One-Stage Relief of Aortic Coarctation with Mitral Valve Replacement via Median Sternotomy

This video shows a sixteen-year-old male patient who underwent two previous sternotomies for repair of a complete atrioventricular septal defect, followed by re-repair of the left atrioventricular valve (mitral valve) and resection of subaortic membrane. In addition, he had a known mild aortic coarctation that was followed over the years with no interventions.

The patient presented with progressive left atrial enlargement, increasing gradient across the mitral valve, and recurrent left ventricular outflow tract (LVOT) gradient. Because of elevated right sided pressure and severe mitral valve stenosis, the decision was made to proceed with a repeat operation. A preoperative computed tomography scan showed coarctation of the aorta, distal aortic arch hypoplasia, and poststenotic dilation of the proximal descending aorta.

The Surgery

Through a third sternotomy with aortic and bicaval cannulation, cardiopulmonary bypass (CPB) was initiated and the heart was elevated cephalad to expose the posterior pericardium. Next, the descending aorta was exposed at the level of the diaphragm and a side-biting clamp was applied. The distal anastomosis of a 14 mm Hemashield graft was constructed to the descending aorta in an end-to-side fashion. The anastomosis was de-aired, and the graft was temporarily clamped. 

Cardioplegic arrest was achieved in antegrade fashion and both cavae were snared. This was followed by an oblique right atriotomy, where the mitral valve was approached via a transseptal approach. A 29 mm bioprosthetic valve was placed in the mitral position and secured with multiple interrupted, pledgeted 2-0 Ethibond sutures placed in a horizontal mattress fashion with the pledgets on the ventricular side. 

An oblique aortotomy was then performed, and the left ventricular outflow tract (LVOT) was evaluated. The subaortic membrane was resected, and a limited septal myectomy was performed. The interatrial septal incision and the aortotomy were then closed, followed by de-airing the heart and removal of the aortic cross-clamp. The patient regained his normal sinus rhythm. The right atriotomy was then closed, and the caval snares were removed.

Next, a side-biting clamp was placed on the anterolateral side of the ascending aorta, and the Hemashield graft was brought to the right side of the free wall of the right atrium. Its proximal anastomosis was reconstructed in an end-to-side fashion using running 4-0 Prolene suture.

The patient was then weaned off (CPB) without difficulty. A transesophageal echocardiogram showed a well-seated mitral prosthesis with single digit gradient and a mean gradient of 10 to 11 mmHg across the LVOT. The patient was then decannulated and heparin was reversed, followed by chest closure in the standard fashion.

The aortic cross-clamp and CPB times were 73 and 204 minutes, respectively. The patient was extubated shortly after the operation and the remaining postoperative course was uneventful. He was discharged four days later.

A predischarge CT scan showed a well-seated mitral prosthesis and a widely patent aortic bypass graft with no pseudoaneurysms. The patient continued to do well during his follow-up.

Reference(s)

1. Said SM, Burkhart HM, Dearani JA, Connolly HM, Schaff HV. Ascending-to-descending aortic bypass: a simple solution to a complex problem. Ann Thorac Surg. 2014 Jun;97(6):2041-7

2. Camporrotondo M, Pagni S. Role of Extra-anatomic Ascending to Descending Bypass in Complex Thoracic Aortic Pathology. Aorta (Stamford). 2021 Dec;9(6):228-230

3. Reents W, Froehner S, Diegeler A, Urbanski PP. Ascending-to-descending bypass for simultaneous surgery of aortic coarctation with other cardiac pathologies. Thorac Cardiovasc Surg. 2012 Apr;60(3):210-4

4. Said SM, Dearani JA, Burkhart HM, Schaff HV. Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction. Operative Techniques in Thoracic and Cardiovascular Surgery 2012; Vol. 17 Issue 4: 261–270