[HSF] ADULT Coarctation repair

[Prasanna Simha M]

I have done this but remember that this is the operation of second choice
for eg  a redo coarctation procedure.Basically the descending thoracic aorta
is approached by lifting the heart, exposing the oblique sinus. Using a DPRS
(Lima suture) high up in the oblique sinus , taking vertical SVC and IVC
release indcisions to allow the right pericardium to move laterally to allow
the heart to lux into the right space , tilting the table to the right all
help . The posterior pericardium can be incised over the area medial to the
IVC. Remember to have a thick Ryles tube or TEE probe in the esophagus as
you do not want to perforate that !!! An 18 mm Graft  works well. It is
actually better to pass it "behind the IVC" after looping the IVC to allow a
smooth lie.
You must remember to have a femoral and aortic arterial cannulae (bifid
3/8th 3/8th line). After the distal anastomosis, release the clamp and
ensure absolute hemostasis of this as it will be virtually impossible to see
the heel post CPB.An old wise trick is to have a small purse string of the
surrounding tissues brought around the anastomosis  and kept loose and ready
in case of troublesome inaccessible bleeding. It can be snared and tied down
to stop heel bleeding
After the distal anastomosis pass it behind the IC and then right side and
then anastomosis it to the lateral wall of the aorta.
I would like to reiterate that this is an operation for a second do as the
dP/dT will still remain high due to the nonexpansile conduit.
I would still prefer anend to end or modified Wauldahausen or combined
Wauldhausen + augmentation patch for adult coarcts. If there is severe LV
dysfunction rather than an ascending descending bypass a modified Blalock
Park type of anastomosis from the dilated left subclavian to the descending
aorta is simple and effective with a shorter conduit but again it must be
remembered that this an operation of second choice as the isthmic region
will be replaced by a nonexpansile conduit giving an unfavorable dP/dT. The
late Timothy Cartmill who was on this forum had quite a lot of opinions and
experience wrt this. I remember discussing with him this problem a few years
back.
Prasanna
On Jan 30, 2008 4:52 PM, M. Gordillo <mangordi at yahoo.com> wrote:

>
>
>  Talkiing about Coarctation in adults,  I saw some  months ago a video of
> an aortic bypass ascending/descending  under CPB,  lifting the apex and
> working through pericardial sac in descending aorta.
>
> Has anyone experience in this approach?  Tips and advices are welcome,
>  Thanks in advance
>
> Manuel Gordillo
>
>
>
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-- 
Prasanna Simha M