Coarctation of Aorta.ppt

Coarctation of AortaSeoul National University Hospital Department of Thoracic male:female = 2:1CoA + VSD 11%, COA + other cardiac anomalies 7%* Complex CoA ; no sex difference2. Survival of pure CoA* 15% : CHF in neonate or infancy* 85% : survive late childhood without operation* 65% : survive 3rd decade of life (2% at 60 years) 3. Bacterial endocarditis : common in 1st 5 decades4. Aortic rupture : 2~3rd decade5. Intracranial lesion : subarachnoid hemorrhage(cong. Berry aneurysm)Collaterals in CoACoarctation of AortaØClinical features very common * Valvar heart disease* Heart failure at 30 years of age4. Associated syndrome* Turner syndrome (XO) : 2% * Von Recklinghausen’s D * Noonan’s syndrome or congenital rubellaCoarctation of AortaØIndications for operation1. Reduction of luminal diameter greaterthan 50% at any age2. Upper body hypertension over 150mmHgin young infant ( not in heart failure )3. CoA with congestive heart failure at any age Coarctation of AortaØTechniques of operation1. Subclavian flap aortoplasty Neonate, infant and child up to 10 years2. End-to-end anastomosisPreferred in any age group* Extended end-to-end anastomosis * Radically extended end-to-end anastomosis3. Patch angioplasty or graft replacementPrevention of RecoarctationØIdeal operative procedure • Successfully address transverse arch hypoplasia (if present), • Resection of all ductal tissue, and • Prevention of residual circumferential scarring at the aortic anastomotic sit. ØFactors • Younger age at operation • Presence of aortic arch hypoplasia remain risk factors for recoarctation Regional Cerebral PerfusionØTechnique • We begin full-flow CPB at a calculated baseline of 150 mL · kg–1 · min–1 and, after snare placement on the proximal brachiocephalic vessels, initiate RLFP by reducing pump flow to 50% of baseline. • We make further adjustments such that baseline cerebral blood flow velocity as measured by transcranial Doppler and cerebral oximetrics as measured by NIRS are optimally maintained. • RLFP provides consistent cerebral circulatory support and that this support is bilateral, despite being applied to the inominate artery. Pediatric Cardiac SurgeryØNeurologic complications • Incidence of 2.3% for overt clinical presentation & up to 60% when sensitive magnetic resonance imaging is applied in heart surgery of infants & children. • In control of the arch proximal to the left carotid artery, during COA surgery, this assumes that collateral blood flow and completeness of the circle of Willis allows for a favorable and even distribution of cerebral blood flow. • But patients undergoing coarctation repair, proximal occlusion of the aortic arch results in transient but significant impairment in contralateral cerebral oxygen balanceBlood Supply to Spinal CordThe most important blood supply to spinal cord comes from spinal artery, a minor supply is from Adamkiewicz arteryCoA ExposureCoALSCA flapCoA Patch AugmentationCoA Subclavian Artery FlapCoA End-to-End AnastomosisCoA Extended end-to-end AnastomosisCoactationCoactation of Aorta of AortaResection and Resection and AnastomosisAnastomosisCoactationCoactation of Aorta of Aorta Resection & Extended end-to-end Resection & Extended end-to-end AnastomosisAnastomosisCoarctationCoarctation of Aorta of AortaEnd-to-Side End-to-Side AnastomosisAnastomosisCoarctationCoarctation of Aorta of Aorta Enlargement of VSD, Resection of VSD, Resection of ConalConal Septum SeptumCoA + VSD, One-stage RepairCoA + VSD, One-stage RepairCoarctationCoarctation of Aorta of AortaEnd-to-Side End-to-Side AnastomosisAnastomosisOpening of Resected SegmentCoactation of AortaCoactation of AortaØOperative results • Hospital mortalityCauses of early death areacute and chronic cardiac failure or severe pulmonary insufficiency • Incremental risk factor for death1) Older age2) Hypoplastic left heart class3) Techniques of operationCoactation of AortaCoactation of Aorta ØOperative results • Mobidity1) Paraplegia (0.2 ~ 1.5%)2) Hypertension and abdominal pain3) Persistent or recurrent coarctation- more than 20mmHg - high incidence in young 4) Upper body hypertension without resting gradient- increased vascular activity in the forearm- age at operation is risk factor 5) Late aneurysm formation- higher in onlay patch technique6) Valvular disease7) Congestive heart failure with hypertension8) Bacterial endocarditis Coactation of AortaCoactation of AortaØSpecial features of postoperative care1. Systemic arterial hypertensionUsually, but infant or young child doesn’t need to be treated.2. Abdominal painUsually mild abdominal discomfort for a few days,and prominent in 5 - 10%.Control hypertension, nasogastric decompression, IV maintain3. Chylothorax 5%Coactation of Aorta Coactation of Aorta RepairØPostoperative hypertension• SealyAltered baroreceptor response with increase。