Extraanatomic thoracic aortic bypass grafts: indications, techniques, and results

OBJECTIVE

Even in the age of extensive aortic replacement special circumstances may warrant the insertion of extraanatomic thoracic aortic bypass grafts. Our experience with 17 patients is analyzed.

METHODS

Between 1988 and 1994, ten female and seven male patients (mean age 37.5 years, range 9-69 years) were treated for the following indications: (1) complex CoA (n = 5); (2) reoperation for CoA (n = 6); (3) extensive aortic occlusive disease (n = 4); and (4) complicated aneurysm (n = 2). Routing of the grafts was: ascending-descending aorta (8); ascending-abdominal aorta (4); left subdavian artery- descending aorta (2); descending-descending aorta (2); and descending-abdominal aorta (1). Eight procedures were reoperations. In four patients concomitant cardiac operations were performed: one aortic valve replacement, one patch plasty of the LCA, and two composite graft replacements of aortic valve and ascending aorta, one of them with CABG.

RESULTS

Three early deaths occurred. two after emergency operation in thoracic aneurysm under dire conditions (one perforation, one infection), one after ascending-abdominal aortic grafting with multiple branch revascularization. The underlying pathology was relieved successfully in all 14 survivors. In the two patients with concomitant aortic valve and isthmic stenosis, critical anterior motion of the mitral valve, presumably because of the massive afterload reduction of the left ventricle, complicated the perioperative course. One patient was reoperated because of aneurysm 4 years after descending-descending aortic grafting for complex CoA with poststenotic dilatation.

CONCLUSIONS

In complex aortic coarctation or hypoplasia extraanatomic bypass grafts are expedient and effective procedures, especially for reoperation. Their use in the treatment of aneurysmal lesions remains an exception.

Impact of re-coarctation following the Norwood operation on survival in the balloon angioplasty era

OBJECTIVES

The objective of this study was to determine the efficacy of balloon angioplasty (BA) by comparing the immediate and long-term outcomes of patients with and without re-coarctation after a Norwood procedure.

BACKGROUND

Although BA has become the standard means for treating recurrent coarctation following a Norwood operation, it has been suggested that re-coarctation remains a significant cause of morbidity and mortality.

METHODS

Patients who survived a Norwood operation from December 1986 through June 2001 were studied. Differences between groups were evaluated by t test and logistic regression. Survival differences were tested by log-rank tests using Kaplan-Meier survival curves.

RESULTS

Fifty-eight of 633 patients underwent treatment for re-coarctation (9.2%). Thirty-five patients underwent BA (before 1988, 23 had surgery). Median age at catheterization was 6.6 months (1.9 to 35.6 months). Balloon angioplasty was successful (gradient <10 mm Hg) in 32 of 35 patients (92%). There were no BA-related deaths or neurologic complications. Recurrent obstruction after BA occurred in seven patients (20%); five underwent re-dilation. Kaplan-Meier estimates of freedom from recurrent obstruction after initial BA were 97% at one month, 79% at one year, and 79% at five years. There were no differences in survival between patients with re-coarctation treated by BA and patients who did not undergo treatment for re-coarctation.

CONCLUSIONS

We found that 9.2% of patients underwent treatment for re-coarctation following a Norwood operation. Balloon angioplasty is effective, with low morbidity, no early mortality, and no difference in long-term survival when compared with patients who did not have re-coarctation. Recurrent coarctation following BA occurred in 17% of patients, usually within the first year after BA.

Operative survival and 40 year follow up of surgical repair of aortic coarctation

OBJECTIVE

To study early and late mortality after surgical correction of coarctation of the aorta.

DESIGN

Data on 223 patients operated on at the Westminster Hospital, London, between 1946 and 1981, were collected and updated by questionnaire.

PARTICIPANTS

All 223 patients recorded as undergoing operation for aortic coarctation up to the end of 1981. Fifteen of 197 survivors were lost to follow up; most of them were patients from overseas.

OUTCOME AND RESULTS

The early mortality (within one month of operation) was 12% overall, 2.6% for elective surgery, and 0% for the 77 patients undergoing surgery since 1968. Survivors were followed up for a total of 3288 patient years; in 27 follow up lasted more than 30 years. In a few it reached 40 years. Twenty two patients died during this period, 18 from causes that could be attributed to coarctation or its repair. Mortality was highest more than 20 years after the operation.

CONCLUSION

Repair increased life expectancy in patients with aortic coarctation. Late problems caused by persistent hypertension or recoarctation became apparent in long term survivors. The increased risk of late mortality associated with the duration of preoperative hypertension was not statistically significant. There were no deaths from cerebrovascular accidents. (In an earlier necropsy series cerebrovascular accidents accounted for 11.8% of deaths.) The incidence of deaths from aneurysms resembled that in the earlier necropsy series.

Repair of aortic coarctation in the first three months of life: immediate and long-term results

The optimum surgical procedure for treatment of coarctation of the aorta in the neonatal period remains controversial. To assess immediate and long-term results of using primarily the subclavian flap angioplasty procedure (SFA), we reviewed our initial 5-year experience. The average follow-up was 6 years. From 1977 to 1981, 25 infants under 3 months of age (1 to 86 days, mean 21) required emergency surgery for repair of coarctation of the aorta. Three groups of patients were identified. Group I consisted of 10 patients with or without patent ductus arteriosus. In group II, 10 patients had coarctation association with one or multiple ventricular septal defects (VSDs) without other congenital defects. In group III, 5 patients had coarctation associated with more complex congenital heart lesions. Twenty-three SFAs and two patch aortoplasties were performed. No patient with isolated VSD was banded. All patients except one in group III with an associated atrioventricular canal survived initial hospitalizations. Four late deaths occurred, all in patients with associated complex heart defects. There were three recurrent coarctations requiring surgery or balloon angioplasty (12%)--one in each group, with a total rate of 0.77 recurrences per 100 patient-months. SFA for coarctation in the neonatal period is a safe and effective operation with a low initial mortality (4%, 0-19%, 70% confidence limits) well tolerated in this group of ill patients. Long-term outcome is primarily related to the presence of associated complex congenital defects. Infants with VSD associated with coarctation did not require pulmonary artery banding unless primary intracardiac repair was not feasible.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of aortic coarctation in the first year of life

Twenty-five infants under 1 year of age (mean, 10.3 weeks and 4.0 kg) underwent coarctation repair. Eight had ventricular septal defect (VSD), 3 had transposition of the great arteries with VSD, and 5 had severe tubular hypoplasia. One infant required mitral valve replacement, and 1 required repair of total anomalous pulmonary venous return. Fifteen had repair by primary anastomosis. Seven underwent Dacron or subclavian aortoplasty; the advantages and technique of angioplasty are reviewed. Three patients required bypass grafts. Seventeen patients survived operation. All 5 patients who had severe tubular hypoplasia died postoperatively. The mortality for repair of coarctation with VSD by simultaneous pulmonary artery banding was high; for coarctation with VSD we currently recommend repair without banding, followed by VSD closure if indicated. Three infants have been treated successfully in this manner, with early VSD closure in 1 and regression of the VSD during follow-up in 2. The 17 survivors have been followed for a mean of 41 months with 3 late deaths. Of the 17 survivors, all of whom had a primary anastomosis, 3 have residual gradients. Of the 11 survivors who had preoperative hypertension, 6 are still hypertensive; 3 of these have a gradient between the upper and lower extremities. It is striking that 3 have persistent hypertension despite repair under the age of 1 year.

Abnormal responses for blood pressure in children and adults with surgically corrected aortic coarctation

BACKGROUND

Despite successful surgical repair of aortic coarctation, life expectancy is reduced, and up to one-third of patients remain or become hypertensive. So as to characterize the responses for blood pressure, we have studied 55 patients with surgically repaired coarctation. Their mean age was 11.3 +/- 5.97 years. We documented maximal uptake of oxygen, anaerobic threshold, plasma renin activity and blood pressures during a Bruce protocol treadmill test. The velocity across the site of repair as imaged by cross-sectional echocardiography was measured before and after exercise. We measured the changes in heart rate and blood pressure subsequent to an infusion of 1 ug per kg of isoprenalin, monitoring blood pressure over 24 hours in all patients.

RESULTS

When compared with 40 healthy age-matched controls, the patients with coarctation had a normal exercise capacity. Resting systolic blood pressures above the 95th percentile were present in 45% of the patients. Exercise-induced hypertension, and an elevation in the average systolic 24 hour blood pressures, were observed, but less frequently than elevated baseline values, suggesting that so-called white-coat" hypertension may be present in this population. Abnormal reactions and elevation of plasma renin activity were related to a history of paradoxical hypertension at the time of surgery. Attenuation of the circadian rhythm for blood pressure was a frequent finding, and may have implications in the development of long-term damage to end-organs. A high correlation was found between mean systolic blood pressure measured by 24 hour monitoring and left ventricular hypertrophy (r=0.65, p<0.05).

CONCLUSIONS

Abnormalities in blood pressure occurred independently of significant mechanical obstruction. Despite successful surgical repair, abnormalities in the shape of the aortic arch, reduced sensitivity of baroreceptor reflexes, and neurohumoral factors may all contribute to the development of hypertension.

Late aneurysms after patch aortoplasty for coarctation of the aorta in adults

Sixty-eight patch aortoplasties were performed for coarctation of the aorta (CoA) in adult patients from 1967 to 1978 in our hospital. The mortality was 1.5% and the immediate result of the surgical repair seemed good. Long-term follow-up of 2 to 14 years later revealed aneurysm formation at the repair area in 27% of the 62 patients for whom sufficient follow-up data are available. Two aneurysms had ruptured with a fatal outcome. Other repair methods used for coarctation in 106 patients were free from aneurysm complication. Thirteen patients with an aneurysm underwent reoperation without mortality. The etiology of these unexpected aneurysms is discussed.

Surgical versus balloon therapy for aortic coarctation in infants < or = 3 months old

OBJECTIVES

This study compared the efficacy and safety of balloon angioplasty with surgical correction of native aortic coarctation in infants < or = 3 months old.

BACKGROUND

There is a controversy with regard to the role of balloon angioplasty in the treatment of aortic coarctation, especially in young infants.

METHODS

Data from 29 infants < or = 3 months old undergoing therapy for aortic coarctation during the decade ending 1992 were analyzed. Fourteen infants underwent surgery, and 15 had balloon angioplasty. The sole criterion for allotment to the balloon group was the availability of an interventional cardiologist at the time of presentation of the infant.

RESULTS

The surgical and balloon groups were comparable (p > 0.1) with regard to age (27 +/- 35 [mean +/- SD] vs. 29 +/- 27 days), weight (3.5 +/- 0.9 vs. 3.8 +/- 1.0 kg) and prevalence (7 of 14 vs. 8 of 15) and type of associated defects. Operative (1 of 14 vs. 1 of 15) and late (3 of 13 vs. 3 of 14) mortality, immediate gradient relief (36 +/- 25 to 10 +/- 9 mm Hg vs. 41 +/- 14 to 6 +/- 6 mm Hg) and follow-up gradient (27 +/- 27 vs. 24 +/- 19 mm Hg) were similar (p > 0.1). Infants with a gradient > 20 mm Hg at follow-up (6 of 13 vs. 7 of 14) and need for reintervention (6 of 13 vs. 7 of 14) were also similar (p > 0.1) in both groups. Duration of hospital stay during the first intervention was higher (p < 0.05) in the surgical (32 +/- 37 days) than the balloon (7 +/- 6 days) group. Similarly, duration of endotracheal intubation and mechanical ventilation was longer (p < 0.05) in the surgical (12 +/- 16 days) than the balloon (2 +/- 3 days) group. Complications after surgical intervention (0.86 events/patient) were higher (p < 0.01) than those seen after balloon angioplasty (0.27 events/patient). However, the lack of significant differences observed for mortality rates and residual gradients may be due to low statistical power to detect differences (16% to 49%), implying that this may be due to either actual lack of statistical difference or small sample size.

CONCLUSIONS

The data indicate that the degree of relief from aortic coarctation and the frequency with which reintervention is needed are similar in both groups. However, the morbidity and complication rates are lower with balloon than with surgical therapy. These data suggest that balloon angioplasty may be an acceptable alternative to surgical correction in the treatment of symptomatic aortic coarctation in infants < or = 3 months old.

Coarctation of the aorta in infants: which operation?

In this series, 178 infants (age, less than or equal to 3 months old) underwent repair of aortic coarctation. Pure coarctation was present in 63 patients (Group 1), 47 infants had additional ventricular septal defects (Group 2), and 68 patients had associated complex heart disease (Group 3). Subclavian flap angioplasty was used in 26 patients, limited resection and end-to-end anastomosis in 45 patients, extended resection and end-to-end anastomosis in 99 patients, and miscellaneous procedures in 8 infants. The early mortality was 8% for the first group, 11% for the second group, and 37% for the third group (p less than 0.001). Mean follow-up was 32 months and included 97% of patients. Actuarial survival at five years was 90% for the first group, 84% for the second group, and 40% for the third group. Recoarctation occurred in 15 operative survivors (11%); 7 necessitated reoperation. Freedom from recoarctation at five years was 89% after subclavian flap angioplasty, 81% after end-to-end anastomosis, and 86% following extended resection and end-to-end anastomosis. Early mortality and late results were not influenced by the type of coarctation repair but were determined by the clinical status and the presence of associated major cardiac anomalies. These results suggest that the surgical procedure should be individualized for each infant to optimize the aortic anatomy.

Repair of coarctation of the aorta in infancy: comparison of surgical and balloon angioplasty

Surgical repair of coarctation of the aorta in infancy has recently been challenged by some investigators who suggest that balloon angioplasty results in a lower mortality rate and similar risk of restenosis. Over a 44-month period, 37 consecutive infants with a mean age of 33 days (median, 15 days; range, 1 to 200 days) and mean and median weight of 3.7 kg (range, 2.4 to 5.4 kg) underwent surgical repair of coarctation of the aorta with either an end-to-end anastomosis (24 patients) or subclavian flap angioplasty (13 patients). There were no operative deaths (95% confidence interval, 0% to 10%). Four patients died late (> 30 days) after surgery (11%). Four patients (11%) (95% confidence interval, 3% to 25%) had residual gradients greater than 20 mm Hg. A review of the recent literature on treatment of native coarctation in infants with surgical repair (18 reports, 1189 patients) and balloon angioplasty (8 reports, 57 patients) reveals a similar early mortality rate but a much higher rate of recoarctation in infants who were treated with balloon dilation (57%) as compared with those who underwent surgical repair (14%). Because of the incidence of restenosis, balloon dilation as compared with surgical repair does not yet offer an improved outcome for native coarctation of the aorta in infancy.

Considerations in the surgical management of infantile coarctation of aorta

The results of a recent 5 year experience with resection of coarctation of the aorta in infants less than 1 year of age are compared with those of an earlier series from the same institution. The significant improvement in mortality and morbidity statistics is attributed to modifications in operative and postoperative care. Operative mortality has decreased from 38 to 17 percent and the incidence rate of significant restenosis has diminished from 60 to 33 percent. It is suggested that in patients with large associated intracardiac shunt banding of the main pulmonary artery should be performed before resection of the coarctation. Three of five patients have survived procedures performed in this sequence. Microsurgical techniques and careful approximation of the aortic lumen with interrupted sutures are the major factors responsible for the reduced incidence of recoarctation. Prolonged ventilatory support postoperatively with the occasional addition of controlled positive airway pressure and continued aggressive medical therapy for heart failure are recommended.

Children with congenital heart disease: probability of natural survival

The age distribution of death in all children with congenital heart disease (CHD), who died in a 27-year period in Central Bohemia (population of 1.2 million), and the data on the incidence of CHD in children born in Bohemia (population of 6.3 million) in 1980 were used to calculate the probability of survival of a child born with CHD. Eighty-six percent of these children survived to the first month of life--mostly those with pulmonary stenosis (PS, 99%), aortic stenosis (AS, 95%), ventricular septal defect (VSD, 92%), and atrioventricular septal defect (AVSD, 91%). Seventy-one percent of patients survived the first year of life--mostly those with PS (97%), AS (91%), atrial septal defect (ASD, 89%), VSD (80%), and persistent ductus arteriosus (PDA, 78%). In total, 67% of CHD patients can be expected to survive childhood. The highest survival rates were found in PS (94%), AS and ASD (84%), VSD and PDA (70-80%), and coarctation of the aorta (COA, 68%). The survival rate for the remaining forms of CHD was less than 50%. The highest mortality rate (10% of all children born with CHD) can be expected in the first postnatal week. The lowest survival in the first week was found among those with hypoplastic left heart (HLHS, 39%), double-outlet right ventricle (DORV, 50%), truncus arteriosus (TrA, 57%), pulmonary atresia (PA, 70%), and transposition of the great arteries (TGA, 83%). In addition, total anomalous pulmonary venous connection (TAPVC) and single ventricle had the highest risk of death in the first year of life.

Congenitally corrected transposition and Ebstein's anomaly of the systemic atrioventricular valve: association with aortic arch obstruction

Aortic arch abnormalities are uncommon in patients with congenitally corrected transposition of the great arteries. Over a 20-year period, 10 patients with congenitally corrected transposition and Ebstein's anomaly of the systemic atrioventricular (AV) valve were identified. Five neonates had severe systemic AV valve regurgitation with severe coarctation of the aorta (n = 4) or aortic atresia (n = 1) and presented with heart failure. Four died in the neonatal period and one who had coarctation repair died 7 months postoperatively. The remaining five patients with congenitally corrected transposition and Ebstein's anomaly had mild left AV valve regurgitation; none of these had aortic arch obstruction. In neonates who have coexisting Ebstein's anomaly of the systemic AV valve and congenitally corrected transposition, obstruction to aortic arch flow is common. Severe systemic AV valve regurgitation with a morphologic systemic right ventricle may have contributed to low anterograde flow in the ascending aorta prenatally and thereby to the aortic arch abnormality.

Coarctation of the aorta in infants and children. A review of 333 operative cases, including 179 infants

The operative experience with 333 children (179 [54%] under one year of age) is reported. Associated cardiac anomalies were present in 75%. All those requiring operation before the age of one year had congestive heart failure. Early recognition of the failure of medical treatment and early operative correction are imperative if an avoidable fatal outcome is to be prevented. This study demonstrates that the operative mortality is small (2.8%) in patients over the age of six months, and that almost half of the very ill infants under six months of age can be saved by early operation.

Transposition of the great arteries associated with ventricular septal defect: surgical results and long-term outcome

OBJECTIVES

To identify potential risk factors influencing early and late outcome following the arterial switch operation (ASO) for transposition of the great arteries associated with ventricular septal defect including double-outlet right or left ventricle.

METHODS

All patients who underwent ASO in our department until August 2000 (n=105) were included in this study. There were 77 transpositions of the great arteries with ventricular septal defect, 22 Taussig-Bing hearts and six patients with double-outlet morphology. The median age at operation was 24 days. Aortic arch obstruction was present in 25 patients; in 13 of these patients, a repair with aortic arch reconstruction was done before ASO. The usual coronary artery pattern was present in 59% of the patients. In six patients, we found an intramural course of at least one coronary artery. The ventricular septal defect was closed with a patch through the right atrium (n=35), the aorta (n=25), the pulmonary artery (n=25) or the right ventricle (n=3); in 17 patients a combined approach was necessary.

RESULTS

There were five hospital deaths (4.7%, 95% confidence limit 2-11%). The median duration of follow-up was 72 months. Fourteen patients underwent 15 reoperations 33 months after repair (median), eight for right ventricular outflow tract obstruction or neopulmonary stenosis. Four late deaths occurred, two due to complications related to coronary artery anomalies. Statistical analysis revealed no significant risk factor whatsoever correlating with death or need for reoperation. Survival after 12 years was 91.6%, and freedom from reoperation was 82.6%. Latest follow-up data showed that 13% of patients were in NYHA class II and/or required medical treatment; 87% were in NYHA class I.

CONCLUSIONS

ASO associated with patch closure of ventricular septal defect can be performed early in life with a low risk of mortality (<5%), low incidence of reintervention (<15%) and promising long-term outcome.

Left-sided lesions after anatomic repair of transposition of the great arteries, ventricular septal defect, and coarctation: Surgical factors

OBJECTIVE

This study was undertaken to identify potential anatomic and surgical factors creating left-sided lesions, namely recoarctation of the aorta and neoaortic regurgitation, after anatomic repair of transposition of the great arteries with ventricular septal defect and aortic coarctation.

METHODS

From 1983 to September 2002, 109 survivors out of 120 patients were studied. Two-stage repair was performed in 42 patients (group A), and single-stage repair was performed in 67 (groups B and C). Before repair, the diameters of the ascending aorta and main pulmonary artery were measured. In the patients with single-stage repair, coarctation was repaired by extended end-to-end anastomosis in 35 patients (group B) and by pulmonary homograft patch augmentation in 32 patients (group C). The ventricular septal defect was closed through the pulmonary artery in 70 patients and through the right ventricle or atrium in 39 patients. The neoaorto-aortic discrepancy was treated by V-shaped resection of the posterior sinus of Valsalva in 7 cases, pulmonary homograft patch in 32 cases, and anterior splitting of the ascending aorta in all cases. Before discharge from the hospital, neoaortic root and ascending aorta diameters and aortic regurgitation grade were recorded. Neoaortic regurgitation progression and reintervention were the end points of follow-up (97.2 +/- 61.2 months).

RESULTS

Early and late survivals were significantly better in group C (P <.001). Risk factors for neoaortic regurgitation at discharge by univariate analysis were single-stage repair (P <.05) and ventricular septal defect closure through the pulmonary artery (P =.0076). On multivariate analysis, the latter was the only risk factor for neoaortic regurgitation at discharge and at last follow-up. Multivariate analysis showed that higher neoaortic root/ascending aorta ratio and ventricular septal defect closure through the pulmonary artery were risk factors for neoaortic regurgitation evolution at last follow-up. There were 29 reinterventions, 19 for recoarctation of the aorta and 10 for neoaortic regurgitation with or without aortic root dilatation. Group B (P <.05), high neoaortic root/ascending aorta ratio (P <.01), and progressive neoaortic regurgitation (P <.05) were risk factors for recoarctation of the aorta. Group A was a risk factor for aortic valve replacement at 10 years (P <.05).

CONCLUSION

Neonatal single-stage repair with pulmonary homograft aortic augmentation remains the optimal approach to transposition of the great arteries with ventricular septal defect and aortic coarctation. It provides better early and late survivals and freedoms from left-sided lesions. Avoidance of late recoarctation of the aorta and progressive neoaortic regurgitation requires meticulous closure of the ventricular septal defect and evenly sized reconstruction of the aorta from root to distal arch.

Poor outcome of very low birthweight babies with serious congenital heart disease

OBJECTIVE

To evaluate incidence and mortality of congenital heart disease in very low birthweight babies.

METHOD

Retrospective analysis of a 12 year period.

RESULTS

Forty seven babies were diagnosed with severe congenital heart disease. The most common lesions were ventricular septal defect and coarctation of the aorta. Mortality attributed to congenital heart disease was 32%. Coarctation of the aorta, the second most common lesion, was fatal in 62% of cases. Closure of a patent ductus arteriosus with indomethacin proved to be detrimental in babies with undiagnosed coarctation, causing rapid deterioration in some.

CONCLUSION

Very low birthweight neonates with severe congenital heart disease have a higher mortality than babies with higher birth weight. A contributing factor is closure of a patent ductus arteriosus if an underlying lesion has not been recognised. This could be of significance if the use of prophylactic treatment with indomethacin becomes more common.

Appraisal of resection and end-to-end anastomosis for repair of coarctation of the aorta in infancy: preference for resection

Between 1973 and 1987, 70 consecutive infants under-went repair of coarctation of the aorta. Age at operation was 80.0 +/- 77 days (mean +/- standard deviation); mean weight was 3.0 +/- 0.5 kg. Isolated coarctation was present in 25 patients (group 1); in 19 patients coarctation existed in association with ventricular septal defect (group 2); and in 26 patients coarctation was associated with major intracardiac defects (group 3). Subclavian flap angioplasty was performed in 19 patients and resection and end-to-end anastomosis in 51 patients. Hospital mortality was not significantly different between subclavian flap angioplasty (11%) and resection and end-to-end anastomosis (24%). Freedom from reintervention for recoarctation after 5 years was 87% in the subclavian flap angioplasty group and 95% in the group having resection and end-to-end anastomosis. Actuarial survival at 5 years was 100% for group 1, 73% for group 2, and 28% for group 3. In the subclavian flap angioplasty group, we observed detrimental effects of the sacrifice of the left subclavian artery: 1 patient had a 2.5-cm shortening of the left upper arm, and 5 others complained of claudication in the left upper limb during strenuous exercise. As no major advantage in terms of mortality and recoarctation to either technique of coarctation repair was found, and as subclavian flap angioplasty carries the possible disadvantage of late contracture of isthmic ductal tissue and possible detrimental effects on the left upper limb, resection and end-to-end anastomosis is recommended.

Subclavian flap repair: review of 399 patients at median follow-up of fourteen years

BACKGROUND

Conflicting results have been obtained for the same operation for repair of coarctation of the aorta by different institutes. The purpose of this study was to assess the results of subclavian flap aortoplasty (SFA) alone, performed on 399 patients in a single institute between 1966 and 1995.

METHODS

Data were collected retrospectively from the congenital cardiac surgical database at the institute.

RESULTS

The median age at operation was 22 days (3 days-49 months). One hundred thirty-four patients had isolated coarctation while 265 children had complex coarctation. Maximum follow-up was 24 years (median, 14 years). Overall mortality over the whole duration of follow-up was 24.8%. Mortality for isolated coarctation at first intervention was 7.4% (operative mortality, 2.6%) while it was 12.8% for complex coarctation. At second intervention the mortality for isolated coarctation was 5%. For the second, third, and fourth interventions the mortality for complex coarctation was 25%, 25%, and 27%, respectively. The survival for isolated coarctation at 1, 5, 10, and 20 years was 94%, 93.2%, 92.4%, and 88.4%, respectively, while it was 74.6%, 66.3%, 63%, and 61.4%, respectively, for complex coarctation. Of the total patients, 15.3% had interventions for recoarctation. The incidence of recoarctation was 13.6% on those patients operated on in the first month of life, while it was 3.6% in older children. A percentage of 3.3% of patients continue to be hypertensive and require medication. There was a significant difference between the systolic blood pressure and anthropometric measurements between the arms. Despite this none of the patients complained of effect on lifestyle.

CONCLUSIONS

Despite improved early results the long-term mortality for coarctation remains high. Mortality is higher for complex coarctation as compared with isolated procedures. The incidence of recoarctation after SFA at long term is acceptable and is higher in patients operated on in the first month of life. The overall incidence of hypertension is quite low. Patients remained normotensive when operated upon at the age of 0.9 months. The SFA, no doubt, effects the limb development; however it does not cause limitation in the lifestyle.

Surgical repair of coarctation of the aorta: up to 40 years of follow-up

OBJECTIVE

Coarctation of the aorta (CoA) was previously considered cured after surgical repair. Evidence for excess mortality and late morbidity has later accumulated, although studies with long-term follow-up remain sparse. The aim was to identify patients operated for CoA at Aarhus University Hospital, Denmark between 1965 and 1985 and to assess surgical and late mortality and cardiovascular morbidity in this cohort and possible predictors for an adverse outcome.

METHODS

Two hundred and twenty nine patients were identified. Baseline characteristics and morbidity and mortality data were obtained from medical records, registries and databases and analysed by Kaplan-Meier graphs and multivariate Cox regression analyses.

RESULTS

There were 14 (6%) surgical deaths. The survival in patients who were alive 30 days postoperatively was 95% 10 years after surgery, and 91%, 83% and 69% after 20, 30 and 40 years, respectively. The mortality rate ratio for all long-term survivors compared with an age- and sex-matched reference group was 4.3 (2.9-6.4). In those with no cardiovascular comorbidity at the time of repair, it was 3.4 (1.8-6.4). The causes of late deaths were cardiovascular in 63%. CoA repair in the early decade, age below 1 year at repair and high level of comorbidity were predictors for late mortality. Twenty five percent of current survivors were on antihypertensive medication and further cardiovascular morbidity had occurred in 46 (26%), including cardiovascular surgery and catheter interventions in 35 (19%). Freedom from death, reintervention and cardiovascular complications other than hypertension was 60% 30 years after surgery in the entire study population.

CONCLUSIONS

Repaired CoA is associated with excess cardiovascular mortality and morbidity and often in need of reintervention. These patients, therefore, need careful follow-up.

Coarctations of descending and abdominal aorta: long-term results of surgical therapy

PURPOSE

Nonarteriosclerotic and nonarteritic descending and abdominal aortic coarctation (DAAC) is a rare disease with a great variety of morphologic findings. The additional affliction of renal and other splanchnic arteries often affords complex corrective procedures. We report on our single-center long-term experiences with operative treatment of this malformation.

METHODS

Over a period of 21 years, 15 patients (10 female and 5 male patients; age range, 8 to 57 years) were operated on for DAAC. Six patients had additional stenoses of eight renal arteries, and three had splanchnic arterial obstructions. At 4 to 25 years after the operation, all surviving patients underwent a clinical and a spiral computed tomography examination.

RESULTS

There was one intraoperative death due to exsanguination after the rupture of a poststenotic aneurysm of the infrarenal aorta. Fourteen patients were discharged free of symptoms. During follow-up, four repeated operations were necessary for renal arterial bypass stenoses or aneurysms. One late death occurred as the result of an unrelated disease.

CONCLUSIONS

Complete operative correction of DAAC usually can be accomplished as a single-stage procedure with low morbidity and mortality rates. The reconstruction of all renal arteries is essential to cure hypertension. Consequent follow-up is recommended for detection of late postoperative complications.

Balloon angioplasty of coarctation of the aorta: a safe alternative for surgery in adults: immediate and mid-term results

Patients with coarctation of the aorta can be treated either with surgery or with balloon angioplasty. So far, the last method has proved to be successful in children, but results of this treatment in (young) adults are virtually unknown. The aim of this study was to evaluate the immediate and mid-term follow-up results of balloon angioplasty of native coarctation in (mainly young) adults. Coarctation of the aorta was diagnosed by means of ultrasound or angiography, and defined as a stenosis with a pressure gradient greater than 20 mm Hg. The balloon angioplasty-procedure was carried out under complete anesthesia, and was considered to be successful, if the pressure gradient was reduced to less than 20 mm Hg. Nineteen consecutive adults (12 males, 7 females; aged 14-67 years, median 29) with native coarctation were treated from 1995-99. Mean pressure gradient decreased from 49.3+/- 20.8 to 4.8+/-8.2 mm Hg (P<0.0001). One patient showed a suboptimal result with a residual pressure gradient of 28 mm Hg. In one other patient a stent was placed on request of the referring physician. Follow-up was 100% complete and ranged from 3-47 months (mean 20.2+/- 12.9). At 1-year follow-up mean systolic blood pressure was reduced from 159.4+/-19.5 to 132.5+/-17.6 mm Hg (n = 18; P<0.0001), and mean ankle-arm pressure index improved from 0.73+/-0.09 to 0.96+/-0.05 (n = 18; P<0.0001). Anti-hypertensive medication could either be reduced or stopped in 7 patients (53.8%). With ultrasound or angiography or MRI, no patients had signs of aneurysm formation or worsening restenosis during follow-up. In adult patients with uncomplicated native coarctation of the aorta, balloon angioplasty (without stenting) would seem to be an excellent and safe alternative for surgery. In our hospital it has completely replaced surgical correction in such patients.

Role of extended aortoplasty related to the definition of coarctation of the aorta

One hundred thirty-nine patients underwent operation for coarctation of the aorta. Age ranged from 1 day to 21 years and weight, from 1.5 to 70.4 kg. Numerous methods of repair were used. The operative mortality was low (1.3%), and 17 patients (11.3%) died late. Recoarctation occurred in 13 patients (9.4%). We attempted to correlate mortality and recoarctation with the surgical procedure. A review of the literature revealed no classifications of coarctation that applied to the anatomical and pathological variations we found at the time of operation. Therefore, we devised a surgical classification to separate the various entities in the spectrum of coarctation: type I = primary coarctation; type II = coarctation with isthmus hypoplasia; and type III = coarctation with tubular hypoplasia involving the isthmus and segment between the left carotid and left subclavian arteries. Each of these types has subtypes: A = with ventricular septal defect and B = with other major cardiac defects. We believe that rather than labeling one procedure as "the procedure of choice," providing this classification will allow the surgeon to use a method of repair that is suited to the anatomical variation.

Systemic obstruction in univentricular hearts: surgical options for neonates

BACKGROUND

The surgical management for bridging patients with univentricular heart and systemic obstruction to a Fontan procedure remains controversial.

METHODS

Twenty-seven of 96 patients with univentricular heart and unobstructed pulmonary blood flow referred for surgical palliation were seen with systemic obstruction. Twenty-six were neonates with coarctation of the aorta in 21 and subaortic stenosis in 5. In 8 other patients, subaortic stenosis developed after initial pulmonary artery banding. Four different palliative procedures were performed: coarctation repair with pulmonary artery banding (group I, n = 15); Norwood or Damus-Kaye-Stansel or arterial switch operation (group II, n = 9); coarctation repair with pulmonary artery banding and bulboventricular foramen enlargement (group III, n = 2); and orthotopic heart transplantation with coarctation repair (group IV, n = 1).

RESULTS

The mortality rate was 34.3% (n = 12) for all patients, 53.3% in group I, 33.3% in group II (p = 0.003 versus group I), and 50% in group III. Nine patients (8 in group I and 1 in group II) had development of subaortic stenosis and underwent a subsequent procedure: Damus-Kaye-Stansel operation in 5, arterial switch operation in 3, and bulboventricular foramen enlargement in 1. Three had a concomitant or subsequent Fontan procedure and 2, a bidirectional Glenn procedure. In group II, 1 patient underwent a subsequent Fontan procedure and another, a bidirectional Glenn anastomosis. Six of the 8 patients with subaortic stenosis after initial pulmonary artery banding underwent a second stage consisting of a Damus-Kaye-Stansel procedure (n = 3), bulboventricular foramen enlargement (n = 2), or creation of an aortopulmonary window (n = 1). Three had a concomitant Fontan procedure and 2, a bidirectional Glenn procedure. Actuarial 4-year survival was 65.5% +/- 8.4% (70% confidence limits) for all patients; it was 40% +/- 13.3% in group I and 66.6% +/- 16.3% in group II (p < 0.05).

CONCLUSIONS

Initial management of patients with univentricular heart and systemic obstruction by Norwood-like procedures provides a better outcome. Success of the Fontan operation relies on the ability to provide timely relief of subaortic stenosis.

The neonatal hypoplastic aortic arch: decisions and more decisions

Neonatal patients with hypoplasia of the aortic arch constitute a heterogeneous group with a wide spectrum of severity. The milder end of the spectrum comprises patients with aortic coarctation and isthmus hypoplasia. At the other end of the spectrum are patients with severe transverse arch hypoplasia or hypoplastic left heart syndrome. The aim of this paper is to discuss the various strategies and surgical approaches available for this group of patients, focusing on the surgical decisions that influence individual patient management. Many of the things discussed are applicable to any neonatal arch problem. We also describe and discuss in detail our surgical technique for patients who undergo neonatal repair of a hypoplastic aortic arch via median sternotomy.