Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 AFRICA 347 the left axillary artery. There was a long segment of narrowing, the narrowest diameter being 2 mm. The descending aorta at the level of the diaphragm was 4.5 mm, and the pressure gradient (PG) across the coarctation was 77 mmHg. Ballooning of this segment was performed by a Tyshack mini balloon (6 × 20 mm), which was inflated twice to 6 atmospheres (atm). Unfortunately, there was no significant improvement in the patient’s clinical condition or myocardial contractility. The FS was 9%. She was discharged on high doses of anti- failure treatment pre- and post load reduction (furosemide and captopril) plus inotrope (digoxin). By the age of three years, her weight was only 10 kg. She was rescheduled for cardiac catheterisation in a hybrid setting for direct access to the aorta. This would allow placement of a suitable-sized stent, which could be dilated later to adult size, through a large sheath. In the catheterisation laboratory (cath lab), our surgeon performed a right anterior mini-thoracotomy through the third intercostal space (Fig. 3), placed a retractor and then opened the pericardium, exposing the ascending aorta. He placed two purse-string sutures, through which he fixed a 9-F sheath in the ascending aorta and then handed the patient to our team. The PG across the coarctation was 50 mmHg. The descending aorta proximal to the coarctation measured 6 mm and distal to the coarctation, it measured 4 mm. The diameter of the coarctant segment was 2.9 mm. First, we balloon dilated this segment using a Tyshack II balloon (7 × 40 mm) at 3.5 atm. Then we chose a genesis Palmaz unmounted stent (39 × 10 mm), which was mounted on an Opta balloon (8 × 40 mm). We placed the stent and confirmed its position by hand injections. The balloon was inflated twice to 7 atm and then carefully withdrawn (Fig. 4). The surgeon then removed the sheath, tied the purse string and closed the chest wall in layers and a right chest tube was inserted. The patient stayed in the intensive care unit (ICU) for two days and was discharged home on medical treatment in the form of furosemide, captopril and digoxin. The LVEDD on discharge was 52.4 mm, Z -score was 8 and FS increased to 18%. The patient’s contractility did not return to normal, however, she did not need further hospitalisations. The FS gradually increased to 25% and the Z -score of the LV decreased to 3.5. Case 2: William’s syndrome with severe aortic coarctation At the age of five months, a female patient presented to our clinic with asymptomatic systemic hypertension. Echocardiographic examination revealed LV hypertrophy with short segment CoA distal to the origin of the left subclavian artery. Coarctectomy was done, with a smooth postoperative course. At the age of nine months, the patient was not growing Fig. 3. Right lateral mini-thoracotomy incision. Fig. 2. The surgical procedure: end-to-end anastomosis with an anterior PTFE patch. Fig. 4. Hybrid procedure in case 1; sheath placed through the ascending aorta and stent placement.