A 38 year old gentleman presented with the complaints of chest pain and dyspnea on exertion (NYHA II) for 3 months. He was evaluated by his GP and found to be hypertensive. Cardiomegaly was observed on chest X Ray and he was sent for further evaluation.
Echocardigrphy revealed a bicuspid aortic valve with severe incompetence with dilated ascending aorta. A CT angiogram was performed which revealed a 8.5 cm aneurysm of the ascending aorta involving the aortic sinuses. The arch was hypoplastic with evidence of tight coarctation of aorta just after the origin of the left subclavian artery.( Image Below)
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| Post operative photo. |
The patient underwent a single stage correction of the defect via a median sternotomy. Innominate artery was used formarterial cannulation. A 8mm dacron graft was used to cannulate this artery. Bicaval venous cannulation was used for venous return. Custodial cardioplegia was used for myocardal protection. A Bentalls procedure was performed with a size 23 valve conduit. With the heart arrested it was retracted to the right using the Starfish retractor. The descending aorta was dissected out posterior to the pericardium. A size 20 dacron graft was sutured to it end to side. This graft was then brought over the diaphragm, IVC and the right atrium to the right side of the heart. It was then connected to the aortic valved conduit in an end to side fashion. An extra anatomic bypass of the coarctation was therefore created.(Images below). There was no gradient of pressures between the upper and lower limbs post op.
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| Post operative CT. |
Comment- Coarctation of the aorta may occassionaly be diagnosed in adulthood. It sis often associated with disease of the aortic root and valve. Traditionalyl, a staged operation requiring a median sternotomy and thoracotomy were performed to correct this defect. In the recent years a single stage approach as described above is recommended. The morbidity is less and the fragile area of the coarctation is not touched at all. 