CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 8, September 2013
e12
AFRICA
and CoA, establishing adequate blood flow to the upper body
during CPB can be difficult, especially when the gradient across
the coarctation is severe. The problem can be solved by putting a
Y-graft into the arterial line, perfusing the lower body via a tube
graft attached to the supracoeliac aorta, and perfusing the upper
body and head via a cannula in the aortic arch. This allows for
the maintenance of adequate flow to both areas of the body.
7
Furthermore, using this approach, the two lesions can be
treated in a single operation. Therefore bypass is performed
from the ascending aorta beyond the coarctation, bypassing the
stenosis and resulting in normal blood pressures.
There is also a risk of inadequate blood flow to the organs
beyond the coarctation, leading to end-organ failure, including
spinal cord ischaemia, hepatic failure and bowel ischaemia
when the coarctation is not relieved in the same session. When
weaning the patient from cardiopulmonary bypass, there is a risk
of detachment of the anastomosis to the acutely inflamed aorta
because of the CoA.
Valve-sparing aortic replacement for a root aneurysm with a
morphologically intact valve has become a common procedure
with acceptable results, but this operation for a dilated aorta with
bicuspid valve remains challenging. However, some reports have
demonstrated acceptable early and mid-term results of a valve-
sparing root replacement in patients with a bicuspid valve.
16,17
Because of the patient’s haemodynamic instability, we did not
consider either a single-stage procedure, due to the increased
operating time and possible malperfusion, or percutaneous
treatment of the CoA. Since the aortic valve was bicuspid and
intact, valve-sparing replacement of the ascending aorta was
performed, and repair of the CoA was planned for a second
operation at a later stage.
Conclusion
Repair of the AAD takes precedence over CoA repair. A
two-stage surgical approach appears to be a safe choice, taking
into account the feasibility of perfusing all arterial regions during
replacement of the ascending aorta.
References
1.
Bricker DL, Parker TM, Mistrot JJ, Dalton ML. Repair of acute dissec-
tion of the ascending aorta, associated with coarctation of the thoracic
aorta in a Jehovah’s Witness.
J Cardiovasc Surg (Torino)
1980;
21
(3):
374–378.
2.
Hovaguimian H, Aru GM, Floten HS. Acute type 1 aortic dissection
with coarctation of the aorta: discussion of management and the report
of a successful brain perfusion across an aortic coarctation.
J Thorac
Cardiovasc Surg
1990;
100
: 152–153.
3.
Horai T, Shimokawa T, Takeuchi S,
et al
. Single-stage surgical repair of
type II acute aortic dissection associated with coarctation of the aorta.
Ann Thorac Surg
2007;
83
: 1174–1175.
4.
Svensson LG. Management of acute aortic dissection associated with
coarctation by a single operation.
Ann Thorac Surg
1994;
58
: 241–243.
5.
Furukawa K, Ohteki H, Cao ZL,
et al
. Does dilatation of the sinotu-
bular junction cause aortic regurgitation?
Ann Thorac Surg
1999;
68
:
949–953; discussion 953–954.
6.
Sabet HY, Edwards WD, Tazelaar HD, Daly RC. Congenitally bicuspid
aortic valves: a surgical pathology study of 542 cases (1991–1996) and
a literature review of 2,715 additional cases.
Mayo Clin Proc
1999;
74
: 14–26
7.
Sampath R, O’Connor WN, Noonan JA, Todd EP. Management of
ascending aortic aneurysm complicating coarctation of the aorta.
Ann
Thorac Surg
1982;
34
: 125–231.
8.
Rampoldi V, Trimarchi S, Tolva V, Righini P. Acute type A aortic
dissection and coarctation of aortic isthmus.
J Cardiovasc Surg
2002;
43
: 701–703.
9.
Plunkett MD, Bond LM, Geiss DM. Staged repair of acute type I aortic
dissection and coarctation in pregnancy.
Ann Thorac Surg
2000;
69
:
1945–1947.
10. Erkut B, Koço
ğ
ullari CU, Ozyazicio
ğ
luA, Koçak H. Two-stage success-
ful surgery in an aortic coarctation case operated initially for ascending
aortic aneurysm.
Anadolu Kardiyol Derg
2007;
7
(4): 445–448.
11. 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
: 584–586.
12. Ananiadou OG, Koutsogiannidis C, Ampatzidou F, Drossos GE. Aortic
root aneurysm in an adult patient with aortic coarctation: a single-stage
approach.
Interact Cardiovasc Thorac Surg
2012;
15
(3): 534–536.
13. Lawson RA, Fenn A. Dissection of an aneurysmal ascending aorta in
association with coarctation of the aorta.
Thorax
1979;
34
: 606–611.
14. Imamura M, Aoki H, Eya K, Murakami T, Yasuda K. Balloon angio-
plasty before Wheat’s operation in a patient with Turner’s syndrome.
Cardiovasc Surg
1995;
3
: 70–72.
15. Heper G, Yorukoglu Y, Korkmaz ME. Clinical and hemodynamic
follow-up of a patient after operation for dissection of an ascending
aortic aneurysm secondary to coarctation of the aorta.
Int Heart J
2005;
46
(6): 1123–1131.
16. Aicher D, Langer F, Kissinger A, Lauberg H, Fries R, Schafers HJ.
Valve-sparing aortic root replacement in bicuspid aortic valves: a
reasonable option?
J Thoracic Cardiovasc Surg
2004;
128
: 662–668.
17. Kallenbach K, Karck M, Pak D,
et al
. Decade of aortic valve sparing
reimplantation: are we pushing limits too far?
Circulation
2005;
112
:
I253–259
.
