An unusual Case of Coarctation the Aorta and PDA

Case report: Patient M, 5 mo, female, was hospitalized for cardiac evaluation after bilateral pneumonia. ECHO showed marked
biventricular hypertrophy, CoAo gradient 45 mm Hg, PDA 3 mm, pulmonary hypertension. ECG suggested biventricular
hypertrophy. Cardiac cath: Asc Ao = 142/60 mmHg, RV = 110/10 mmHg, PA = 110/50 mmHg. Thoracotomy revealed CoAo
and PDA. During PDA ligation with simultaneous aortic clamping there was severe bradycardia and collapse, without signs of
ischemia on ECG. Inotropes were ineffective. Patient recovered with direct cardiac massage, declamping of the aorta and removal
of PDA ligature. Our interpretation was vagal stimulation. After stabilization, PDA ligation was repeated with resection of
coarctation with “end-to-end” anastomosis. Further temporary hemodynamic instability occurred during chest closure but was
stabilized, however 3 hours after surgery child suddenly developed refractory cardiac arrest.
Postmortem study: PDA ligated, anastomosis of the aorta “end-to-end”. A single coronary artery was
found on the front of the pulmonary trunk, divided into anterior and posterior descending branches and
circumflex branch. No coronaries were present from aorta. RV wall – 8 mm, left - 11 mm.
Discussion: We suppose, that ischemic symptoms of anomalous origin of coronary supply were not seen
in this case due to CoAo with PDA resulting in high PA pressure maintaining high coronary perfusion
pressure. After correction of CoAo and PDA, PA pressure fell and led to an acute fall in coronary
perfusion. Following postmortem we reviewed the preoperative cardiac catheterization, which clearly
showed the absence of coronary arteries from the aorta – not seen by our team focusing on the aortic arch
and ductus.

Department of Cardiac Surgery, International Children’s Heart Foundation

Institute of General and Urgent Surgery, Ukraine