Transesophageal echocardiography and intraoperative phlebotomy during surgical repair of coarctation of aorta in a patient with atrial septal defect, moderately severe mitral regurgitation and severe pulmonary hypertension

  • Praveen Kumar Neema
  • Subrata K. Singha
  • S. Manikandan
  • Ramesh Chandra Rathod


Acute left ventricular (LV) or right ventricular (RV) dysfunction during repair of coarctation of aorta (CoA) is rare. Well-developed collateral circulation between branches of both the subclavian arteries (SCAs) and upper descending thoracic aorta decompress LV and prevents acute rise in afterload. An adult patient presented for CoA repair. On chest X-ray, rib notching was not seen. Magnetic Resonance Imaging showed about 7 mm long CoA distal to the origin of left common carotid artery. Reconstruction images of distal arch and descending thoracic aorta showed origin of both the SCAs from CoA segment. Transthoracic echocardiography showed 1.3 cm atrial septal defect (ASD), left to right shunt, moderately severe mitral regurgitation (MR), dilated RV, and severe pulmonary artery hypertension (PH). During cardiac catheterization, the peak gradient across CoA was 60 mmHg. On aortic-root angiography, both the common carotids and the distal arch opacified simultaneously, the CoA segment and the distal aorta opacified a little later. Both the SCAs were filling retrograde. A unique anatomy in which aortic-clamping proximal to CoA and both the SCAs would increase flow to spinal-cord as clamping of the SCAs will stop stealing of blood into the CoA but potentially increase LV afterload, MR, left to right shunt across ASD and RV volume and pressure load depending on the magnitude of flow across the CoA. The increases in LV afterload, MR, and RV afterload and volume overload were managed by controlled phlebotomy and fine-tuned by manipulating inhaled isoflurane concentration whereas the Transesophageal echocardiography (TEE) monitored and guided the management.


Coarctation of Aorta Transesophageal echocardiography Aortic clamping Phlebotomy 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Kirklin JW, Barratt-Boyes BG. Coarctation of aorta and interrupted aortic arch. In: Kirklin JW, Barratt- Boyes BG, editors. Cardiac surgery, vol. 2. New York: Churchill Livingstone; 2003. pp. 1315–75.Google Scholar
  2. 2.
    Waltham M, Agrawal V, Bowman L, Hughes C, White GH. Right arm ischemia following intentional stent-graft coverage of an anomalous right subclavian artery. J Endovasc Ther. 2005;12:110–4.PubMedCrossRefGoogle Scholar
  3. 3.
    Neema PK, Manikandan S, Bodhey N, Gupta A. Perioperative implications of retrograde flow in both the subclavian arteries in an adult undergoing surgical repair of coarctation of aorta. Interactive Cardio Vasc Thoracic Surg. 2011;12:316–8.CrossRefGoogle Scholar
  4. 4.
    Roizen MF, Beaupre PN, Alpert RA, Kremer P, Cahalan MK, Shiller N, et al. Monitoring with two-dimensional transesophageal echocardiography. Comparison of myocardial function in patients undergoing supraceliac, suprarenal-infraceliac, or infrarenal aortic occlusion. J Vasc Surg. 1984;2:300–5.Google Scholar
  5. 5.
    Gelman S. Venous function and central venous pressure. A physiologic story. Anesthesiology. 2008;108:735–48.PubMedCrossRefGoogle Scholar
  6. 6.
    Poli de Figueiredo LF, Mathru M, Tao W, Solanki D, Uchida T, et al. Hemodynamic effects of isovolemic hemodilution during descending thoracic aortic cross clamping and lower torso reperfusion. Surgery. 1997;122:132–8.CrossRefGoogle Scholar
  7. 7.
    Neema PK, Vijayakumar A, Manikandan S, Rathod RC. Infrarenal abdominal aortic aneurysm repair in presence of coronary artery disease: optimization of myocardial stress by controlled phlebotomy. Ann Card Anaesth. 2010;13:64–5.CrossRefGoogle Scholar
  8. 8.
    Gelman S. The pathophysiology of aortic cross-clamping and unclamping. Anesthesiology. 1995;82:1026–60.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Praveen Kumar Neema
    • 1
  • Subrata K. Singha
    • 2
  • S. Manikandan
    • 2
  • Ramesh Chandra Rathod
    • 2
  1. 1.Department of AnaesthesiologySree Chitra Tirunal Institute for Medical Sciences and TechnologyKumarapuram, TrivandrumIndia
  2. 2.Department of AnaesthesiologySree Chitra Tirunal Institute for Medical Sciences and TechnologyTrivandrumIndia

Personalised recommendations