One-stage neonatal repair of complex aortic arch obstruction or interruption. Recent experience at Texas Children's Hospital

The optimal surgical approach for complex aortic coarctation or an interrupted aortic arch with associated intracardiac defects is not universally agreed upon. We reviewed our experience with 18 consecutive patients (10 with coarctation, 8 with interrupted aortic arch) undergoing a 1-stage repair through median sternotomy between September of 1995 and February of 1997. Age at operation ranged from 3 days to 3 months (mean 23 days) and weight ranged from 1,700 g to 5,100 g (mean 3,350 g). Under hypothermic circulatory arrest, the aortic arch was reconstructed using native tissue-tissue anastomoses, and coexisting intracardiac anomalies were repaired by standard techniques. All patients survived the procedure and were ultimately discharged from the hospital. There were 2 late deaths in the interrupted aortic arch group, 1 during reoperation for subaortic stenosis and the other from noncardiac causes 5 months after discharge. Another interrupted aortic arch patient required a Ross-Konno procedure 8 months later. There has been no recoarctation among the 16 survivors. Thus a 1-stage repair for complex aortic arch obstruction in neonates can be accomplished with low operative risk, although long-term outcome is strongly influenced by the presence of subaortic obstruction.

Repair of aortic arch interruption by direct anastomosis

OBJECTIVE

Evaluation of surgical treatment of interrupted aortic arch (IAA) by direct anastomosis.

METHODS

A consecutive series of 17 infants with IAA (type A in eight patients, type B in nine) were operated upon. The mean age at arch repair was 1.0 month (range 0.2-7.7), mean weight was 3.7 kg (range 2.2-6.2). All arch repairs were done by direct anastomosis. This included a persistent arterial duct in one and a subclavian turnup in another case. The aortic reconstruction included reimplantation of a lusoric artery in three patients, patch enlargement of the ascending aorta in three and of the complete arch in one patient. The arch repair was done through a lateral thoracotomy in three patients. In 14 patients the aortic repair was part of a single-stage approach through a median sternotomy using cardiopulmonary bypass and circulatory arrest.

RESULTS

There was no operative mortality. One patient (single-stage approach) died 2 days after operation due to respiratory problems caused by tracheobronchomalacy. One patient (lateral approach) died suddenly 3 months after aortic repair and banding. Median follow up was 4.8 years (range 0.1-12.9). In five patients restenosis of the aortic arch developed, all within 1.5 years after repair. This was not correlated with the type of interruption, weight at operation, age at operation or the surgical approach. The actuarial freedom from restenosis was 61% at 5 years with a 70% confidence limit (CL70%) of 46-75. All restenoses were balloon dilated, but two needed redo surgery, which was done by the median approach. In three patients discrete subaortic stenosis developed. This was not correlated with the type of interruption, weight at operation, age at operation or the surgical approach. The actuarial freedom from subaortic stenosis was 68% at 5 years (CL70% = 54-83). These stenoses were treated by enucleation, followed in one patient by a pulmonary autograft procedure for recurrent root stenosis after another year. At the end of follow up all patients were thriving well, lacked symptoms, were normotensive and had normal femoral artery pulsations.

CONCLUSIONS

IAA can be treated well with primary anastomosis. Possible restenosis of the aortic arch can adequately be treated by percutaneous balloon dilatation or redo surgery if necessary. Arch repair by median single-stage approach has our preference.

Primary repair of coarctation of the thoracic aorta by patch graft aortoplasty. A three-decade experience and follow-up in 60 patients

OBJECTIVES

The present report is a critical review on primary repair of aortic coarctation by patch aortoplasty on the basis of over 30 years surgical experience.

METHODS

Since 1962, 60 patients (mean age 9.4 +/- 4.8 years, range 2-25 years), affected by aortic coarctation, underwent patch aortoplasty repair. During the operation protective guidelines were adopted: additional external Dacron was placed around the repaired site in cases of friable host tissue, the aortic ridge was not excised to leave the posterior aortic wall intact, and the patent ductus arteriosus or ligamentum arteriosum was transected and sutured. Prophylactic measures of neurologic sequelae were: dual pressure monitoring, sequential aortic clamping, surgical shunt or left heart bypass associated with moderate hypothermia when the distal aortic pressure was less than 50 mmHg.

RESULTS

No early deaths occurred. The overall survival rate was 92.77 +/- 4.04% at 31 years from surgery. Three late deaths occurred. Pressure gradients across the patch ranged between 9 and 20 mmHg. Late aneurysm occurred in one patient (1.3%), 2 years after bacterial endocarditis had developed on a biscuspid aortic valve.

CONCLUSIONS

Patch aortoplasty is an effective and safe surgical procedure for primary repair of isthmic aortic coarctation when other surgical techniques cannot be performed.

Surgical repair of coarctation of the aorta in neonates: factors affecting early mortality and re-coarctation

Between October 1979 and January 1993, 85 Chinese neonates in Hong Kong underwent surgical repair for coarctation of the aorta. Their mean (s.e.) age and body weight at operation was 15.6(8.5) days and 3.06(0.56) kg, respectively. Simple coarctation was present in 17 babies, while 36 had additional ventricular septal defect and 31 had associated major complex intracardiac lesions. Subclavian flap aortoplasty was performed in 56 babies, resection with end-to-end anastomosis in 18 and aortoplasty with the use of a GORETEX patch in 11. The overall early mortality rate was 16.5%. To identify risk factors for early operative mortality, various clinical variables, surgical options, associated heart lesions and dimensions of the aortic arch at different sites for each patient were reviewed. Univariate analysis identified statistically significant differences between the survivors and non-survivors for the following factors: preoperative body-weight, arterial pH and base excess, serum urea and creatinine levels. Stepwise logistic regression further distinguished serum creatinine levels and the period of operation as two significant risk factors. Contrary to previous reports, the dimensions of the aortic arch and type of surgery did not affect early operative mortality. Among the 71 hospital survivors followed for 38.2(38) months, residual or recurrent coarctation of the aorta was detected in 12(17%). The different surgical operations were not related to the incidence of late complication. The size of the distal transverse arch, however, was different (P=0.05) in those who did and did not develop aortic sequela. Successful balloon angioplasty was subsequently performed in 11 patients. In an era of echocardiography with prenatal diagnosis and therapeutic catheterization, early recognition of the disease with prompt prostaglandin infusion should prevent collapse of the baby, thus avoiding renal impairment and sever metabolic acidosis. Balloon angioplasty would offer a simple effective treatment of patients who developed aortic re-coarctation.

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.

Coarctation of the aorta in infants and neonates: results and assessment of prognostic variables

From 1984 until 1994, 75 consecutive patients younger than 12 months of age were operated on for coarctation of the aorta. We retrospectively analyzed predictive factors for morbidity and mortality, and also interaction between surgical procedures and recoarctation. Surgical procedures were as follows: resection with a traditional end-to-end (E-E) anastomosis in 55 patients (73.3%), prosthetic patch aortoplasty (PPA) in 12 patients (16%) and subclavian flap aortoplasty (SFA) in 8 patients (10.7%). Early mortality was 9.33% (7 patients). Logistic regression analysis proved that age at operation, associated anomalies of heart, type of coarctation, aortic arch hypoplasia and pulmonary banding were independent predictors of hospital death. Late mortality occurred in 7 patients (10.3%). Associated anomalies of heart were an independent prognostic factor for late mortality. Actuarial freedom from recoarctation at 1 year was 91% [confidence limits (CL): 82% to 97%] and 5 years were 74% (CL: 67% to 86%). Immediate postrepair gradient was equal after E-E anastomosis and other procedures. We conclude that the treatment of first choice in the management of coarctation of the aorta in infants is E-E anastomosis.

[Clinical-therapeutic aspects and surgical treatment of aortic coarctation associated with hypoplasia of the aortic arch in less than 3-month-old patients]

The surgical treatment of the CoAo plus Hypoplastic Aortic Arch is debated. The point is whether to treat or not the associated tubular hypoplasia performing an extended Resection and "End to End" Anastomosis (ERETE) or a subclavian flap angioplasty (Waldhausen). According to some report in the literature we called an arch hypoplastic if its diameter in the first or second portion was less than the patient body weight plus 1. Between January 1988 and December 1992 in our Institution 38 patients less than 3 months underwent aortic coarctation repair. In 14 cases we were able to consider the aortic arch as hypoplastic. These patients were aged between 3 days and 45 days (median 15 days), the body weight was between 2.6 and 3.9 kgs (median 3.2 kgs). 6 patients had CoAo as isolated lesion, in 3 cases there was Ventricular Septal Defect (VSD) associated. In 5 patients major intracardiac anomalies were associated (1 DORV, 1 TGA, 2 SV, 1 SV+Arterio-Ventricular discordance). In 7 cases in order to treat the arch an ERETE was performed. The other 7 patients had a Waldhausen procedure. In 5 cases a Pulmonary Artery Banding (PAB) was associated, in 1 case a palliative arterial switch operation. The hospital death was 43% (3 patients) in the ERETE group, and 28% (2 patients) in the Waldhausen group. The echocardiography and or angiography performed during the follow-up period showed a nice growth of the arch in both groups. Although from our present data it's impossible to get definitive conclusions, the ERETE doesn't give better result in terms of hospital death and long term aortic arch growth.(ABSTRACT TRUNCATED AT 250 WORDS)

Repair of neonatal aortic coarctation

From 1981 to 1991, 146 infants under 1 month of age underwent repair of aortic coarctation. Forty-two had isolated coarctation, 53 had associated ventricular septal defect, and 51 had complex cardiac defects. The principal mode of presentation was congestive heart failure. The mean age at operation was 10.6 days. The technique for repair was left subclavian artery flap angioplasty in 126, resection with end-to-end anastomosis in 14, and a variety of repairs in 6 patients. Concomitant pulmonary artery banding was performed in 62 patients. The overall hospital mortality rate was 11%, and there was a strong association with pre-existing renal failure. The mean aortic clamp time in survivors was 23.9 minutes; mean hospital stay was 13.4 days. Significant restenosis occurred in 16 patients (11%) with an incidence of 10% after subclavian artery flap angioplasty. Eleven patients have undergone reoperation, and 5 were managed successfully with balloon dilatation.

[Therapeutic strategy in newborn infants with multivisceral failure caused by interruption or hypoplasia of the aortic arch]

Left heart obstructive lesions, in particular interrupted aortic arch or severe forms of coarctation with hypoplasia of the aortic arch, are the main cause of cardiac failure in the neonate and are often at the root of multiple organ failure which worsens the prognosis. Based on a retrospective study of 35 neonates admitted between July 1984 and June 1994, the authors attempted to identify the prognostic factors for admission to the intensive care unit and the optimal timing for operation of these patients. All neonates with a ductus-dependent aortic obstructive lesion and severe multiple (at least four) organ failure, were included in the study. There was a high mortality (54%) including firstly 7 patients who died in the three days following admission to the intensive care unit (20%); this was so-called "medical" mortality for which there was no identifiable poor prognostic factor. On the other hand, the surgical mortality (12 out of 28 cases, 43%) was significantly different in neonates operated before recovery from multiple organ failure (72%) and those operated after recovery from multiple organ failure (17%). Based on these results, the authors propose a therapeutic strategy based on prolonged preoperative intensive care until the initial multiple organ failure is reversed rather than early surgery.

Surgical management of neonatal coarctation

Between 1983 and 1994, 307 consecutive neonates underwent coarctation repair by a single surgical technique: extended end-to-end anastomosis. Mean age at operation was 13 +/- 8 days. Isolated coarctation was present in 95 patients (group 1), 102 patients had associated ventricular septal defect (group 2), and 110 patients had associated complex intracardiac lesions (group 3). Aortic arch hypoplasia was present in 81% of the patients (62% in group 1 versus 85% in group 2 and 93% in group 3: p < 0.001). In 271 patients, the aortic arch reconstruction was performed via a left thoracotomy with normothermia (100% of group 1, 95% of group 2, and 72% of group 3); in the other 36 patients, undergoing one-stage repair or palliation of the associated lesion, it was performed via a midline sternotomy during a short period of deep hypothermia and circulatory arrest (5% of group 2 and 28% of group 3). Pulmonary artery banding was performed in 94 patients. Spontaneous ventricular septal defect closure was observed in 39% of the patients of group 2 operated on via thoracotomy. Early mortality rates in groups 1 (2%) and 2 (2%) were significantly lower than in group 3 (17%) (p < 0.001). There were 29 late deaths, all related to associated cardiac lesions or their subsequent repair. The overall total mortality was 16.9%. In group 3 this rate was significantly higher in patients undergoing two-stage procedures (47%) than in those undergoing one-stage repair (23%) (p < 0.05). All but 14 survivors were followed up for a mean of 61 +/- 36 months. Actuarial survivals at 10 years were 98% in group 1, 94% in group 2, and 60% in group 3. The recoarctation rate was 9.8%, leading to 21 reoperations and three angioplasties without mortality. Patients with a more extended or severe form of aortic arch hypoplasia had a significantly higher risk of recoarctation (p < 0.001). Actuarial freedom from reoperation for recoarctation at 10 years was 93%. The findings of this study suggest that extended end-to-end anastomosis provides an adequate and safe repair of neonatal coarctation. Low recoarctation rate, owing to effective relief of the obstruction created by aortic arch hypoplasia and to complete resection of ductal tissue, freedom from major morbidity, and feasibility via both lateral and anterior approaches are the main advantages of the extended end-to-end anastomosis.(ABSTRACT TRUNCATED AT 400 WORDS)

[The anatomical correction of transposition of the great arteries in the neonatal period]

INTRODUCTION AND OBJECTIVES

Anatomic correction of transposition of the great arteries in simple and complex form is theoretically the only procedure which offers the possibility of real cure to the problem. We report there our operative results and mid-term follow-up with this approach.

METHODS

From June 1989 to February 1994, anatomical surgical correction was performed in 41 patients in the neonatal period, 31 with simple TGA and 9 patients with transposition associated with ventricular septal defect. We report our preoperative management, anatomic findings and surgical technique.

RESULTS

Our initial experience with the arterial repair was associated with a high operative mortality. The actuarial survival rate was 74% at 56 months. Hospital mortality of the last 31 patients was 12.9%. Intermediate-term follow-up was 18 months. No late deaths. One patient underwent reoperation for supravalvular pulmonary stenosis. All survivors are in functional class I. The only significant risk factor of in-hospital mortality was the time of surgery (learning curve).

CONCLUSION

The initial experience with arterial repair is associated with a difficult learning curve. Primary repair must be performed during the newborn period in simple and complex transpositions. Mid-term results are very encouraging. Longer follow-up is necessary to secure this technique and to render obsolete all other types of repair.

Repair of coarctation of the aorta in neonates and infants: a thirty-year experience

Between January 1962 and December 1991, 179 children less than 1 year of age underwent repair of coarctation of the aorta. Group I (1962 to 1971) consisted of 19 patients, group II (1972 to 1981) of 57 patients, group III (1982 to 1991) of 103 patients. Neonates (< 30 days old) made up 60% of group I, 57% of group II, and 70% of group III. The proportion of infants with associated complex cardiac abnormalities was 7% in group I, 25% in group II, and 39% in group III. Techniques of repair included resection with end-to-end anastomosis (n = 65), subclavian flap repair (n = 85), patch aortoplasty (n = 18), and other procedures (n = 11). The early mortality (< 30 days) was lowest in group III (group I, 21%; group II, 21%; and group III, 7%; p < 0.05), but the late mortality was similar in all groups (group I, 11%; group II, 13%; and group III, 15%). The overall actuarial survival was 57.7% +/- 0.15% at 27.1 years in group I, 65.7% +/- 0.07% at 19.7 years in group II, and 77.5% +/- 0.04% at 9.3 years in group III (p = not significant). Twenty-five restenoses requiring intervention occurred in 23 patients, for an overall restenosis rate of 16.4%. The incidence of restenosis was 23% for the patients who underwent end-to-end anastomosis, 11% for those who underwent subclavian flap repair (p < 0.1), and 27% for those who underwent patch aortoplasty (p < 0.01). Balloon angioplasty was successful in relieving 11 of the 12 restenoses in groups II and III.(ABSTRACT TRUNCATED AT 250 WORDS)

Coarctation of the aorta: diagnostic imaging after corrective surgery

The clinical evaluation and management of the patient with coarctation of the aorta continues to evolve. Traditional imaging evaluation by plain film chest radiography, barium esophagography, and arteriography with pressure measurements across the coarctation has been largely supplanted by Doppler echocardiography and magnetic resonance imaging (MRI). The complications of surgery and balloon angioplasty, including residual or recurrent coarctation and aneurysm, can also be evaluated noninvasively by echocardiography and MRI. Chest radiography continues to play an important role in "first discovery" imaging in asymptomatic patients.

Outcomes in seriously ill neonates with coarctation of the aorta. A multiinstitutional study

Among 326 severely symptomatic neonates with coarctation with or without ventricular septal defect, four died before an initial procedure was performed. Among the 322 undergoing an initial procedure, survival for at least 24 months was 84%; the hazard function for death was lower initially but more prolonged in patients without than in those with ventricular septal defect. Important mitral valve anomalies coexisted in 5% of patients, left ventricular hypoplasia in 5% (more commonly in patients without ventricular septal defect), narrowing of the left ventricular outflow tract in 9% (more common in patients without ventricular septal defect), and narrowing of the proximal arch in 1%; one or more of these anomalies was present in most patients without ventricular septal defect who died. Five percent of the 322 patients had more than one of these coexisting anomalies, and 8% had just one. The most commonly used technique of repair of the coarctation was resection and end-to-end anastomosis, but no technique was a risk factor for death by multivariable analysis. Extension of the area of resection so that the end-to-end anastomosis was proximal to the left subclavian artery but distal to the left common carotid artery did not increase risk; extensions beyond this, and in the case of patch graft repair, extensions proximal to the left subclavian artery, did increase risk. Patch graft repair was associated with the highest prevalence (21%) of reintervention to the coarctation repair. Among patients with coexisting moderate-sized or large ventricular septal defects, repair of the coarctation, pulmonary trunk banding, and subsequent repair of the defect were associated with the highest 2-year survival, 97% in those with single ventricular septal defect. The risk-adjusted outcomes in two institutions were less good than in all others.

Presentation of obstructive left heart malformations in infancy

This study documents the presentation of acutely life threatening congenital heart disease in infancy in order to assess the performance of screening examinations soon after birth and at 6 weeks of age. All cases of obstructive left heart malformations presenting in infancy in one health region from 1987-91 were analysed retrospectively. Altogether, 120 infants presented with either hypoplastic left heart syndrome, interruption of the aortic arch, coarctation of the aorta, or aortic valve stenosis. Twelve became symptomatic or died within 24 hours. Thirty four had an abnormal neonatal examination, eight of whom were referred. Six more became symptomatic before discharge. Ninety four babies went home, 51 developed heart failure before 6 weeks, and another seven died without diagnosis. Twenty five of 36 (69%) reaching 6 weeks without diagnosis had a second examination which was abnormal in 17. Two babies died undiagnosed after 6 weeks and the other 18 presented at up to 11 months of age. The neonatal and 6 week examinations perform poorly as screening tests for congenital heart disease. A normal neonatal examination does not exclude life threatening congenital heart disease.

Influence of age on survival, late hypertension, and recoarctation in elective aortic coarctation repair. Including long-term results after elective aortic coarctation repair with a follow-up from 25 to 44 years

The optimal age for elective repair of aortic coarctation is controversial. The optimal age should be associated with a minimal risk of recoarctation, late hypertension, and other cardiovascular disorders. The purpose of this retrospective study is to determine the actuarial survival after aortic coarctation repair 25 years or more after operation and to calculate the optimal age for elective aortic coarctation repair. From 1948 to 1966, 120 consecutive patients underwent aortic coarctation repair. Eighty-seven were male (72.5%). The mean age at operation was 15.5 years (SD +/- 9.1 years). Resection and end-to-end anastomosis was performed in 103 patients (85.8%). Early mortality occurred in 6 patients as a result of surgical problems, whereas late mortality in 15 patients was predominantly caused by cardiac causes. The mean follow-up period was 32 years (range 25 to 44.2 years). Ninety-two patients 96.8%) were in New York Heart Association class I. The probability of survival 44 years after operation was 73%. Patients younger than 10 years at operation had the highest probability of survival at 97%. Multivariate analysis produced age at operation as the only incremental risk factor for the occurrence of recoarctation, of late hypertension, and of premature death. So that these sequelae can be avoided, elective aortic coarctation repair should be performed around 1.5 years of age. At that age, the probability of recoarctation will have decreased to less than 3%, and the probability of upper body normotension and long-term survival will be optimal.

Operative risk factors and durability of repair of coarctation of the aorta in the neonate

The risk factors for the operative mortality and long-term durability of repair after surgical correction of coarctation of the aorta in neonates remain controversial. Between January 1970 and January 1993, 139 patients under 1 month of age underwent repair of coarctation of the aorta. Complex intracardiac defects were present in 59 patients. Another 44 patients had an associated ventricular septal defect. Subclavian artery flap repair was performed in 92 patients; end-to-end anastomosis (38 patients) and patch angioplasty (9 patients) were performed less commonly. The hospital mortality was significantly higher in patients with complex intracardiac defects (9 of 59 patients; 15.2%) than in those with a ventricular septal defect (1 of 44 patients; 2.3%) or with isolated coarctation (none of 36 patients; p = 0.007). Elevated pulmonary artery diastolic pressure (p = 0.041) and complex intracardiac anomalies (p = 0.048) were found to be independent predictors of hospital mortality. The presence of a complex cardiac defect (p < 0.001) was an independent predictor of poor long-term survival. Recurrent stenosis requiring reoperation had occurred or balloon dilation had been necessary in 27.9% of the children at 5 years postoperatively. In patients followed up for at least 5 years, the recurrence-free survival was better in those who had undergone subclavian artery flap repair than in those who had undergone end-to-end repair (p = 0.017). When coarctation of the aorta must be repaired in the neonate, operative mortality and long-term survival are affected by the complexity of associated intracardiac anomalies.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Effect of introducing balloon dilation of native aortic coarctation on overall outcome in infants and children

The outcome of 40 consecutive newborns and children with normal cardiac connections presenting with unoperated (i.e., no previous surgical or balloon dilation treatment) aortic coarctation since the introduction of balloon dilation as a treatment option (group A) was compared retrospectively with that of a similar cohort of 38 patients (group B) presenting in the period immediately before the introduction of balloon dilation. Group A consisted of 18 newborns (< 30 days) and 22 children and Group B consisted of 20 newborns and 18 children. In group A, 30 patients had balloon dilation but 10 underwent surgery because of parental preference, unfavorable anatomy or for logistic reasons. Group B had conventional surgical repair by various methods. All patients were followed up clinically by Doppler echocardiography and, when possible, by magnetic resonance imaging. Repeat cardiac catheterization was only performed in those with suspected recoarctation. Survival and freedom from reintervention were investigated using Kaplan-Meier analysis. Patients of all ages in group A and those who had balloon dilation were at higher risk for reintervention (25 and 30%, respectively, at 1 year) than those in group B or those who had surgery (20 and 18%, respectively, at 1 year). Mortality was not significantly different between groups A and B, but there were 2 neonatal deaths directly attributable to the dilation procedure. Two patients developed aneurysms after dilation. Balloon dilation is an effective treatment for unoperated coarctation, but the recoarctation rate appears to be higher than for surgery.

Arterial switch operation: a new technique of coronary transfer

A successful outcome after arterial switch operation (ASO) for transposition of the great arteries (TGA) depends in large part on the adequacy of transfer of the coronary arteries to the neoaorta. The present paper describes a new technique of coronary transfer which was used in 43 patients: 28 neonates with TGA and intact septum (with coarctation in one), 10 neonates with TGA and ventricular septal defect (with coarctation in one), 2 children undergoing ASO after failed Senning operation and 3 patients with complex TGA. A standardized uniform technique of coronary transfer was used; this technique involved reimplantation of the two coronary ostia side by side after excision of a single button of neoaortic wall. Most coronary patterns were encountered: the usual pattern in 30, circumflex from right coronary artery in 7, inverted coronary arteries in 3, inverted circumflex and right coronary arteries in 3. There was no early coronary-related mortality or morbidity. One late death (3 months) was probably coronary-related. The overall coronary risk was 2.3% (70% confidence limits = 0.3%-7.5%). The proposed technique of coronary transfer can be used in most patients with TGA (all patients without coronary arteries running between the great arteries) and entails a low coronary risk.

More than thirty-five years of coarctation repair. An unexpected high relapse rate

Between 1953 and 1985, 109 consecutive patients (17% with isolated coarctation) younger than 3 years of age underwent resection of aortic coarctation. These patients had nonelective operations because of congestive heart failure or severe systemic hypertension not responding to medical therapy. Special surgical techniques were used to lower the prevalence of restenosis. Hospital mortality was 32% (35 patients). Logistic regression analysis proved that age at operation, pulmonary artery banding, and type of repair were independent predictors of hospital death. Late mortality occurred in 9 patients. Associated cardiac anomalies were an independent prognostic factor for late mortality. The operation rate for recoarctation was low (5.8%). However, the follow-up study revealed that 30 patients (41%) had recoarctation. The Kaplan-Meier estimate of recoarctation is 86% after 30 years' follow-up in patients undergoing classic end-to-end anastomosis with silk sutures (n = 48). None in the group with an "extended" anastomosis and polypropylene sutures (n = 26) had recoarctation. The Cox analysis revealed age at operation under 6 months to be prognostic for recoarctation. Because of the shorter period of follow-up, the extended anastomosis with polypropylene sutures proved not to be a significant prognostic factor for recoarctation. In the late postoperative period (mean follow-up 16.7 years), blood pressure was elevated in 49% of the patients. At last follow-up 27 (36%) of the 74 survivors had aortic valve disease. Patients operated on for coarctation of the aorta under the age of 3 years need lifelong follow-up for detection of restenosis, hypertension, and valvular disease. Reoperation-free rate is not a good criterion to judge the outcome of operation for coarctation. Longer follow-up will be needed to investigate whether or not the use of the extended anastomosis technique with polypropylene sutures lowers the prevalence of recoarctation.

"The antero-axillary thoracotomy for operations of the distal aortic arch and the proximal descending aorta"

Antero-axillary thoracotomy in a 45 degrees position has become the most frequent approach for lung resection in our country. This approach also offers an ideal view of the aortic arch with the supraaortic vessels being closer to the incision site than in sternotomy or standard thoracotomy. We have therefore used this approach in our last 14 patients with lesions of the distal aortic arch and proximal descending aorta. Operative diagnoses included three arteriosclerotic aortic arch aneurysms, one post-traumatic aneurysm and two acute traumatic transections, as well as four acute type B dissections, three aneurysms after coarctation patch plasty and one recurrent stenosis after primary interposition of a vascular graft. Two patients died of sudden cardiac arrest on the 4th and 6th postoperative day, respectively, both following repair of a ruptured aneurysm. Except for recurrent laryngeal nerve palsy in six patients there were no further operations or morbidity. All operations were performed with the aid of left heart bypass. Induction of deep hypothermia and circulatory arrest, as is advocated for some of these lesions, was not required. This approach is especially useful in those cases where there is indecision as to whether a median sternotomy or a standard thoracotomy would provide the most optimal exposure.

Surgical treatment of aortic coarctation in infants younger than three months: 1985 to 1990. Success of extended end-to-end arch aortoplasty

There remains controversy regarding the appropriate surgical treatment of coarctation of the aorta in infants. In 1985 we introduced the extended end-to-end repair into our practice and now wish to present a review of our recent experience. One hundred fifty-one infants younger than 3 months of age underwent repair of coarctation between 1985 and 1990. In 25% and 33% of the patients, there was hypoplasia of the isthmus and of the transverse arch, respectively. Surgical procedures were as follows: subclavian flap angioplasty in 15 patients, resection with a traditional end-to-end anastomosis in 43, and resection with an extended end-to-end anastomosis into the arch in 77. In 30 patients, the extension was proximal to the origin of the left carotid artery (radically extended end-to-end anastomosis). Other procedures were used in 16 patients. Mortality (13 early and 12 late deaths) was related on multivariate analysis to the presence of an associated major heart defect, preoperative resuscitation, and direct postoperative gradient over the arch. This immediate postoperative gradient was significantly lower after both extended and radically extended end-to-end anastomosis if there was a hypoplastic isthmus, and after radically extended end-to-end anastomosis if the transverse arch was hypoplastic. Actuarial freedom from recoarctation at 4 years was 57% (confidence limits 28% to 78%) after subclavian flap angioplasty, 77% (confidence limits 60% to 87%) after end-to-end anastomosis, 83% (confidence limits 66% to 92%) after extended end-to-end anastomosis and 96% (confidence limits 77% to 100%) after radically extended end-to-end anastomosis. We conclude that the extended end-to-end anastomosis and radical end-to-end anastomosis appear to offer the best prognosis for all infants with coarctation. The technique can be applied successfully to almost all types of arch anomalies.

[Extra-anatomic ascending-supraceliac aortic bypass in treatment of complex or recurrent aortic isthmus stenosis]

Several surgical approaches have been reported for operative correction of complex or recurrent form of aortic coarctation. In this study we report our experience with extra-anatomic ascending-supraceliac abdominal bypass grafting for complicated form of aortic coarctation in 12 patients. All patients survived the operations, without late mortality. This type of surgical correction of complex or recurrent form of coarctation is a safe and effective procedure.

Neonatal coarctation repair. Influence of technique on late results

BACKGROUND

Coarctation repair in the neonate (< or = 28 days) is associated with higher mortality and increased incidence of restenosis compared with older infants. It has been suggested that resection of pericoarctation ductal tissue may reduce this risk of restenosis.

METHODS AND RESULTS

To further clarify these issues, we reviewed our experience with 111 consecutive neonates undergoing primary repair between 1973 and 1991. Hospital mortality was 14.4% (16 of 111) and was not significantly different for the type of repair:resection and end-to-end anastomosis (RETE) 10.7% (6 of 56), subclavian flap angioplasty (SFA) 16.7% (6 of 36), and patch angioplasty (PA) 16.7% (3 of 18). Associated complex cardiac pathology was associated with higher operative risk: 25% (10 of 40) versus 8.4% (6 of 71) (P = .02). Median follow-up of 4.2 years (range, 0.1 to 18.5 years) was 99% complete. Late mortality was 13.6% (13 of 95), of which 92% occurred within 1 year of repair. Twenty percent (19 of 95) needed reintervention for restenosis, RETE 16% (8 of 50), SFA 13% (4 of 30), and PA 47% (7 of 15) (P = .02). Of these, 84.2% (16 of 19) required reintervention within 1 year of repair. Freedom from reintervention 1 and 8 years after operation was 80 +/- 4% and 77 +/- 5%, respectively. Actuarial survival 8 years after operation was 73 +/- 4%; for simple coarctation, this was 90 +/- 4%. By multivariate analysis, survival was negatively influenced only by presence of associated cardiac pathology (P = .002) and reintervention only by patch angioplasty technique of repair (P = .007).

CONCLUSIONS

In the neonate, resection of coarctation (RETE) does not diminish the risk for reintervention compared with SFA. The risk for both late death and recurrent coarctation are highest within the first year after repair, and follow-up should be particularly vigilant during this period.