CASE REPORT BRINK ET AL TRACHEOPLASTY WITH AORTIC ARCH REPAIR IN A NEONATE
removed the pulmonary root with the valve and translocated it with or without a transannular patch enlargement, depending on a z score greater than 3 for the pulmonary valve. Most consecutive patients had acceptable results on follow-up; however, the pulmonary root translocation without the patch enlargement showed better late outcomes than did that with the patch enlargement for pulmonary valve growth. Those authors suggested that pulmonary root translocation might offer permanent resolution for complex congenital heart defects with malposition of the great arteries. Some authors recommend performing an arterial switch operation and subpulmonary conal resection for TGA and LVOT obstruction with mild pulmonary stenosis [3]. Park and coworkers [6] reported acceptable results in 8 patients with TGA, VSD, and pulmonary stenosis using this approach. The aortic z score of the pulmonary annulus was 1.50 1.13 ( 3.42 to 0.35) preoperatively and increased to 1.10 1.15 ( 0.8 to 2.10) postoperatively [6]. They concluded that the indication for arterial switch operation could be extended to patients with a pulmonary annulus having an aortic z score of 3, despite a bicuspid pulmonary valve. The valve-sparing approach has been proposed and adopted for patients with tetralogy of Fallot [7]. We have performed this approach for tetralogy of Fallot from 2005 and have been able to spare valves in more than 80% of consecutive patients. Moreover, more than 50% of patients with z scores ranging from 5 to 4 could be treated without transannular patches [8]. Thus, we aggressively chose DRT and used a valve-spared pulmonary root on this patient and observed an acceptable intermediate outcome. In our limited experience, valvespared pulmonary root translocation may be feasible and effective for patients with a pulmonary annulus having a z score of approximately 4, even when DRT is performed.
References 1. Yeh T Jr, Ramaciotti C, Leonard SR, Roy L, Nikaidoh H. The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure. J Thorac Cardiovasc Surg 2007;133:461–9. 2. Hu SS, Li SJ, Wang X, et al. Pulmonary and aortic root translocation in the management of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg 2007;133: 1090–2. 3. Hazekamp M, Portela F, Bartelings M. The optimal procedure for the great arteries and left ventricular outflow tract obstruction: an anatomical study. Eur J Cardiothorac Surg 2007;31:879–87. 4. Hu SS, Li SJ, Liu ZG, Li Y, Wang L. The double-root translocation technique. Oper Tech Thorac Cardiovasc Surg 2009;14:35–44. 5. da Silva JP, da Silva LF, Lopes LM, et al. Pulmonary root translocation in malposition of great arteries repair allows right ventricular outflow tract growth. J Thorac Cardiovasc Surg 2012;143:1292–8. 6. Park CS, Seo DM, Park JJ, Kim YH, Park IS. The significance of pulmonary annulus size in the surgical management of transposition of the great arteries with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 2010;139:135–8. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
1057
7. Stewart RD, Backer CL, Young L, Mavroudis C. Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg 2005;80:1431–9. 8. Ito H, Ota N, Murata M, et al. Technical modification enabling pulmonary valve-sparing repair of a severely hypoplastic pulmonary annulus in patients with tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2013;16:802–7.
Slide Tracheoplasty With Concomitant Aortic Arch Repair in a Low-Weight Neonate Johann Brink, MD, Yves d’Udekem, MD, PhD, and Igor E. Konstantinov, MD, PhD Cardiac Surgery Unit, Royal Children’s Hospital, Murdoch Children’s Research Institute and University of Melbourne, Melbourne, Australia
We report the successful surgical management of a hypoplastic aortic arch, severe tracheal stenosis, and acute respiratory failure in a low-birth-weight neonate. The technical details that facilitated concomitant slide tracheoplasty and aortic arch reconstruction are discussed. (Ann Thorac Surg 2014;97:1057–9) Ó 2014 by The Society of Thoracic Surgeons
A
lthough the outcomes of tracheoplasty have improved during the last decade [1, 2], surgical procedures on the trachea remain difficult, especially when associated with simultaneous repair of coexisting cardiovascular anomalies in low-birth-weight neonates. Herein, we describe the successful surgical treatment in a neonate with a hypoplastic aortic arch, severe tracheal stenosis, and acute respiratory failure that required emergent extracorporeal membrane oxygenation (ECMO) before repair. A 5-day-old girl weighing 2.2 kg born at 37 weeks of gestation with an antenatal diagnosis of aortic coarctation and duodenal atresia underwent a duodenoduodenostomy and experienced severe respiratory acidosis despite high-frequency oscillatory ventilation. Emergency ECMO was initiated in the intensive care unit through a midline sternotomy with cannulation of the aorta and right atrium. The echocardiogram revealed a hypoplastic transverse aortic arch, coarctation, and a large patent ductus arteriosis. The proximal and distal aortic arch had z score values of 2.0 and 1.6, respectively. The z score of the aortic isthmus was 2.8. Computed tomography confirmed the hypoplastic aortic arch and a distal tracheal stenosis with complete tracheal rings (Fig 1). ECMO was converted to cardiopulmonary bypass (CPB) with bicaval cannulation and cooling to 26 C. The aortic arch and
Accepted for publication June 3, 2013. Address correspondence to Dr Konstantinov, Cardiac Surgery Unit, Royal Children’s Hospital, Flemington Rd, Parkville 3052, Melbourne, VI 3052, Australia; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.092
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1057–9
1058
CASE REPORT BRINK ET AL TRACHEOPLASTY WITH AORTIC ARCH REPAIR IN A NEONATE
Ann Thorac Surg 2014;97:1057–9
FEATURE ARTICLES
patent foramen ovale. The aorta was transected at the isthmus, and all ductal tissue was resected. The posterior wall of the descending aorta was sutured to the transverse arch. The lesser curvature of the transverse arch was then augmented with a homograft pericardial patch. Full CPB was re-established, the patent foramen ovale was closed, the aortic cross-clamp was removed, and the patient was rewarmed. The trachea was transected in the middle of the narrowing. Incisions were made in the left main bronchus and the opposing proximal tracheal stump (Fig 2B). The slide tracheoplasty was completed with a running 6-0 polydioxanone suture. The left recurrent laryngeal nerve was left behind the aorta (Fig 2C). A right-sided pedicled pericardial flap was positioned behind the superior vena cava to cover the tracheal anastomosis (Fig 2D) as previously described [3]. A small amount of Tisseel (Baxter, Westlake Village, CA) was then injected over the anastomosis, and the pericardial flap was secured with a suture. A bronchoscopy confirmed stable airways, and conventional ventilation was achieved. The aortic cross-clamp time was 61 minutes, and the CPB time was 197 minutes. The chest was left open and was closed in the intensive care unit 2 days later. The patient was extubated 5 days after the chest closure. Laryngoscopy confirmed normal vocal cord function. The follow-up echocardiogram showed an unobstructed aortic arch repair. The patient was discharged home and was asymptomatic 2 months after the repair. Fig 1. Three-dimensional computed tomographic view of reconstruction of the tracheobroncheal tree.
descending aorta were mobilized. The left recurrent laryngeal nerve was dissected along its course around the aorta (Fig 2A). Great care was taken to preserve this nerve during mobilization. The arterial cannula was then advanced into the innominate artery, and arch branches were snared to establish selective low-flow cerebral perfusion. The aorta was clamped, and cardioplegic heart arrest was induced. The right atrium was opened, and the left atrium was drained through the
Fig 2. Operative technique. (A) Surgical anatomy. (B) Slide tracheoplasty with extension into the left main bronchus. (C) Aortic arch repair with left recurrent nerve left behind the aorta. (D) Pericardial flap positioning between aorta and tracheobroncheal tree.
Comment Younger age and CPB duration are risk factors for mortality after slide tracheoplasty [1]. Simultaneous repair of the aortic arch and tracheoplasty can be challenging because slide tracheoplasty shortens the trachea and brings the carina upward [1–4], whereas repair of the aortic arch shortens the aorta and brings the aortic arch down [5]. Thus, concomitant repair of the aortic arch and tracheoplasty may result in compression of the left main bronchus. Moreover, this may also cause damage and compression of the left recurrent nerve, resulting in left vocal cord palsy and further contributing to
Ann Thorac Surg 2014;97:1059–61
References 1. Manning PB, Rutter MJ, Lisec A, Gupta R, Marino BS. One slide fits all: the versatility of slide tracheoplasty with cardiopulmonary bypass support for airway reconstruction in children. J Thorac Cardiovasc Surg 2011;141:155–61. 2. Yong MS, d’Udekem Y, Robertson CF, Butt W, Brizard CP, Konstantinov IE. Tracheal repair in children: reduction of mortality with advent of slide tracheoplasty. ANZ J Surg 2013 Apr 18. http://dx.doi.org/10.1111/ans.12132 [Epub ahead of print]. 3. Konstantinov IE, d’Udekem Y, Saxena P. Interposition pericardial flap after slide tracheoplasty in pulmonary artery sling complex. Ann Thorac Surg 2010;89:289–91. 4. Konstantinov IE. Carinal stabilization technique in severe tracheobronchial malacia after slide tracheoplasty. J Thorac Cardiovasc Surg 2010;140:717–9. 5. Hussein A, Iyengar AJ, Jones B, et al. Twenty-three years of single-stage end-to-side anastomosis repair of interrupted aortic arches. J Thorac Cardiovasc Surg 2010;139:942–7.
Repair of an Unusual Aortic Coarctation Using an Extracellular Matrix Patch Luca Deorsola, MD, Carlo Pace Napoleone, MD, and Pietro Angelo Abbruzzese, MD Pediatric Cardiac Surgery Division, Ospedale Infantile Regina Margherita, Turin, Italy
The surgical treatment of neonatal aortic coarctation is usually accomplished with a termino-terminal anastomosis or a subclavian flap. The use of a patch to enlarge the isthmal narrowing may be an alternative but is frequently complicated by aneurysmal dilatation on the aortic wall opposite to the patch, probably because it disrupts the vascular anatomic integrity. Extracellular matrix patches promise to restore the original tissue structure and could therefore be a valid alternative to other materials. We describe an aortic coarctation with an Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
1059
uncommon anatomic aspect treated with a CorMatrix (CorMatrix, Alpharetta, GA) extracellular matrix patch. (Ann Thorac Surg 2014;97:1059–61) Ó 2014 by The Society of Thoracic Surgeons
S
urgical treatment of neonatal aortic coarctation is usually accomplished with either a termino-terminal anastomosis or a subclavian flap [1, 2]. When anatomy is not suitable for these procedures, a patch may be used to enlarge the narrowed isthmus [3]. Although technically simple, this solution is frequently burdened by the late development of aneurysmal dilatation of the aorta. It occurs at the level of the patch, on the opposite native wall, regardless of the kind of patch [4]. This complication is probably determined by the disruption of the circumferential fibers of the aortic wall where the patch has been inserted [5]. The recent introduction of extracellular matrix (ECM) patches could represent a solution because they are showing capable of being colonized and replaced by the original tissue, restoring its integrity [6]. The ECM patches employed for coarctation surgery should prevent aneurysmal development. A 3-week-old male was referred to our center by his family pediatrician, with the suspect of aortic coarctation. At clinical examination he showed a continuous murmur and an arterial pressure difference between upper and lower limbs (107/62 mm Hg vs 46/31 mm Hg). Echocardiography confirmed the diagnosis but showed a quite unusual anatomy. The aortic arch was normally developed; at its end a very small left subclavian artery originated. Immediately after the left subclavian, the aortic lumen reduced to 2 mm and maintained this dimension for more than 3 cm, then returned to a normal diameter. The patent ductus arteriosus (PDA) was well evident and entered the thoracic aorta at the end of the narrowed segment, extremely far from the left subclavian. A 40 mm Hg pressure gradient with diastolic runoff was measured (Fig 1). The patient underwent surgery through a left thoracotomy and anatomy appeared exactly as described by echocardiography. Because of the extension of the narrowing and the small left subclavian, either a terminoterminal anastomosis or a subclavian flap were not feasible, and we decided for an enlargement patch. After heparin infusion, proximal and distal aortic crossclamping, the PDA was ligated with a silk string and the entire narrow tract incised longitudinally, from the foot of the left subclavian to almost 1 cm downstream of the PDA. The opened aortic segment was then enlarged with a CorMatrix (CorMatrix, Alpharetta, GA) patch tailored and sutured with a polydioxanone running suture (Fig 2).
Accepted for publication June 3, 2013. Address correspondence to Dr Deorsola, Ospedale Infantile Regina Margherita, Piazza Polonia 94-10126 Turin, Italy; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.109
FEATURE ARTICLES
postoperative compromise of the airways. To prevent left recurrent laryngeal nerve injury, we dissected the nerve and brought it above the aorta, preventing its entrapment between the aorta and the tracheobronchial tree. We found this technique particularly helpful in the patient described herein, as we extended the slide tracheoplasty into the left main bronchus because of the narrowing of the origin of the left main bronchus. In isolation, we would repair a hypoplastic aortic arch with an end-to-side anastomosis [5]. To prevent bronchial compression in this patient, we augmented the aorta with a homograft pericardial patch. Furthermore, we used a pericardial flap as previously described [3] to securely seal the site of tracheal repair and to prevent subsequent erosion of the aorta and its branches into the tracheobronchial tree. This pericardial flap is easy to place, and it functions as native pretracheal fascia. In conclusion, slide tracheoplasty involving the left main bronchus and concomitant hypoplastic aortic arch repair can be successfully performed in a high-risk low-weight neonate.
CASE REPORT DEORSOLA ET AL REPAIR OF AORTIC COARCTATION USING AN EMP
removed the pulmonary root with the valve and translocated it with or without a transannular patch enlargement, depending on a z score greater than 3 for the pulmonary valve. Most consecutive patients had acceptable results on follow-up; however, the pulmonary root translocation without the patch enlargement showed better late outcomes than did that with the patch enlargement for pulmonary valve growth. Those authors suggested that pulmonary root translocation might offer permanent resolution for complex congenital heart defects with malposition of the great arteries. Some authors recommend performing an arterial switch operation and subpulmonary conal resection for TGA and LVOT obstruction with mild pulmonary stenosis [3]. Park and coworkers [6] reported acceptable results in 8 patients with TGA, VSD, and pulmonary stenosis using this approach. The aortic z score of the pulmonary annulus was 1.50 1.13 ( 3.42 to 0.35) preoperatively and increased to 1.10 1.15 ( 0.8 to 2.10) postoperatively [6]. They concluded that the indication for arterial switch operation could be extended to patients with a pulmonary annulus having an aortic z score of 3, despite a bicuspid pulmonary valve. The valve-sparing approach has been proposed and adopted for patients with tetralogy of Fallot [7]. We have performed this approach for tetralogy of Fallot from 2005 and have been able to spare valves in more than 80% of consecutive patients. Moreover, more than 50% of patients with z scores ranging from 5 to 4 could be treated without transannular patches [8]. Thus, we aggressively chose DRT and used a valve-spared pulmonary root on this patient and observed an acceptable intermediate outcome. In our limited experience, valvespared pulmonary root translocation may be feasible and effective for patients with a pulmonary annulus having a z score of approximately 4, even when DRT is performed.
References 1. Yeh T Jr, Ramaciotti C, Leonard SR, Roy L, Nikaidoh H. The aortic translocation (Nikaidoh) procedure: midterm results superior to the Rastelli procedure. J Thorac Cardiovasc Surg 2007;133:461–9. 2. Hu SS, Li SJ, Wang X, et al. Pulmonary and aortic root translocation in the management of transposition of the great arteries with ventricular septal defect and left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg 2007;133: 1090–2. 3. Hazekamp M, Portela F, Bartelings M. The optimal procedure for the great arteries and left ventricular outflow tract obstruction: an anatomical study. Eur J Cardiothorac Surg 2007;31:879–87. 4. Hu SS, Li SJ, Liu ZG, Li Y, Wang L. The double-root translocation technique. Oper Tech Thorac Cardiovasc Surg 2009;14:35–44. 5. da Silva JP, da Silva LF, Lopes LM, et al. Pulmonary root translocation in malposition of great arteries repair allows right ventricular outflow tract growth. J Thorac Cardiovasc Surg 2012;143:1292–8. 6. Park CS, Seo DM, Park JJ, Kim YH, Park IS. The significance of pulmonary annulus size in the surgical management of transposition of the great arteries with ventricular septal defect and pulmonary stenosis. J Thorac Cardiovasc Surg 2010;139:135–8. Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
1057
7. Stewart RD, Backer CL, Young L, Mavroudis C. Tetralogy of Fallot: results of a pulmonary valve-sparing strategy. Ann Thorac Surg 2005;80:1431–9. 8. Ito H, Ota N, Murata M, et al. Technical modification enabling pulmonary valve-sparing repair of a severely hypoplastic pulmonary annulus in patients with tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2013;16:802–7.
Slide Tracheoplasty With Concomitant Aortic Arch Repair in a Low-Weight Neonate Johann Brink, MD, Yves d’Udekem, MD, PhD, and Igor E. Konstantinov, MD, PhD Cardiac Surgery Unit, Royal Children’s Hospital, Murdoch Children’s Research Institute and University of Melbourne, Melbourne, Australia
We report the successful surgical management of a hypoplastic aortic arch, severe tracheal stenosis, and acute respiratory failure in a low-birth-weight neonate. The technical details that facilitated concomitant slide tracheoplasty and aortic arch reconstruction are discussed. (Ann Thorac Surg 2014;97:1057–9) Ó 2014 by The Society of Thoracic Surgeons
A
lthough the outcomes of tracheoplasty have improved during the last decade [1, 2], surgical procedures on the trachea remain difficult, especially when associated with simultaneous repair of coexisting cardiovascular anomalies in low-birth-weight neonates. Herein, we describe the successful surgical treatment in a neonate with a hypoplastic aortic arch, severe tracheal stenosis, and acute respiratory failure that required emergent extracorporeal membrane oxygenation (ECMO) before repair. A 5-day-old girl weighing 2.2 kg born at 37 weeks of gestation with an antenatal diagnosis of aortic coarctation and duodenal atresia underwent a duodenoduodenostomy and experienced severe respiratory acidosis despite high-frequency oscillatory ventilation. Emergency ECMO was initiated in the intensive care unit through a midline sternotomy with cannulation of the aorta and right atrium. The echocardiogram revealed a hypoplastic transverse aortic arch, coarctation, and a large patent ductus arteriosis. The proximal and distal aortic arch had z score values of 2.0 and 1.6, respectively. The z score of the aortic isthmus was 2.8. Computed tomography confirmed the hypoplastic aortic arch and a distal tracheal stenosis with complete tracheal rings (Fig 1). ECMO was converted to cardiopulmonary bypass (CPB) with bicaval cannulation and cooling to 26 C. The aortic arch and
Accepted for publication June 3, 2013. Address correspondence to Dr Konstantinov, Cardiac Surgery Unit, Royal Children’s Hospital, Flemington Rd, Parkville 3052, Melbourne, VI 3052, Australia; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.092
FEATURE ARTICLES
Ann Thorac Surg 2014;97:1057–9
1058
CASE REPORT BRINK ET AL TRACHEOPLASTY WITH AORTIC ARCH REPAIR IN A NEONATE
Ann Thorac Surg 2014;97:1057–9
FEATURE ARTICLES
patent foramen ovale. The aorta was transected at the isthmus, and all ductal tissue was resected. The posterior wall of the descending aorta was sutured to the transverse arch. The lesser curvature of the transverse arch was then augmented with a homograft pericardial patch. Full CPB was re-established, the patent foramen ovale was closed, the aortic cross-clamp was removed, and the patient was rewarmed. The trachea was transected in the middle of the narrowing. Incisions were made in the left main bronchus and the opposing proximal tracheal stump (Fig 2B). The slide tracheoplasty was completed with a running 6-0 polydioxanone suture. The left recurrent laryngeal nerve was left behind the aorta (Fig 2C). A right-sided pedicled pericardial flap was positioned behind the superior vena cava to cover the tracheal anastomosis (Fig 2D) as previously described [3]. A small amount of Tisseel (Baxter, Westlake Village, CA) was then injected over the anastomosis, and the pericardial flap was secured with a suture. A bronchoscopy confirmed stable airways, and conventional ventilation was achieved. The aortic cross-clamp time was 61 minutes, and the CPB time was 197 minutes. The chest was left open and was closed in the intensive care unit 2 days later. The patient was extubated 5 days after the chest closure. Laryngoscopy confirmed normal vocal cord function. The follow-up echocardiogram showed an unobstructed aortic arch repair. The patient was discharged home and was asymptomatic 2 months after the repair. Fig 1. Three-dimensional computed tomographic view of reconstruction of the tracheobroncheal tree.
descending aorta were mobilized. The left recurrent laryngeal nerve was dissected along its course around the aorta (Fig 2A). Great care was taken to preserve this nerve during mobilization. The arterial cannula was then advanced into the innominate artery, and arch branches were snared to establish selective low-flow cerebral perfusion. The aorta was clamped, and cardioplegic heart arrest was induced. The right atrium was opened, and the left atrium was drained through the
Fig 2. Operative technique. (A) Surgical anatomy. (B) Slide tracheoplasty with extension into the left main bronchus. (C) Aortic arch repair with left recurrent nerve left behind the aorta. (D) Pericardial flap positioning between aorta and tracheobroncheal tree.
Comment Younger age and CPB duration are risk factors for mortality after slide tracheoplasty [1]. Simultaneous repair of the aortic arch and tracheoplasty can be challenging because slide tracheoplasty shortens the trachea and brings the carina upward [1–4], whereas repair of the aortic arch shortens the aorta and brings the aortic arch down [5]. Thus, concomitant repair of the aortic arch and tracheoplasty may result in compression of the left main bronchus. Moreover, this may also cause damage and compression of the left recurrent nerve, resulting in left vocal cord palsy and further contributing to
Ann Thorac Surg 2014;97:1059–61
References 1. Manning PB, Rutter MJ, Lisec A, Gupta R, Marino BS. One slide fits all: the versatility of slide tracheoplasty with cardiopulmonary bypass support for airway reconstruction in children. J Thorac Cardiovasc Surg 2011;141:155–61. 2. Yong MS, d’Udekem Y, Robertson CF, Butt W, Brizard CP, Konstantinov IE. Tracheal repair in children: reduction of mortality with advent of slide tracheoplasty. ANZ J Surg 2013 Apr 18. http://dx.doi.org/10.1111/ans.12132 [Epub ahead of print]. 3. Konstantinov IE, d’Udekem Y, Saxena P. Interposition pericardial flap after slide tracheoplasty in pulmonary artery sling complex. Ann Thorac Surg 2010;89:289–91. 4. Konstantinov IE. Carinal stabilization technique in severe tracheobronchial malacia after slide tracheoplasty. J Thorac Cardiovasc Surg 2010;140:717–9. 5. Hussein A, Iyengar AJ, Jones B, et al. Twenty-three years of single-stage end-to-side anastomosis repair of interrupted aortic arches. J Thorac Cardiovasc Surg 2010;139:942–7.
Repair of an Unusual Aortic Coarctation Using an Extracellular Matrix Patch Luca Deorsola, MD, Carlo Pace Napoleone, MD, and Pietro Angelo Abbruzzese, MD Pediatric Cardiac Surgery Division, Ospedale Infantile Regina Margherita, Turin, Italy
The surgical treatment of neonatal aortic coarctation is usually accomplished with a termino-terminal anastomosis or a subclavian flap. The use of a patch to enlarge the isthmal narrowing may be an alternative but is frequently complicated by aneurysmal dilatation on the aortic wall opposite to the patch, probably because it disrupts the vascular anatomic integrity. Extracellular matrix patches promise to restore the original tissue structure and could therefore be a valid alternative to other materials. We describe an aortic coarctation with an Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
1059
uncommon anatomic aspect treated with a CorMatrix (CorMatrix, Alpharetta, GA) extracellular matrix patch. (Ann Thorac Surg 2014;97:1059–61) Ó 2014 by The Society of Thoracic Surgeons
S
urgical treatment of neonatal aortic coarctation is usually accomplished with either a termino-terminal anastomosis or a subclavian flap [1, 2]. When anatomy is not suitable for these procedures, a patch may be used to enlarge the narrowed isthmus [3]. Although technically simple, this solution is frequently burdened by the late development of aneurysmal dilatation of the aorta. It occurs at the level of the patch, on the opposite native wall, regardless of the kind of patch [4]. This complication is probably determined by the disruption of the circumferential fibers of the aortic wall where the patch has been inserted [5]. The recent introduction of extracellular matrix (ECM) patches could represent a solution because they are showing capable of being colonized and replaced by the original tissue, restoring its integrity [6]. The ECM patches employed for coarctation surgery should prevent aneurysmal development. A 3-week-old male was referred to our center by his family pediatrician, with the suspect of aortic coarctation. At clinical examination he showed a continuous murmur and an arterial pressure difference between upper and lower limbs (107/62 mm Hg vs 46/31 mm Hg). Echocardiography confirmed the diagnosis but showed a quite unusual anatomy. The aortic arch was normally developed; at its end a very small left subclavian artery originated. Immediately after the left subclavian, the aortic lumen reduced to 2 mm and maintained this dimension for more than 3 cm, then returned to a normal diameter. The patent ductus arteriosus (PDA) was well evident and entered the thoracic aorta at the end of the narrowed segment, extremely far from the left subclavian. A 40 mm Hg pressure gradient with diastolic runoff was measured (Fig 1). The patient underwent surgery through a left thoracotomy and anatomy appeared exactly as described by echocardiography. Because of the extension of the narrowing and the small left subclavian, either a terminoterminal anastomosis or a subclavian flap were not feasible, and we decided for an enlargement patch. After heparin infusion, proximal and distal aortic crossclamping, the PDA was ligated with a silk string and the entire narrow tract incised longitudinally, from the foot of the left subclavian to almost 1 cm downstream of the PDA. The opened aortic segment was then enlarged with a CorMatrix (CorMatrix, Alpharetta, GA) patch tailored and sutured with a polydioxanone running suture (Fig 2).
Accepted for publication June 3, 2013. Address correspondence to Dr Deorsola, Ospedale Infantile Regina Margherita, Piazza Polonia 94-10126 Turin, Italy; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.06.109
FEATURE ARTICLES
postoperative compromise of the airways. To prevent left recurrent laryngeal nerve injury, we dissected the nerve and brought it above the aorta, preventing its entrapment between the aorta and the tracheobronchial tree. We found this technique particularly helpful in the patient described herein, as we extended the slide tracheoplasty into the left main bronchus because of the narrowing of the origin of the left main bronchus. In isolation, we would repair a hypoplastic aortic arch with an end-to-side anastomosis [5]. To prevent bronchial compression in this patient, we augmented the aorta with a homograft pericardial patch. Furthermore, we used a pericardial flap as previously described [3] to securely seal the site of tracheal repair and to prevent subsequent erosion of the aorta and its branches into the tracheobronchial tree. This pericardial flap is easy to place, and it functions as native pretracheal fascia. In conclusion, slide tracheoplasty involving the left main bronchus and concomitant hypoplastic aortic arch repair can be successfully performed in a high-risk low-weight neonate.
CASE REPORT DEORSOLA ET AL REPAIR OF AORTIC COARCTATION USING AN EMP
