methods: Patients that underwent one-stage surgery with posterior pericardial bypass between ascending and descending aorta during 2003-2007 were reviewed. Data from early and mid-term follow-up, including mortality, perioperative blood loss, graft-related complications, patency, and persistant hypertension, were noted. Results: Six male patients with a mean age of 20.8 ± 0.7 years were operated for coarctation of the aorta associated with additional pathologies (three cases of ascending aortic aneurysm—one with associated aortic valve insufficiency, one case of isolated aortic valve regurgitation, two cases of mitral valve regurgitation). No early or mid-term mortality was observed during follow-up of a mean of 21.6 ± 10.0 months. No late graft-related complications or reoperations were observed with patent grafts. Systolic blood pressure decreased after surgery by an average of 43 mmHg. Conclusions: Coarctation of the aorta with concomitant cardiac lesions can be repaired simultaneously through sternotomy and posterior pericardial approach, when patients present in adulthood, to minimize morbidity and mortality.     

Extraanatomic aortic bypass for repair of aortic coarctation

We describe two adult patients who underwent extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic coarctation through a median sternotomy and posterior pericardial approach. Of the two patients, one presented with coarctation and concurrent cardiovascular disorders, and the other, with residual coarctation. Cardiopulmonary bypass was established with double arterial cannulation in the aorta or axillary artery and the femoral artery ensure adequate perfusion proximal and distal to coarctation and bicaval cannulation. The heart was retracted cephalic and superiorly, and the descending thoracic aorta was exposed through the posterior pericardium. After achieving distal anastomosis, the graft was directed anterior to the inferior vena cava and lateral to the right atrium, and anastomosed to the right lateral aspect of the ascending aorta. A 14-mm graft was used. In one patient receiving concomitant procedures, mitral valve repair and replacement of the ascending aorta was performed after the distal anastomosis.     

Aortic coarctation in the adult: management of complications and coexisting arterial abnormalities with hypothermic cardiopulmonary bypass and circulatory arrest

OBJECTIVES: Adult patients with aortic coarctation may have complications after childhood repair. Other adult patients have coarctation and aneurysms of the aorta and the left subclavian artery. The optimal management of such cases is not clearly established. We evaluated the role of hypothermic cardiopulmonary bypass and circulatory arrest. METHODS: Thirteen adult patients (mean age 38 years) with coarctation and coexisting abnormalities of the aorta and left subclavian artery were treated. Five patients had pseudoaneurysms develop after bypass grafting (n = 3) or patch angioplasty (n = 2). These were detected a mean of 21 years (range 13-44 years) after the initial operation. Four pseudoaneurysms were asymptomatic, and 1 had ruptured. One patient had recurrent coarctation from fibrous obliteration of a 10-mm bypass graft inserted 15 years previously. The remaining 7 patients had aneurysms of the left subclavian artery (n = 5), aneurysms of the ascending aorta and arch (n = 1), or stenosis of the left subclavian artery (n = 1) in combination with moderate or severe coarctation. Resection and interposition graft replacement of the aneurysmal or stenotic aortic segments were performed in all cases with an interval of hypothermic circulatory arrest that averaged 44 +/- 5 minutes (range 33-54 minutes). Seven patients had interposition graft replacement of aneurysmal or stenotic left subclavian arteries. RESULTS: There were no in-hospital or late deaths (maximal follow-up 7 years). No patient had brain injury, paralysis, myocardial, respiratory, or renal failure. No patient has evidence of recurrent coarctation or aneurysm formation. CONCLUSIONS: Cardiopulmonary bypass with hypothermic circulatory arrest can safely be used in the treatment of complex adult coarctation. It permits accurate delineation of the anatomy with minimal dissection, avoidance of aortic clamping and sacrifice of intercostal arteries, precise interposition graft repair, and adequate protection of vital organs.     

Anesthesia for total and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis

We experienced anesthesia for total arch and descending aorta replacement and aortic valve replacement for post-repair aneurysm of coarctation of aorta and aortic stenosis. Because there was possibility that post coarctectomy syndrome would occur after repair of coarctation of aorta, administration of depressor that acts on renin-angiotensin-aldosterone and careful observation were needed postoperatively. In consideration of the development of collateral vessels, preoperative imaging evaluation was added and operative method in cardiopulmonary bypass was adjusted. Careful preoperative evaluation is very important in cardiac anesthesia.     

Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy: midterm clinical and magnetic resonance imaging results

BACKGROUND: We analyzed our 22 years of experience with extraanatomic bypass grafting for repair of aortic arch coarctation in adults. Results from early and midterm follow-up with clinical evaluation and magnetic resonance angiography are reported. METHODS: Between November 1979 and December 2001, 18 consecutive patients aged 18 to 61 years (mean, 31.8 +/- 13.3 years) underwent extraanatomic bypass grafting to repair coarctation of the aortic arch. Six patients (33.3%) had recoarctation after previous repair through a left thoracotomy, and 3 (16.7%) had associated cardiac diseases. The operative technique used in all patients was ascending aorta-to-descending thoracic aorta bypass with a polyethylene terephthalate fiber (Dacron) graft through a median sternotomy and posterior pericardial approach. RESULTS: Follow-up was completed in all patients, with a mean duration of 5.6 +/- 5.7 years (range, 12 months to 22 years). The follow-up interval exceeded 10 years in 5 patients. No neurologic complications, early or late mortality, late reoperations, or graft complications occurred. Six patients (33.3%) had mild hypertension. All patients were asymptomatic with patent Dacron grafts confirmed by echocardiography. Magnetic resonance angiography, performed in 15 (83.3%) patients, revealed that the Dacron grafts were still patent at a mean interval of 4.0 +/- 6.2 years (range, 5 days to 22 years) after repair. CONCLUSIONS: Extraanatomic ascending aorta-to-descending thoracic aorta bypass grafting for repair of aortic arch coarctation in adults is safe, with low morbidity and no mortality. The favorable midterm results indicate this technique is a safe and less invasive means of repairing aortic arch coarctation or recoarctation in adults.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

Extra-anatomic aortic bypass via sternotomy for complex aortic arch stenosis in children

OBJECTIVE: Recurrent aortic narrowing after repair of aortic coarctation or interrupted aortic arch, as well as diffuse, long-segment aortic hypoplasia, can be difficult to manage. Extra-anatomic ascending aorta-descending aorta bypass grafting through a sternotomy is an alternative approach for this problem. METHODS: Since 1985, 19 patients aged 2 months to 18 years (mean 10.7 years) underwent extra-anatomic bypass with 10- to 30-mm Dacron grafts. The initial diagnosis was coarctation with hypoplastic arch in 15, interrupted aortic arch in 3, and diffuse long-segment aortic hypoplasia in 1. Seventeen of the children had a total of 22 previous operations: transthoracic interposition or bypass graft (n = 7), end-to-end anastomosis (n = 7), subclavian arterioplasty (n = 6), and synthetic patch (n = 2). The mean time from initial repair was 8.0 years (range 0.6-18 years). Three children had previous sternotomies. Cardiopulmonary bypass was avoided in all but 6 patients (5 with simultaneous intracardiac repairs). RESULTS: No hospital or late deaths occurred. On follow-up from 4 months to 14.7 years (mean 7.9 years), no reoperations for recurrent stenosis were performed. Two patients have arm-to-leg pressure gradients: 20 mm Hg at rest in 1 patient and a 60-mm Hg systolic exercise gradient with no resting gradient in the other. One patient required exclusion of an aortic aneurysm at the old coarctation repair site 13 years after extra-anatomic bypass. Three children had subsequent successful cardiac operations. CONCLUSIONS: Extra-anatomic bypass is an effective and relatively easy approach for selected cases of complex or reoperative aortic arch obstruction. It should be considered as an alternative operative technique for complex aortic arch reconstruction.     

Dilatation of ascending aorta in patients with repaired coarctation

The long-term outcome following repair of typical aortic coarctation in adulthood may be complicated by disorders of the ascending aorta. Follow-up averaging 15 years revealed a 3.8% incidence of dilatation of the ascending aorta after such late repair. Hypertension and concomitant aortic valvular disease were common in these patients. Aortic dilatation can appear years after coarctation repair, irrespective of the operative technique and its success, and can lead to death from aortic dissection or rupture of an aortic aneurysm. Careful follow-up after coarctation repair in adulthood is advisable to detect late aortic complications.     

Aortic root aneurysm in an adult patient with aortic coarctation: a single-stage approach

Coarctation of the aorta is a common congenital defect that may be undiagnosed until adulthood. Moreover, coarctation is associated with congenital and acquired cardiac pathology that may require surgical intervention. The management of an adult patient with aortic coarctation and an associated cardiac defect poses a great technical challenge since there are no standard guidelines for the therapy of such a complex pathology. Several extra-anatomic bypass grafting techniques have been described, including methods in which distal anastomosis is performed on the descending thoracic aorta, allowing simultaneous intracardiac repair. We report here a 37-year old man who was diagnosed with an aortic root aneurysm and aortic coarctation. The patient was treated electively with a single-stage approach through a median sternotomy that consisted of valve-sparing replacement of the aortic root and ascending-to-descending extra-anatomic aortic bypass, using a 18-mm Dacron graft. Firstly, the aortic root was replaced with the Yacoub remodelling procedure, and then the distal anastomosis was performed to the descending aorta, behind the heart, with the posterior pericardial approach. The extra-anatomic bypass graft was brought laterally from the right atrium and implanted in the ascending graft. Postoperative recovery was uneventful and a control computed tomographic angiogram 1 month after complete repair showed good results.     

Extended repair of thoracic aorta through left thoracotomy after aortic root replacement

A patent distal false lumen after repair of type A aortic dissection often poses serious late complications. We present a successful repair of dissecting aortic aneurysm through left thoracotomy, extending from the ascending to descending thoracic aorta after composite graft replacement of the aortic root. Although staged operations, including the elephant trunk procedure, are usually chosen for remaining extensive aortic disease after replacement of the aortic root or the ascending aorta, a single-stage repair from the ascending to the descending thoracic aortas through left thoracotomy can be a favorable option to treat a patient with this type of aortic disease.     

Management of Ascending Aortic Aneurysm Complicating Coarctation of the Aorta

Four patients with coarctation of the aorta complicated by an aneurysm of the ascending aorta are described. One patient, treated only medically, died suddenly. For the 3 patients who underwent operation, management was similar. Pharmacological control of blood pressure and repair of the aortic coarctation to achieve anatomical reduction in afterload (stage I) were followed after an interval of one to five weeks by surgical repair of the ascending aortic aneurysm (stage II).Initial repair of the coarctation relieves proximal hypertension, thereby decreasing the chance of progressive dissection or rupture of the aneurysm. It also permits safe arterial cannulation for perfusion during correction of the aneurysm in the second stage. In patients not requiring valve replacement in stage II, continued long-term follow-up for progression of aortic valvular disease appears to be necessary.     

Ascending-to-descending aortic bypass via posterior pericardium for complex coarctation of aorta

Abstract   We introduce our surgical experience in treating recurrent aortic coarctation or coarctation associated with intracardiac abnormalities, which is difficult to manage. Four patients underwent the operation with hypothermic cardiopulmonary bypass. During the surgery, the posterior pericardium was opened and the thoracic aorta was dissected and sidebiting clamped, and an end-to-side anastomosis of the artificial graft to the descending aorta was performed. The graft was passed in between the inferior vena cava and the inferior right pulmonary vein and posterior to the pericardium. After that, the aorta was clamped and intracardiac repair was finished. Then the proximal artificial graft was anastomosed to the right side of the ascending aorta with heart beating. All patients recovered smoothly. There was no early or late death, without bleeding or other complications after operation. Conclusion : "Complex coarctation" can be treated with ascending-to-descending aortic bypass via posterior pericardium and satisfied result can be achieved.     

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.     

Surgery of the dilated aortic root and ascending aorta in pediatric patients: techniques and results.

OBJECTIVE: Dilatation of the aortic root is a well-known cardiovascular manifestation in children and adult patients with connective tissue disease (e.g. Marfan syndrome). Dilatation of the ascending aorta is extremely rare and may be associated with bicuspid aortic valve. This report evaluates the incidence of dilatative aortic root and ascending aortic pathology in patients younger than 18 years and analyzes the results obtained after repair and replacement strategies. METHODS: Between 1/1995 and 12/2002, a total of 752 operations on the thoracic aorta were performed in adult and pediatric patients. We present our experience with a group of 26 patients <18 years of age, who required isolated surgery of the aortic root and/or ascending aorta because of a dilatative lesion. Fifteen patients had isolated aortic root dilatation (13 of them suffered from Marfan syndrome), eight patients presented with an idiopathic dilatation of the ascending aorta and three patients had dilatation in association with a bicuspid aortic valve. Mean age was 10 +/- 4.8 years (4-18 years). Repair of the aortic root with preservation of the aortic valve (Yacoub, David or selective sinus repair) was performed in nine patients, replacement using a homograft was performed in five patients, composite graft with mechanical prosthesis in two patients, with biological prosthesis in one patient and Ross operation was performed in one case. Isolated supracoronary graft replacement was performed in eight patients. RESULTS: Two patients died during hospitalization: a 10-year old girl developed respiratory failure on the 2nd postoperative day and autopsy revealed Ehlers-Danlos syndrome with a massive intrapulmonary emphysema. A 14-year-old Marfan patient with severely depressed preoperative LV function died from low cardiac output following composite-graft, mitral and tricuspid valve repair. One patient required aortic valve replacement 7 days after an aortic valve sparing root repair. There was no additional perioperative morbidity. In the long-term, two patients died from rupture of the thoracic aorta, both following minor non-cardiovascular surgical procedures. Both had normal sized descending and abdominal aorta. CONCLUSION: Repair of the aortic root and/or ascending aorta in children and adolescent patients can be performed with acceptable early and late results. While the presence of severe comorbidity may adversely affect early outcome, long-term survival was mainly determined by rupture of the descending aorta.     

Total Simultaneous Repair of Coarctation and Intracardiac Pathology in Adult Patients

Background. Thoracic aortic coarctation accompanied by a second surgically reparable lesion is a rare combination in the adult patient. The simultaneous operative management of both lesions is desirable because of the higher morbidity and mortality that would occur with staged procedures.

Methods. We describe the simultaneous operative management in three adult patients with coarctation and a second cardiac lesion. All 3 patients had intrapericardial ascending aorta–descending aorta bypass and concomitant repair of a cardiac lesion. The attendant repairs in the 3 patients, respectively, were aortic valve replacement, orthotopic heart transplantation, and coronary artery bypass grafting.

Results. Double arterial cannulation, retrograde cardioplegia, large-bore aorto–aortic bypass grafts, and early use of -agonists to stabilize systemic pressure were all key to ensuring safe conduct of the operation. Each patient had an essentially uneventful postoperative course.

Conclusions. Thoracic coarctation and concomitant cardiac pathology can be safely and readily managed with a single-stage approach involving cardiac repair and extraanatomic ascending aorta–descending aorta bypass grafting. A review of the English-language literature of patients managed similarly is included.     

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The preoperative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.     

Combined repair of adult coarctation of the aorta and aortic valvular stenosis

A 57-year-old man with a high-grade aortic stenosis and aortic coarctation was treated with concomitant valve replacement and insertion of a conduit from the ascending aorta to the retrocardiac descending aorta via the left pleura. Because heart failure has been reported shortly after cardiopulmonary bypass using this technique, the conduit was initially clamped until the postrepair haemodynamics was stable. Computed tomography after 14 months verified patency of the shunt.     

Aortic operation after previous coronary artery bypass grafting

OBJECTIVES: Aortic surgery for progressive aortic valve disease or aortic aneurysm after previous coronary artery bypass grafting (CABG) is a challenging procedure. We report the outcome of aortic reoperation after previous CABG and evaluate our management of patent grafts and our methods for obtaining myocardial protection. METHODS: From February 2001 to July 2003, 6 patients with progressive aortic valve disease and aneurysm of the thoracic aorta were operated on. The group comprised 3 men and 3 women with a mean age of 67.6 years. There were 4 patients with an aneurysm of the aortic arch, 1 with chronic ascending aortic dissection, and 1 with progressive aortic valve stenosis. The interval between previous CABG and aortic surgery was 74.0 +/- 44.2 months. All reoperations were performed via median resternotomy. Myocardial protection was obtained by hypothermic perfusion of patent in-situ arterial grafts following cold-blood cardioplegia administration via the aortic root under aortic cross clamping. RESULTS: The operative procedure was aortic arch replacement in 4 patients, ascending aortic replacement with double CABG in 1, and aortic valve replacement in 1. All patients survived the reoperation. Postoperative maximum creatine kinase-MB was 49.2 +/- 29.8 and no new Q-waves occurred in the electrocardiogram nor were any new wall motion abnormalities recognized on echocardiography. There were no late deaths during a follow-up of 30.7 months. CONCLUSION: Reoperative aortic procedures after CABG can be performed safely with myocardial protection via hypothermic perfusion of a patent in-situ arterial graft.