Does posterolateral thoracotomy with cardiopulmonary bypass play a role in the surgical management of aortic coarctation?

Objectives: The aim of this study was to evaluate the surgical treatment of aortic coarctation (CoA) using cardiopulmonary bypass (CPB) and posterolateral thoracotomy.

Methods: Between 1997 and 2011, 26 patients underwent surgical repair of CoA through a left thoracotomy utilizing CPB. CPB cannulation was performed at aorta descendens distal from the coarctation site and the main pulmonary artery for venous return (“beating heart technique”). The clinical outcome regarding the development of restenosis, major neurologic complication as well as spinal deformities was studied.

Results: Patients' median age was 15 years (range 10 days to 70 years) at surgery. Primary surgery was performed in 12 patients. 14 patients received reoperation due to re-coarctation or development of aneurysma. Mean duration of CPB was 139 minutes. The repair was performed either by direct anastomosis (n=5) or by graft replacement (n=21). One patient who was operated in cardiogenic shock died. One patient acquired rethoracotomy for hemorrhagic control. At a mean follow-up of 3 years (range from 7 days to 12 years), one patient developed a recurrent stenosis at the CoA repair site. In the remaining 25 patients, echocardiography and MRI showed a widely patent anastomosis with no evidence of a hemodynamically significant gradient. None of the patients developed paraplegia, 3 patients demonstrated left diaphragmatic paresis and 3 patients developed left recurrent nerve palsy. One patient obtained generalizes seizure without pathologic correlate in cranial CT. Physical examination, together with evaluation of X-rays noted one patient with marked scoliosis. One patient developed chylothorax, which was successfully treated with medium-chain triglycerides diet. One patient remained with persistent arterial hypertension.

Conclusions: CoA without hypoplasia of the proximal aortic arch and intracardiac anomalies can be repaired with low mortality and morbidity via a left thoracotomy with CPB. The use of CPB prevents spinal cord and lower body ischemia. It provides a sufficient amount of time for the anastomosis, which allows a better anastomotic quality. In addition, CPB offers a possibility to carry out hypothermic circulatory arrest in management of difficult anatomy and collateral blood flow.