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.