Stefanou Protopapas Shore Rosendahl: Aneurysm of the Neo-Aortas

A PARADIGM IN CARDIOVASCULAR INTEGRATION

Aortic Surgery and surgery for Adult Congenital Heart Disease (ACHD) are evolving subspecialties of integrated thoracic and cardiovascular surgery.

Three decades of palliative surgery for Hypoplastic Heart has produced survivors with Fontan circulation.

Neo-aortas may dilate in early adulthood, reaching threshold for empirical prognostic re-do surgery.

Stefanou Protopapas Shore Rosendahl: Aneurysm of the Neo-Aortas

CASE REPORT 1

HISTORY AND PRESENTING FINDINGS:

40-year-old male, staged repair for pulmonary atresia and HLHS, neo-aortic root 6 centimetres, moderate

valvular regurgitation.

OPERATIVE FINDINGS AND PROCEDURE

• Neo-aorta adherent to the sternum, femoral arteries small and scarred.

• Bilateral carotid cannulation , 8 mm Dacron grafts,

• Left femoral vein outflow

• 19 degrees centigrade hypothermia Re -sternotomy , direct controlled entry to the neo-aorta,

exsanguination to reservoir and cerebral perfusion at 500 millilitres/ minute for 10 minutes,

• Modified Bentall , 27mm composite mechanical graft.

SURGICAL OUTCOME: full recovery to discharge.

Stefanou Protopapas Shore Rosendahl: Aneurysm of the Neo-Aortas

CASE REPORT 2

HISTORY AND PRESENTING FINDINGS:

34-year-old man , staged repair of TGA and pulmonary atresia, moderate to severe aortic

regurgitation and 5cm aneurysm of ascending neo-aorta and neo-aortic root, incomplete posterior

Willis' circle.

OPERATIVE FINDINGS AND PROCEDURE

• Again, neo-aorta adherent to the sternum, femoral arteries small and scarred.

• inflow CPB circuit with a right carotid 8 mm graft and left femoral artery.

• 24 degrees centigrade hypothermia

• re-sternotomy with proximal carotid snaring with again 500-millilitres/ minute flow.

• Right atrial ouflow

• modified Bentall , 27mm composite mechanical graft.

SURGICAL OUTCOME: full recovery to discharge.

Stefanou Protopapas Shore Rosendahl: Aneurysm of the Neo-Aortas

DISCUSSION

• Two Fontan patients from a tertiary specialised urban

cardiovascular center with on-site neonatal, GUCH and Aortic

surgical teams.

• Dual challenge of hostile mediastinum and groins.

• Anatomical variations taken into consideration when planning

CPB.

• Carotid cannulation for the inflow element of the CPB

circumnavigates issues related to access that might warrant

selective cerebral perfusion.

Stefanou Protopapas Shore Rosendahl: Aneurysm of the Neo-Aortas

CONCLUSION

• Personalised cannulation for cerebral and systemic perfusion in

ACHD patients with hostile mediastinum and groins.

• In both our successful cases so far, carotid cannulation via 8 mm

grafts ensured cerebral perfusion until the neo-aorta had been or

entered with reasonable control (Case 1) or dissected free (Case 2).

FUTHER RESEARCH

• What predisposes neo-aortas to dilatation?

QUESTIONS? Thank you