Ascending–descending aortic bypass with the aid of a heart-lifting device

Abstract

Extra-anatomic aortic bypass from the ascending to the descending aorta is an alternative for repair of complex aortic anomalies. We describe a case of repair of recoarctation of the aorta through a median sternotomy and posterior pericardial approach in which surgical exposure of the retrocardiac aorta was obtained by means of a heart-lifting device (Starfish 2; Medtronic, Inc, Minneapolis, Minn) commonly used in off-pump coronary artery bypass grafting. A 70-year-old man was seen with dyspnea on exertion and intermittent claudication. He was hypertensive, in atrial fibrillation, and taking oral anticoagulants. His medical history included repair of aortic coarctation (end-to-end anastomosis) 29 years previously. Echocardiography showed left ventricular hypertrophy with moderately depressed left ventricular function (ejection fraction 40%). He underwent aortic angiography, which confirmed the diagnosis of aortic recoarctation with a gradient of 48 mm Hg across the coarctation. The thoracic descending aorta was tortuous (Figure 1). In view of the patient’s age and left ventricular impairment, it was decided that an extra-anatomic repair would be less harmful than a standard approach for recoarctation. He underwent reoperation through a median sternotomy. Cardiopulmonary bypass (aortic and right atrial cannulation) was instituted with a left ventricular vent through the right superior pulmonary vein. With the heart beating, the posterior pericardium was opened. Because of the tortuosity of the aorta, this was found lying on the right side of the spine. To provide a good, constant exposure, a suction heart-lifting system (Starfish 2) was applied to the apex of the heart, which was retracted cephalad. The view of the operative field was excellent (Figure 2). The esophagus was retracted, and the aorta was surrounded with tapes and partially clamped. A 20-mm vascular graft (Hemashield Platinum; Boston Scientific Medi-tech, Wayne, NJ) was anastomosed to the descending aorta. After repositioning of the heart, the graft was routed around the left margin of the heart, anterior to the main pulmonary artery, and anastomosed to the ascending aorta. The patient was weaned from cardiopulmonary bypass and made an uneventful recovery. He is symptom free and normotensive, with low doses of β-blockers, 6 months after the procedure. Vijayanagar and colleagues1Vijayanagar R. Natarajan P. Eckstein P.F. Bognolo D.A. Toole J.C. Aortic valvular insufficiency and postductal aortic coarctation in the adult combined surgical management through median sternotomy—a new surgical approach.J Thorac Cardiovasc Surg. 1980; 79: 266-268PubMed Google Scholar reported a novel extra-anatomic surgical approach for repair of aortic coarctation through a median sternotomy. Procedures of bypass from the ascending aorta to the abdominal aorta2Wukasch D.C. Cooley D.A. Sandiford F.M. Nappi G. Reul Jr, G.J. Ascending aorta–abdominal aorta bypass indications, technique and report of 12 patients.Ann Thorac Surg. 1984; 37: 261-263Abstract Full Text PDF PubMed Scopus (35) Google Scholar and combined left thoracotomy and median sternotomy3Jacob T. Cobanoglu A. Starr A. Late results of ascending aorta–descending aorta bypass graft for recurrent coarctation of the aorta.J Thorac Cardiovasc Surg. 1998; 95: 782-787Google Scholar have also been described. However, the posterior pericardial approach limits the procedure to a single incision, and it is especially convenient when concomitant cardiac procedures must be performed. Favorable long-term results as late as 22 years have recently been reported.4Almeida de Oliveira S. Lisboa L.A. Dallan L.A. Abreu CA, F. Rochitte C.E. et al.Extraanatomic aortic bypass for repair of aortic arch coarctation via sternotomy. Midterm clinical and magnetic resonance imaging results.Ann Thorac Surg. 2003; 76: 1962-1966Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar In our case, we chose this approach because the patient had mild impairment of the left ventricular function, which precluded total aortic clamping proximal to the coarctation. We believed that cardiopulmonary bypass with a vented, beating heart would be the less deleterious of the available procedures. Operating on the recoarctation area could have been hazardous; we have previously encountered severe calcification of the distal aortic arch and left subclavian artery when repairing an aortic coarctation in patients older than 50 years.5Aris A. Subirana M.T. Ferres P. Torner-Soler M. Repair of aortic coarctation in patients more than 50 years of age.Ann Thorac Surg. 1999; 67: 1376-1379Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Most groups favor positioning the graft in the right side of the pericardium, either posterior or anterior to the inferior vena cava. In our case, however, the aorta was extremely displaced to the right, and directing the graft toward that side would have resulted in a position prone to kinking. The use of a suction heart-lifting device provided an excellent exposure with steady retraction of the heart without damaging it, avoiding crowding of the operative field with the hand of an assistant during the distal anastomosis. It is possible that with the aid of this device the procedure can be performed off pump in selected cases. Drs Aris, Cobiella, Maestre, and Subirana (left to right)