J Thorac Cardiovasc Surg 2006;132:969-970
© 2006 The American Association for Thoracic Surgery
Challenges in early cardiothoracic surgery: Aortic homograft transplantation in coarctation, a 44-year follow-up
R. von Wattenwyl, MD*,
M.T.R. Grapow, MD,
D.C. Reineke, MD,
H.-R. Zerkowski, MD
Division of Cardio-Thoracic Surgery, University Hospital, Basel, Switzerland.
Received for publication March 16, 2006; accepted for publication April 10, 2006.
* Address for reprints: R. von Wattenwyl, MD, Division of Cardio-Thoracic Surgery, University Hospital Basel, Spitalstrasse 21, CH-4031 Basel, Switzerland. (Email: vonwattenwylr{at}uhbs.ch).
We present the case of a woman now 72 years old whom we were surprised to find up and healthy in our outpatient clinic.
Clinical Summary
In 2001, a 68-year-old patient came in for a routine checkup in our outpatient clinic. In 1957, she had undergone an operative correction of a coarctation of the aorta. This operation was performed by Rudolph Nissen (1896-1981), who was at the time professor of surgery at the University of Basel. While still in school, the patient had hypertension and cardiomegaly diagnosed during routine physical examinations. Years later, excessive hypertension with systolic pressures as great as 200 mm Hg forced the family practitioner to initiate medical treatment. Further investigation revealed coarctation of the aorta (Figure 1). Surgical correction seemed the only therapeutic option to avoid further damage to the heart.
Operative Technique and Findings
Because of severe calcification and anatomic particulars, the intervention proved to be extremely difficult. Classic repair forms—such as bridging the defect with subclavian artery, plastic methods in which the left subclavian artery is of inadequate diameter (as described by Johnson and colleagues1
), resection of the coarcted part and end-to-end anastomosis—were impossible. Confronted with these unexpected circumstances, Nissen had to abort the operation. Nissen considered the interposition of an allograft. At that time, officially coordinated organ donor databases and artificial grafts were both nonexistent. These special circumstances made it necessary to seek actively for a donor. In the meantime, the patient was treated conservatively.
After a donor aorta was found 2 months later, it was finally possible to replace the coarctated part of the aorta (Figure 2, A, p. 970). There were no intraoperative or perioperative complications, and the patient was discharged after 5 weeks.
View larger version (61K):
[in this window]
[in a new window]
|
Figure 2. A, Original slide with Nissen's drawings showing technical procedure in general (right side of slide demonstrates situation in our patient). B, Computed tomographic scan, performed in 1992, shows calcification of replaced part of aorta. See also p. 969.
|
|
Follow-up
The patient in question was able to resume a normal life and later gave birth to a healthy son. Hypertension clearly improved, and with antihypertensive treatment an almost normal blood pressure was achieved. In 1994, the patient once again had to be hospitalized, for sepsis of unknown origin that was successfully treated with antibiotics. A computed tomographic scan of the aorta only showed heavily calcification, without any evidence for an infectious process (Figure 2, B). Routine check-ups since have been uneventful.2-5
References
- Johnson J, Kirby C, Hardy JD. Aneurysm formation in experimental vein grafts in the thoracic aorta. Surgery 1957;33:207-212.[Medline]
- Howard J. Historical vignettes of arterial repair: recollections of Korea 1951-1953. Ann Surg 1998;228:716-718.[Medline]
- Bailey CP. Coarctation of the aorta. In: Bailey CP, editor. Surgery of the heart. London: Henry Kimpton; 1955. pp. 134-179.
- Svensson LG, Crawford ES. Congenital abnormalities of the aorta in adults. In: Svensson LG, Crawford ES, editors. Cardiovascular and vascular disease of the aorta. Philadelphia: WB Saunders; 1997. pp. 153-174.
- Rodriguez JA. Coarctation of the aorta. In: Rodriguez JA, editor. An atlas of cardiac surgery. Philadelphia: WB Saunders; 1957. pp. 73-83.
