The Adult With Congenital Heart Disease

The population of patients with adult congenital heart disease is approximately 800,000 in the U.S. Those with prior cardiac surgery often consider themselves "cured," although the majority faces a lifetime of problems including arrhythmias, ventricular dysfunction, and one or more re-operations. Even patients with repaired "simple" lesions such as an atrial septal defect may not have normal survival if they are repaired in adulthood. Patients with repaired coarctation may have premature cardiovascular complications including sudden cardiac death, myocardial infarction, and stroke. They also have aortic complications such as aneurysm and dissection, which result from a diffuse arteriopathy and continued hypertension that may be caused by underlying endothelial dysfunction. In addition, bicuspid aortic valve occurs in more than one-half of the patients with coarctation, so continued surveillance for significant aortic valvular heart disease is necessary. More complex lesions also pose problems after "total correction." Patients with repaired tetralogy of Fallot often have pulmonary regurgitation, which is frequently overlooked on clinical exam and echocardiography. Pulmonary valve replacement should be performed before the development of irreversible right ventricular dysfunction and an increased risk of ventricular tachycardia or sudden cardiac death. Because they are vulnerable to deterioration of systemic ventricular function, those with congenitally corrected transposition require special vigilance, usually with concomitant atrio-ventricular valve regurgitation. Late referral is common with a deleterious effect on long-term survival. These patients need lifelong follow-up and the residua and sequelae of their complex anomalies must be understood in order to provide optimum care.

Long-term follow-up of patients after surgical treatment for isolated pulmonary valve stenosis

OBJECTIVE

To determine the long-term outcome of patients after surgical repair for pulmonary valve stenosis (PVS).

PATIENTS AND METHODS

Fifty-three patients (30 males; mean - SD age, 10+/-13 years; range, 5 days to 50 years) were identified who had surgical treatment for PVS between 1951 and 1982. The status of each patient was determined by medical record review.

RESULTS

The mean +/- SD age at follow-up was 43+/-15 years (age range, 19-77 years). Mean follow-up was 33 years (range, 18-51 years). At a median follow-up of 34 years, 35 reinterventions had been performed in 28 patients (53%), Including pulmonary valve replacement for free pulmonary regurgitation in 21 patients (mean interval after initial surgery, 33 years; range, 14-45 years), open valvotomy in 5 and pulmonary balloon valvuloplasty in 3 for residual PVS, closure of atrial septal defect in 2, right ventricular outflow tract reconstruction in 1, closure of iatrogenic ventricular septal defect in 1, ligation of aortopulmonary fistula in 1, and tricuspid valve annuloplasty with simultaneous coronary artery bypass grafting in 1. In addition, atrial and ventricular arrhythmias were common, occurring in 20 patients (38%). Patients who underwent reintervention were more likely to have undergone closed pulmonary valvotomy as the initial repair (P=.008).

CONCLUSION

Although overall survival after surgical treatment of isolated PVS remains excellent, many patients undergo late reintervention after 30 years of follow-up, emphasizing the need for lifelong cardiac follow-up.

Ebstein's anomaly - review of a multifaceted congenital cardiac condition

Ebstein's anomaly (EA) is a rare but fascinating congenital heart disorder accounting for <1% of all congenital heart defects. Since its description in 1866, dramatic advances in diagnosis and therapy have been made. In this review, we describe current diagnostic criteria and classification, natural history, clinical features, and prognosis, typical echocardiographic features and pathologic findings, and the spectrum of associated cardiac malformations including left heart anomalies associated with EA. Differences between Ebstein-like changes associated with congenitally corrected transposition and EA are described. The spectrum of typical ECG and conduction system changes, arrhythmias including accessory pathways and ectopic atrial tachycardias related to EA are also reviewed. Differential diagnosis of EA is discussed including tricuspid valve dysplasia and prolapse as well as arrhythmogenic right ventricular cardiomyopathy. The review describes management options in EA including catheter interventions, indication for operation and surgical options including tricuspid valve repair and replacement. Overall, EA is a complex congenital anomaly with a broad pathologic-anatomical and clinical spectrum and no two patients are alike. Therefore, precise knowledge of the different anatomic and hemodynamic variables, associated malformations and management options are essential. Management of EA patients is complex. Thus it is important that these patients are regularly seen by a cardiologist with expertise in congenital heart disease.

Prevalence and clinical manifestations of 22q11.2 microdeletion in adults with selected conotruncal anomalies

OBJECTIVES

This study was designed to determine the prevalence and clinical manifestations of 22q11.2 microdeletion in adults with selected conotruncal anomalies and to assess the clinician's ability to predict the presence or absence of 22q11.2 microdeletion on the basis of clinical features.

BACKGROUND

It is known that 22q11.2 microdeletion is a chromosomal anomaly with cardiac and extracardiac manifestations. The prevalence and manifestations in adults have not been well characterized.

METHODS

A total of 103 consecutive adults with either tetralogy of Fallot (TOF), pulmonary atresia/ventricular septal defect (PA/VSD), or truncus arteriosus (TA) were prospectively screened for 22q11.2 microdeletion using a fluorescence in situ hybridization (FISH) assay. Clinicians were asked to predict 22q11.2 microdeletion status on the basis of clinical features. A geneticist blinded to FISH assay results reviewed photographs of the patients for typical dysmorphic features of 22q11.2 microdeletion.

RESULTS

Six patients (prevalence 5.8%, 95% confidence interval 1.3 to 10.3) had 22q11.2 microdeletion (3 with TOF, 2 with PA/VSD, 1 with TA). In two of these patients, the clinician incorrectly predicted absence of the deletion. In three, typical dysmorphic features of 22q11.2 microdeletion were absent.

CONCLUSIONS

Our work showed that 22q11.2 microdeletion is under-recognized in adults with congenital heart disease. The absence of typical phenotypic features makes it difficult to correctly predict if the deletion is present. Screening for 22q11.2 microdeletion should be considered in adults with high-risk cardiac lesions, as it has important implications in reproductive counseling and surveillance for associated extracardiac manifestations.

Left heart lesions in patients with Ebstein anomaly

OBJECTIVE

To identify the incidence of left heart abnormalities in patients with Ebstein anomaly, recognizing that left-sided lesions in this patient group have been overlooked.

PATIENTS AND METHODS

According to the echocardiography database at the Mayo Clinic in Rochester, Minn, 106 consecutive patients with Ebstein anomaly underwent echocardiography between July 1, 2001, and February 28, 2003. Clinical data as well as electrocardiographic and echocardiographic reports and images were reviewed.

RESULTS

Ebstein anomaly was severe in 76 patients (72%). Previous tricuspid valve surgery was reported in 46 patients (43%), and previous closure of an atrial septal defect or patent foramen ovale was reported in 34 patients (32%). Left ventricular (LV) myocardial changes resembling noncompaction occurred in 19 patients (17.9%), LV systolic dysfunction in 7 patients (7%), LV diastolic dysfunction in 34 (36%) of 95 patients, and LV dilatation in 4 patients (4%). Additional left-sided cardiac lesions included mitral valve prolapse in 16 patients (15%), bicuspid aortic valve in 8 (8%), mitral valve dysplasia in 4 (4%), and ventricular septal defect in 8 (8%). Wolff-Parkinson-White syndrome occurred in 22 patients (21%). The QRS axis tended to be different in LV noncompaction with a mean +/- SD axis of 12 degrees +/- 74 degrees vs 36 degrees +/- 66 degrees overall (P=.08). Otherwise, there were no differences in clinical or surgical data between the groups with normal and abnormal LV myocardium.

CONCLUSIONS

In patients with Ebstein anomaly, left heart abnormalities involving the myocardium or valves were observed in 39% of patients. Ebstein anomaly should not be regarded as a disease confined to the right side of the heart.

Syndromic patent ductus arteriosus: evidence for haploinsufficient TFAP2B mutations and identification of a linked sleep disorder

Patent ductus arteriosus (PDA) is a common congenital heart disease that results when the ductus arteriosus, a muscular artery, fails to remodel and close after birth. A syndromic form of this disorder, Char syndrome, is caused by mutation in TFAP2B, the gene encoding a neural crest-derived transcription factor. Established features of the syndrome are PDA, facial dysmorphology, and fifth-finger clinodactyly. Disease-causing mutations are missense and are proposed to be dominant negative. Because only a small number of families have been reported, there is limited information on the spectrum of mutations and resulting phenotypes. We report the characterization of two kindreds (K144 and K145) with Char syndrome containing 22 and 5 affected members, respectively. Genotyping revealed linkage to TFAP2B in both families. Sequencing of TFAP2B demonstrated mutations in both kindreds that were not found among control chromosomes. Both mutations altered highly conserved bases in introns required for normal splicing as demonstrated by biochemical studies in mammalian cells. The abnormal splicing results in mRNAs containing frameshift mutations that are expected to be degraded by nonsense-mediated mRNA decay, resulting in haploinsufficiency; even if produced, the protein in K144 would lack DNA binding and dimerization motifs and would likely result in haploinsufficiency. Examination of these two kindreds for phenotypes that segregate with TFAP2B mutations identified several phenotypes not previously linked to Char syndrome. These include parasomnia and dental and occipital-bone abnormalities. The striking sleep disorder in these kindreds implicates TFAP2B-dependent functions in the normal regulation of sleep.

Peripartum Cardiomyopathy: Current Therapeutic Perspectives

Peripartum cardiomyopathy is a rare condition of unclear etiology that accounts for an important percentage of pregnancy-related deaths. Deaths from peripartum cardiomyopathy can be attributed to profound left ventricular failure, thromboembolic events, or arrhythmia. Prompt recognition of the condition, initiation of appropriate medical management, collaboration with perinatology for delivery management, referral to cardiac transplant centers when necessary, and counseling regarding future pregnancies is required for a successful outcome. Patients should be diagnosed by clinical evaluation and echocardiography. After establishing left ventricular dysfunction, a standard heart failure medical regimen should be instituted. Hospitalization should be considered for patients with class III or greater symptoms, or for those patients not responding to outpatient management. If the diagnosis is made in the antepartum period, delivery should be strongly considered. Endomyocardial biopsy has low yield in this situation and should not be considered standard care, especially because controversy exists over the effectiveness of immunosuppressive therapy for myocarditis. Selenium, pentoxifylline, and immune globulin have all been shown to have a beneficial effect in small series of patients. The addition of these agents to standard therapy, however, should be considered on a case-by-case basis. Anticoagulation should be considered in patients with ejection fractions less than 35%. Transplantation results in survival comparable to women with idiopathic-dilated cardiomyopathy, and should be pursued in the appropriate setting. Future pregnancies should be discouraged, even if the left ventricular function recovers. Significant improvement in ventricular function can be expected in up to 50% of patients.

Survey of specialized tertiary care facilities for adults with congenital heart disease

BACKGROUND

Specialized tertiary care facilities developed in response to the increasing numbers of adults with congenital heart disease (CHD). Because this patient population comprises a relatively new area of specialized cardiovascular interest, the first facilities necessarily evolved without preexisting guidelines or interaction.

OBJECTIVES

To characterize the major features of the six original and largest tertiary adults CHD facilities.

METHODS

Written questionnaire sent to six participating facilities in North America and Europe. Information was analyzed centrally.

RESULTS

All but one facilities was established over 20 years ago, and each cares for over 1500 patients. Hospital admissions ranged from 100 to 660 patients/unit/year. Of the total number of registered patients, 52-81% had undergone one or more reparative surgeries. Reoperations constituted 25-80% of the 50-170 operations/unit/year. Overall mean surgical mortality was 1.9%/year. Inpatient and outpatient care was provided in adult (n = 4) or both adult and pediatric (n = 2) settings. All six facilities enjoyed close collaboration between adult and pediatric cardiologists, cardiac surgeons, nurse specialists and cardiac and non-cardiac consultants. Training and research were pivotal activities.

CONCLUSIONS

Provision of comprehensive care by multidisciplinary teams including adult and pediatric cardiologists, cardiac surgeons, specialized nurses and other cardiac and non-cardiac consultants was the unifying feature for all six tertiary care facilities reported here. There were minor differences among them based on available resources, local expertise and national health care policies. There appears to be a significant shortfall in tertiary care provision for the adult with CHD that requires further planning and resource allocation. These data may be useful for new and evolving adult CHD services.

Outcomes of pregnancy in women with tetralogy of fallot

OBJECTIVES

We sought to determine pregnancy outcomes in patients with tetralogy of Fallot (TOF).

BACKGROUND

Pregnancy outcomes in patients with TOF are incompletely defined.

METHODS

Clinical, hemodynamic, and obstetric data were reviewed for women with TOF and prior pregnancy.

RESULTS

Of 72 respondents, 43 (mean age, 26 years) had 112 pregnancies (range, 1 to 5); 82 pregnancies were successful. Eight women had unrepaired TOF at the time of their 20 successful pregnancies. At first assessment (age > or =18 years), six patients had pulmonary hypertension, three had moderate or severe right ventricular (RV) systolic dysfunction, and 13 had severe RV dilation due to pulmonic regurgitation. Sixteen patients had 30 miscarriages (27%) and one term stillbirth. Mean overall birth weight was 3.2 kg (range, 2.1 to 4.2 kg). Unrepaired TOF (p = 0.05) and morphologic pulmonary artery abnormality (p = 0.03) were independently predictive of infant birth weight. Six patients had cardiovascular complications during pregnancy: supraventricular tachycardia in two, heart failure in two, pulmonary embolism in a patient with pulmonary hypertension, and progressive RV dilation in a patient with severe pulmonic regurgitation. Five infants (6%) had congenital anomalies.

CONCLUSIONS

Patients with TOF have an increased risk of fetal loss, and their offspring are more likely to have congenital anomalies than offspring in the general population. Adverse maternal events, although rare, may be associated with left ventricular dysfunction, severe pulmonary hypertension, and severe pulmonic regurgitation with RV dysfunction.

Noncompacted myocardium in ebstein's anomaly: initial description in three patients

Exercise intolerance in Ebstein's anomaly is usually attributed to desaturation secondary to right-to-left shunting as a result of a small or distorted left ventricle (LV), significant tricuspid valve regurgitation, right ventricular dysfunction, or a combination of these. We observed one boy (age 15 years) and two women (ages 20 and 29 years) with severe Ebstein's anomaly and strikingly abnormal LV myocardium resembling the features described for LV noncompaction. LV size and systolic function were normal in the two women; the boy had a dilated LV with severely diminished ejection fraction. The LV myocardium was found to be unusually coarse and hypertrabeculated, with small intertrabecular recesses and an irregular endocardial surface. The findings in these 3 patients represent the whole spectrum of mild to severe LV noncompaction. Diastolic dysfunction was present in 2 of the 3 patients. Exercise tolerance was diminished in all. There was no mitral or aortic valve disease. The 15-year-old boy underwent heart transplantation 6 months later for biventricular failure. Thus, Ebstein's anomaly does not seem to be a pathology confined to the right ventricle, but may rarely lead to LV noncompacted myocardium. This LV pathology may be an additional explanation for exercise intolerance or signs of left heart failure in patients with Ebstein's anomaly.

Late results of the peel operation for replacement of failing extracardiac conduits

BACKGROUND

Pulmonary ventricle to pulmonary artery conduits have made repairing many complex congenital cardiac anomalies possible. Late patient outcome is adversely affected by the hemodynamic consequences of conduit failure and the need for reoperation for conduit replacement.

METHODS

We retrospectively reviewed 102 patients (65 males, 37 females) who underwent operation with autologous tissue reconstruction ("peel operation") between May 1983 and November 2001, in which a prosthetic roof was placed over the fibrous bed of the explanted conduit. Ages ranged from 5 to 58 years old (median age 19 years old). Explanted conduits were Hancock (n = 54), homograft (n = 21), Tascon (n = 11), and other (n = 16). The conduit roof was constructed with pericardium (n = 91) and other (n = 11). A prosthetic pulmonary valve was utilized in 68 patients: porcine in 65 patients and mechanical in 3 patients. A nonvalved reconstruction was performed in 34 patients. Concomitant cardiac procedures were performed in 66 patients.

RESULTS

Early mortality overall was 2% (n = 2) and was 0% for patients who underwent isolated conduit replacement (n = 36). Mean follow-up was 7.6 years (maximum, 19 years). Overall survival at 10 and 15 years was 91% (84.7, 97.2) and 76% (62.8, 91.7), respectively. Nine patients required reoperation related to the peel operation: regurgitation in nonvalved conduit (n = 7); moderate pulmonary bioprosthesis stenosis and regurgitation with atrial arrhythmia (n = 1); and pulmonary bioprosthesis endocarditis (n = 1). Overall survivorship free of reoperation for peel reconstruction failure at 10 and 15 years was 90.7% (82.6, 99.6) and 82% (69.4, 97.0), respectively. Survivorship free of reoperation for patients with a prosthetic valve was 93.7%, and for those with no prosthetic valve was 80.0% at 15 years (p = 0.57). At late follow-up, 89% of patients were in New York Heart Association functional class I or II.

CONCLUSIONS

The peel operation simplifies conduit replacement, can be performed with low risk, and provides a generous-sized flow pathway. In our experience late results demonstrate a lower freedom from reoperation than conventional prosthetic or homograft conduits.

Intracranial aneurysms in patients with coarctation of the aorta: a prospective magnetic resonance angiographic study of 100 patients

OBJECTIVE

To determine the frequency of intracranial aneurysms (IAs) detected in patients with coarctation of the aorta (CoA) with use of magnetic resonance angiography.

PATIENTS AND METHODS

From January 1, 1980, to September 30, 2002, 277 adult patients with CoA were seen at the Mayo Clinic in Rochester, Minn, and were invited to participate in a study to detect IAs. Of these 277 patients (mean +/- SD age, 41.6 +/- 16.5; 70 men), 100 underwent cranial magnetic resonance angiography.

RESULTS

Ten patients had an IA (95% confidence interval, 5%-18%), with a mean diameter of 3.5 mm (range, 2.0-8.0 mm). The frequency of IA was significantly higher than that predicted in the general population (10% vs 2%; P < .001). One patient had surgical intervention. No clinical or geographical differences were found between patients with CoA and IA and patients with CoA and no IA.

CONCLUSIONS

The frequency of IA among patients with CoA is approximately 5-fold that of the general population. Although no risk factors were identified in this cohort, additional prospective evaluation is warranted. These data suggest that noninvasive cerebral imaging to screen for IA should be considered in patients with CoA.

Surgical management of atrial tachyarrhythmias associated with congenital cardiac anomalies: Mayo Clinic experience

Patients with congenital cardiac anomalies that cause right or left atrial dilatation may have associated atrial tachyarrhythmias, including atrial fibrillation and atrial flutter. Congenital cardiac anomalies may also be associated with Wolff-Parkinson-White syndrome or atrioventricular nodal re-entrant tachycardia. In addition, atrial arrhythmias may develop late after definitive operation for congenital cardiac anomalies, especially after the Fontan procedure. Ebstein's anomaly is the most common congenital cardiac anomaly associated with atrial arrhythmias. Atrial arrhythmias cause significant morbidity and mortality, as well as sudden death. Advances in electrophysiologic catheterization and surgical techniques have allowed the diagnosis, localization, and successful treatment of these arrhythmias.

Low pressure giant pulmonary artery aneurysms in the adult: natural history and management strategies

OBJECTIVE

To describe aspects of the natural history and pathophysiology of giant low pressure pulmonary artery aneurysms and to propose potential surgical strategies.

DESIGN

Cross sectional retrospective review.

SETTING

Supraregional tertiary referral centre.

PATIENTS

All adult patients referred for assessment of giant pulmonary artery aneurysm retrospectively identified from the Mayo Adult Congenital Heart Disease Clinic database.

METHODS

Patient data were reviewed from hospital records, including echocardiograms, magnetic resonance images, radiographs, and histology slides.

RESULTS

Four patients were identified with a median age of 52 years (range 37-64 years). Presenting symptoms were effort related dyspnoea, chest discomfort, and hoarseness in one patient. All patients had pulmonary regurgitation and clinical evidence of right ventricular enlargement in association with a pulsatile mass at the upper left sternal edge. Transthoracic echocardiography showed the giant pulmonary artery aneurysm involving the main pulmonary artery and proximal branches, and confirmed severe pulmonary regurgitation in all patients. None of the patients had intimal tearing, medial dissection, or pulmonary arterial rupture. The pulmonary valve was replaced to relieve symptoms and preserve right ventricular function. Pulmonary arterial histology showed medial degeneration of elastic fibres with accumulation of basophilic ground substance.

CONCLUSIONS

Rupture or dissection of these low pressure aneurysms is rare. The timing of surgical intervention should be determined by changes in right ventricular size and function resulting from pulmonary regurgitation or pulmonary stenosis, and not the size of the aneurysm.

The modified Fontan procedure: early and late results in 132 adult patients

OBJECTIVE

The modified Fontan procedure, usually performed in children, is used for the treatment of anomalies with a single functional ventricle. We reviewed our experience with the modified Fontan procedure performed in the adult patient.

METHODS

Between October 1973 and May 2001, the modified Fontan procedure was performed on 132 adult patients (74 men, 58 women). Median age was 23 years (range, 18 to 53 years). Diagnoses included tricuspid atresia in 34 patients (26%), double-inlet left ventricle in 48 (36%), and complex lesions in 50 (38%). The majority of patients (89%) had at least one prior palliative procedure; the most common procedures were Blalock-Taussig shunt in 85 patients and Glenn anastomosis in 31.

RESULTS

Operations included an atriopulmonary connection in 74 patients, lateral tunnel in 27, intra-atrial conduit in 14, right atrium-to-right ventricle in 9, extra-cardiac conduit in 3, and other in 5. Overall early mortality was 8.3%. Mortality was 6.5% for operations performed after 1980. This is comparable to the mortality of the modified Fontan procedure performed in children during the same time interval at our institution. All 7 of the early deaths since 1980 occurred in the complex lesion group. Morbidity included prolonged pleural effusion in 36 patients, atrial arrhythmias in 25, reoperation for bleeding in 13, permanent pacemaker in 8, and stroke in 2. Mean follow-up was 9.1 years with a maximum of 21.2 years. Actuarial survival for early survivors was 89% (84,95), 75% (67,84), and 68% (58,79) at 5, 10, and 15 years, respectively. Freedom from late reoperation was 89% (83,95), 85% (78,93), and 80% (70,91) at 5, 10 and 15 years, respectively. The majority (90%) of present survivors were New York Heart Association class I or II at follow-up.

CONCLUSIONS

In properly selected adult patients with functional single ventricle, the modified Fontan procedure can be performed with early mortality similar to younger patients. Early mortality is more likely with complex lesions. The majority of late survivors have a good quality of life.

Outcome of the unoperated adult who presents with congenitally corrected transposition of the great arteries

OBJECTIVES

The goal of this study was to determine the presentation and outcome of the unoperated adult with congenitally corrected transposition of the great arteries.

BACKGROUND

The presentation of this disorder and the outcome in unoperated adults have not been well defined.

METHODS

All unoperated patients > or =18 years old were evaluated for spectrum of disease, hemodynamic severity, timeliness of diagnosis and referral, and outcome.

RESULTS

Forty-four patients aged 20 to 79 years (mean, 44) were followed up to 144 months. In 29 (66%), the correct diagnosis was first made at age > or =18 years; the diagnosis was missed in seven of these patients in a prior cardiology consultation, despite cardiac imaging. Systemic atrioventricular valve (SAVV) regurgitation (grade > or =3/4) was noted in 26 patients (59%). Thirty (68%) had surgical intervention, including SAVV replacement in all, with no early mortality. Preoperatively, this subset had significant dysfunction of the systemic ventricle (SV) (ejection fraction [EF], 40 +/- 10%), and most had advanced symptoms (25 with ability index > or =2/4). In 16 (53%), SAVV regurgitation > or =3/4 and ventricular dysfunction had been documented for >6 months. The mean EF of the SV decreased significantly postoperatively (34 +/- 11%, p = 0.006). Four patients (13%) eventually required cardiac transplantation. Poor preoperative EF of the SV predicted eventual need for transplantation (p = 0.001).

CONCLUSIONS

Patients with unoperated congenitally corrected transposition of the great arteries are often misdiagnosed in adulthood and are referred late despite symptomatic SAVV regurgitation and significant SV dysfunction. Although excellent early surgical results can be achieved, significant residual dysfunction of the SV is common.

Spectrum of reoperations after repair of aortic coarctation: importance of an individualized approach because of coexistent cardiovascular disease

OBJECTIVE

To determine the indications for and spectrum of late reoperations in adults who had previously undergone coarctation repair.

PATIENTS AND METHODS

We reviewed clinical, cardiac catheterization, and echocardiographic data and criteria for reoperation, surgical procedures, and outcome in 43 patients who underwent 54 reoperations between 1972 and 1996.

RESULTS

Of the reoperations for recoarctation or associated cardiovascular disease (or both), 20% were performed in asymptomatic patients and 80% in symptomatic patients. Associated cardiovascular disease included bicuspid aortic valve in 36 patients (84%), aortic arch hypoplasia in 12 (28%), true or false aortic aneurysm in 6 (14%), mitral valve disease in 6 (14%), and subvalvular aortic stenosis in 5 (12%). Surgical procedures included 22 recoarctation repairs and 32 other cardiovascular interventions. Simultaneous repair of recoarctation and associated cardiovascular disease was performed as a single-stage repair in 5 reoperations through a median sternotomy using an extra-anatomic, ascending-to-descending aortic bypass, with no complications. One patient died (surgical mortality, 1.9%) of preexisting severe pulmonary vascular obstructive disease.

CONCLUSIONS

After coarctation repair, associated cardiovascular diseases are the most common cause for reoperation. An individualized surgical approach is important and may range from valve replacement or recoarctation surgery to extra-anatomic bypass combined with other cardiovascular procedures, enabling simultaneous repair of recoarctation and associated lesions. Despite complex surgical techniques and multiple reoperations, morbidity and mortality were low in our series.