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Distal aortic pressure during coarctation operation
K G Watterson1, J P Dhasmana, J W O'Higgins
1Department of Cardiac Surgery, Bristol Royal Hospital for Sick Children, England.
Insights
Continuous monitoring of distal aortic pressure (DAP) during coarctation of the aorta repair in children helped surgeons adjust clamps and medications. This improved DAP, reducing the need for hypotensive agents and supporting better surgical outcomes.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Anesthesiology
Background:
- Coarctation of the aorta repair requires careful hemodynamic management.
- Distal aortic pressure (DAP) is a critical indicator of distal perfusion during aortic cross-clamping.
- Optimizing DAP is essential for preventing intraoperative complications in pediatric aortic surgery.
Purpose of the Study:
- To evaluate the impact of continuous distal aortic pressure (DAP) monitoring on surgical management during coarctation of the aorta repair in children.
- To assess the effectiveness of clamp adjustments and hypotensive agent use in achieving adequate DAP.
- To determine if DAP monitoring guides necessary intraoperative interventions.
Main Methods:
- Continuous monitoring of mean distal aortic pressure (DAP) in 67 children undergoing coarctation of the aorta repair.
- Establishing an adequate DAP threshold of 45 mm Hg for proceeding with the operation.
- Implementing adjustments to proximal/distal clamp positions and hypotensive agents when DAP was below the threshold.
Main Results:
- In 25 patients with initial DAP < 45 mm Hg, adjustments increased DAP to 50.6 mm Hg (p < 0.001).
- Adjustments led to increased left subclavian artery patency (60% vs 28%, p < 0.02) and reduced intercostal artery clamping.
- Continuous DAP monitoring identified the need for clamp/medication adjustments, improving distal perfusion and reducing hypotensive agent use.
Conclusions:
- Continuous DAP monitoring is a valuable tool for guiding operative management during coarctation of the aorta repair.
- Adjusting clamp positions and minimizing hypotensive agents can effectively improve DAP.
- Achieving and maintaining adequate DAP is crucial for successful surgical outcomes in pediatric aortic arch reconstruction.
Abstract:
Mean distal aortic pressure (DAP) was monitored continuously during operative repair of coarctation of the aorta in 67 children more than 1 year of age between 1982 and 1987. At initial test clamping a DAP of 45 mm Hg or more was considered adequate. In 42 patients (group A), DAP exceeded 45 mm Hg and the operation proceeded. In 25 patients (group B) the DAP was less than 45 mm Hg, and adjustments were made to the position of the proximal and distal clamps and in the use of hypotensive agents. After these adjustments in group B, DAP rose from 34.7 to 50.6 mm Hg (p less than 0.001), achieving the desired level in all but 5 patients, who required temporary shunts to support the distal circulation. The adjustments were as follows: the left subclavian artery was open in 28% of patients before and 60% after (p less than 0.02); no more than one pair of intercostal arteries was clamped in 64% before and 88% after (p less than 0.05); and no hypotensive agents were used in 56% before and 80% after (p = 0.07). During the first ten minutes of cross-clamping the DAP rose by 5.5 mm Hg (p less than 0.01, n = 52). It is concluded that continuous monitoring of DAP contributed to the operative management of these patients by indicating when adjustments in the position of the clamps or in the use of hypotensive agents were needed. The use of hypotensive agents should be reduced to achieve a higher DAP.