Spontaneous Aortic Thrombosis i6 a Neonate Presenting as Coarctation.pptx

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Spontaneous Aortic Thrombosis i6 a Neonate
Presenting as Coarctation

• By Dr. PATRICIA ANN PENKOSKE, M.D.

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• ABSTRACT Spontaneous aortic thrombosis in the
  neonate is a rare entity of uncertain etiology
  with a high mortality. To our knowledge, this is
  the first report of a newborn surviving surgical
  treatment of spontaneous thrombosis of the
  thoracic aorta.
• Aortic thrombosis in neonates is rare and usually
  related to umbilical artery catheterization.
  Spontaneous aortic thrombosis in a neonate has
  been described 14. The location is more
  commonly abdominal than thoracic. Management has
  been varied and usually unsuccessful. Spontaneous
  thrombosis of the thoracic aorta has been lethal
  in the cases reported 4, 51. We report the case
  of a newborn with spontaneous thrombosis of the
  thoracic aorta who was treated surgically and
  survived.

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• This 2,810-gm, 38-week-gestation male infant was
  born to a 33-year-old gravida I1 para I mother.
  Prenatal history was normal until the day of
  delivery when she was seen with absent fetal
  movements. Emergency cesarean section was
  performed. The infant had marked respiratory
  depression, with Apgar scores of 4 and 8, and
  required resuscitation.

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• The skin appeared mottled but pink. Heart rate
  was 130 beats min, respiratory rate was 64/min,
  and blood pressures were 106194 mm Hg in the
  right arm, 84/66 mm Hg in the left arm, 36/25 mm
  Hg in the right leg, and 48/31 mm Hg in the left
  leg. Precordial impulse was increased, and the
  liver edge was 3 cm below the right costal
  margin. The left femoral pulse was palpable but
  decreased. The right femoral pulse was not
  palpable. A Grade 216 systolic ejection murmur
  was audible at the heart base. Umbilical arterial
  catheterization had not been performed. Arterial
  blood gases were pH 7.27, carbon dioxide tension
  was 48.5 mm Hg, oxygen tension was 37 mm Hg, and
  hematocrit was 66.5. Chest radiograph showed
  moderate cardiomegaly and mild pulmonary
  plethora.

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• Two-dimensional echocardiography demonstrated a
  structurally normal heart but the almost complete
  narrowing of the aorta just above the level of a
  persistent ductus arteriosus. Left ventricular
  contractility was markedly reduced, with a
  shortening fraction of 0.13 (normal, 0.2tL0.50).
  An infusion of prostaglandin El, 0.05 mg/kg/min
  was started. Cardiac catheterization was
  performed. Left ventricular pressure was 86/12 mm
  Hg, and the descending aortic pressure was 32/26
  mm Hg. Figure 1 shows the posteroanterior view of
  the aortic arch from the left ventricular
  angiogram. There was the obstruction in the right
  subclavian artery at the level of its exit from
  the thorax and a severe stenosis of the left the
  subclavian artery with a thrombus within this
  vessel. The lateral view (Fig 2) demonstrated an
  obstruction to flow distal to the left subclavian
  artery.

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• In the operating room, the aortic arch was
  visualized through a left-sided thoracotomy. The
  aorta was opened and an organized, partially
  adherent thrombus was removed. The thrombus
  originated just distal to the left carotid artery
  and sent a tail into the left subclavian artery,
  which was hypoplastic. The ductus arteriosus was
  patent, with no thrombus in its lumen. There was
  no visible external coarctation or posterior
  shelf internally. The aorta was closed with a
  Gore-Tex patch to prevent narrowing from surgical
  scamng at the incision line. Pathological study
  demonstrated a clot measuring 6 x 5 x 4 mm that
  consisted of fibrin and foci of calcification.

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• The platelet count fell gradually to 34,000/1 on
  the fourth postoperative day but then returned to
  normal. Prothrombin time was 13.1 to 13.5 seconds
  (normal, 1S30 seconds). Partial thromboplastin
  time was 45 seconds on the second postoperative
  day (normal, 46-65 seconds). Protein C and
  antithrombin I11 levels were below normal
  protein C was 0.45 units (normal, 0.63-1.27
  units) and antithrombin I11 was 0.47 units
  (normal, 0.75-1.25 units).
• Postoperatively, the left femoral pulse was
  normal. Signs of congestive heart failure
  resolved quickly. The right femoral pulse did not
  return, and an ischemic area developed on the tip
  of the right small toe. The rest of the limb was
  pink and well perfused. The right arm was
  intermittently cyanosed, and the pulse was
  absent. Heart size returned to normal by the
  fifth postoperative day. The infant has been
  followed up for six months and is developing
  normally and is receiving no medications.

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