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(Circulation. 2001;104:I-133.)
© 2001 American Heart Association, Inc.

Surgery for Congenital Heart Disease

Posterior Pericardial Ascending-to-Descending Aortic Bypass

An Alternative Surgical Approach for Complex Coarctation of the Aorta

Heidi M. Connolly, MD; Hartzell V. Schaff, MD; Uzi Izhar, MD; Joseph A. Dearani, MD; Carole A. Warnes, MD; Thomas A. Orszulak, MD

From the Division of Cardiovascular Diseases (H.M.C., C.A.W.) and the Division of Cardiovascular Surgery (H.V.S., U.I., J.A.D., T.A.O.), Mayo Clinic, Rochester, Minn. Dr Izhar is now at Hebrew University Hadassah Medical Center, Jerusalem, Israel.

Reprint requests to Dr Heidi M. Connolly, Division of Cardiovascular Diseases, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail connolly.heidi{at}mayo.edu

Background— Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.

Methods and Results— Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43±13 years) with coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous cardiovascular operations had been performed in 12 patients (67%); 10 patients had 1 prior coarctation repair. Two patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%) included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure, and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery.

Conclusions— CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.

Key Words: heart defects, congenital • coarctation • bypass • aorta • surgery