Surgical technique
In our clinic, we perform resection end-to-end anastomosis with left
thoracotomy in patients with isolated aortic coarctation and we perform
arch reconstruction via median sternotomy to all patients with
transverse and proximal arcus hypoplasia.
Since 2014 we have performed arch repair surgeries under moderate
hypothermia (28°C) and on BH patients using antegrade cerebral and
coronary perfusion. Prior to 2014 we performed arch surgery using
antegrade cerebral perfusion under CA. After performing arch
reconstruction on a BH, we performed an intracardiac repair under CA.
Concomitant surgical procedures were VSD repair, atrioventricular septal
defect (AVSD) repair, Glenn shunt, AV valve repair, pulmonary artery
banding, arterial switch operation, atrial septectomy, VSD enlargement,
aortic valve commissurotomy, pulmonary artery patch plasty, and total
anomalous pulmonary venous connection repair.
Cerebral and somatic near-infrared spectroscopy monitoring and right
radial artery and femoral artery catheterization were routinely used.
When right radial artery catheterization could not be performed,
arterial pressure monitoring was performed by left radial artery
catheterization.
A median sternotomy was performed and the ascending aorta, aortic arch,
and branches of the aortic arch were dissected out. ACP was provided by
direct cannulation (8 Fr aortic cannula) of the innominate artery. In
cases where the diameter of the innominate artery was small, ACP was
achieved by anastomosing the 3.5 mm graft to the innominate artery. In
cases where the right carotid and right subclavian artery were branched
separately, the left or right carotid artery was used for ACP. Patients
were cooled to a rectal temperature of 28°C after being initiated on
cardiopulmonary bypass. Left‐heart decompression via a left atrial vent
was used. For CP, a cardioplegia needle was placed in the aortic root.
The Y-connector was added to the antegrade arterial line and blood was
delivered to the coronary arteries by the cardioplegia line (3/8 in)
with the flow controlled by a single pump head (Figure 1). The arch
branches, ascending aorta, and descending aorta were clamped and arch
reconstruction was performed on the BH. For cerebral and coronary
perfusion, 70–80 mL/kg/min antegrade flow was provided by monitoring
near-infrared spectroscopy (> 65–70%) and radial artery
pressure (mean pressure was maintained at 40–45 mm Hg). Coronary
perfusion was assessed by observing myocardial hue and ventricular
distention and by monitoring electrocardiography. Descending aortic
cannulation was not applied to any of the patients. Although no
myocardial ischemia was observed in any of the patients, we were
prepared to apply cardioplegia.
We performed patch plasty procedures in most of our patients, as well as
resections of all ductal tissue. An incision was made beginning at the
descending aorta, continuing along the inner curvature and ending 1 cm
from the ascending aortic clamp. Upon completion of the repair, the
incision was augmented using prolene sutures and gluteraldehyde treated
autologous pericardium. If autologous pericardium was not suitable,
various patch materials such as a bovine-porcine pericardium, core
matrix or curved patch (No react porcine pericardial, Biointegral
Surgical Inc.) were used (Figure 2).
In the case of aortic coarctation, the coarcted segment was resected and
an inner curvature incision was made. A cutback was made in the
posterior of the descending aorta. Afterwards, the descending aorta and
isthmus were anastomosed end-to-end posteriorly in an interdigitating
fashion (12) and the incision in the small curvature was augmented again
using patch materials (Figures 1-2). After the aortic reconstruction,
coronary perfusion was stopped and cardioplegia applied via the aortic
root cannula for intracardiac repair.
A delayed sternal closure decision was taken in cases of permanent
hypotension when attempting sternal closure, elevation of left atrial
pressure, presence of rhythm disturbances and bleeding that causing
hemodynamic instability.