[Results of coarctectomy in newborn and young infants]

Twenty infants underwent coarctectomy between 1972 and 1979, 12 were less than one month old at surgery. One infant died after the procedure (5% mortality). Seven underwent open heart surgery later in the first year of life for associated intracardiac defects; there were 3 early and one late death. Of the 15 survivors, 12 have been followed up for 6 months to 6 years (mean 3 years). All are actually asymptomatic. Arterial blood pressure is slightly higher in the leg than in the arm in 8 patients (as in normal children), equal in leg and arm in 2 and lower in the leg than in the arm in 2 (recoarctation). Postoperative catheterization was done in six patients. A pressure gradient across the anastomotic site was confirmed in two (32 and 28 mm Hg). In the other four, no pressure gradient was found, and the site of the anastomosis was hardly or not at all detectable on the angiogram. Coarctectomy in newborns and infants now carries a low operative mortality. With proper operative technique, normal growth of the anastomotic site is usually obtained.

[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.

Subclavian flap repair of coarctation of the aorta in neonates. Realization of growth potential?

The subclavian flap repair for coarctation of the aorta allows potential for growth by utilizing autogenous tissue. Although well documented in young children, its promise in the tiny neonate warrants further evaluation. Since August, 1979, 29 patients, including 24 infants, have undergone subclavian flap repair at the University of Maryland Hospital. Weights ranged from 1.4 to 5 kg (mean 3.2 kg). All patients less than 6 months old had associated intracardiac defects and were in severe congestive failure. Fifteen responded to preoperative prostaglandin infusions. The overall early mortality was 14%; among the neonates it was 21%; and among those operated upon within the first week of life, 33%. There was one intraoperative death among the eight patients who underwent simultaneous pulmonary artery banding. There were no deaths among patients older than 5 days at operation. Four of the five neonates who died had some variant of hypoplastic left heart syndrome, with severe stenosis or atresia of the systemic atrioventricular valve, critical aortic stenosis, or hypoplastic left ventricle. Twenty-two survivors continue to do well up to 3.7 years postoperatively (mean follow-up 26 months). At follow-up all patients are normotensive with brisk lower extremity pulses. Patients now weigh 1.3 to 6.9 (mean 2.3) times their operative weight, and only one patient has a measured arm-to-leg gradient greater than 10 mm Hg (mean gradient 3.7 mm Hg). Seven of the neonates have undergone repeat catheterization, and all had satisfactory growth of the subclavian flap segment of repair and no gradient. Two older patients (3 and 4 years old at operation) have undergone exercise testing 3.7 years after repair, with peak exercise gradients of only 7 and 15 mm Hg. We therefore continue to utilize this technique for the treatment of coarctation even in tiny neonates.

Coarctation repair with prosthetic material: surgical experience with aneurysm formation

BACKGROUND

Late aneurysm formation is a common complication after repair of an aortic coarctation with prosthetic material; its incidence varies between 5 and 46%. We reviewed our experience with the management of this complication and propose a radical surgical treatment, which has proved to be free from severe complications; furthermore, we suggest the possibility of a new percutaneous management of this complication.

METHODS

From September 1974 to November 2002, 195 patients underwent primary repair of an aortic coarctation with prosthetic material (Dacron, polytetrafluorethylene or heterologous pericardium), with patch aortoplasty as the most common technique. During the follow-up period, reoperation for aneurysm formation was required in 13 asymptomatic patients. The diagnosis was made at angiography in 3 patients and at magnetic resonance imaging in 10. The indication for reoperation was an isthmic-diaphragmatic aortic diameter ratio > 1.5. Aneurysmectomy and tube graft interposition was performed in 12 patients; femoro-femoral cardiopulmonary bypass with a period of deep hypothermic circulatory arrest was carried out in 7 cases while 5 patients were submitted to normothermic atrio-femoral bypass; 1 patient underwent endovascular prosthesis implantation.

RESULTS

There were no in-hospital deaths. Three patients experienced postoperative complications: bleeding (n = 1), left phrenic nerve paresis (n = 1), and chylothorax (n = 1). The mean follow-up period was 51.8 +/- 46.2 months; all patients were asymptomatic without clinical or instrumental evidence of recurrence.

CONCLUSIONS

Aneurysm formation after primary repair of an aortic coarctation using prosthetic material is a potentially worrisome late complication and lifelong surveillance of these patients by means of magnetic resonance is mandatory. Surgical management, when indicated, has proved to be a definitive treatment and free from major complications. In highly selected patients, interventional management by percutaneous techniques may provide promising results.

[Aortic coarctation in the first 3 months of life. Surgical results]

Between January 1973 and September 1989, 51 patients younger than 3 months with coarctation of the aorta underwent surgery. All of them had atrio-ventricular and ventriculo-arterial concordance with well developed ventricular cavities. Thirty-four were male and 17 female. Thirty five had associated anomalies and catheterism was done in 36 before surgical correction. The surgical procedures we used were 19 subclavian plasty (Waldhausen), 13 end-to-end anastomosis, 13 Alvarez technique and three goterex parch. Twelve died (23.5%), three during surgery and the others in a period of 3 to 20 days after surgery. Eight were younger than 17 days, seven had aortic arch hypoplasia associated and six had ventricular septal defect (five with pulmonary hypertension). Other ten developed recoarctation (gradient greater than 20 mmHg) between 10 days and 8 months after first intervention (media = 3 months). Five had previously end-to-end correction (41.6%), two angioplasty with parch (66%), two Alvarez (20%) and one Waldhausen (7%). The correction of the recoarctation required surgery in 4 patients (three with angioplasty with parch and one with end to end correction), and the other six underwent angioplasty with catheter-balloon. None of the 15 patients without previous catheterism died, and neither did those who underwent surgery during the last 4 years. The associated anomalies required a second time surgery. We conclude that morbimortality is related to the aortic arch hypoplasia, pulmonary hypertension and surgery during the first 2 weeks. We recommend surgery without previous catheterism. The recoarctation is more frequent in patients with end to end correction, without an increase of the mortality.

Surgical treatment of aortic coarctation in adults: Beneficial effect on arterial hypertension

BACKGROUND

The aim of this study was to determine the outcome after surgical repair of aortic coarctation in adults, analysing its effect on arterial blood pressure.

METHODS

Twenty-five adults (9 women, 16 men), mean age 43.4 years (19 to 70 years), underwent aortic coarctation surgical repair. All patients suffered from preoperative hypertension. Mean blood pressure was 182/97 mm Hg. Sixteen (64%) patients demonstrated reduced load capacity. Operative technique was resection and end-to-end anastomosis for 5 patients (20%), interposition of a Dacron-tube graft for 3 patients (12%), Dacron-patch dilatation was performed in 7 (28%) patients, and in 10 (40%) patients we performed an extra-anatomical bypass graft.

RESULTS

Early mortality occurred in 1 patient (4%). The mean blood pressure was reduced [systolic 182 mm Hg vs. 139 mm Hg (p < 0.001), diastolic 97 mm Hg vs. 83 mm Hg (p < 0.001)] in all patients. In 12 patients, blood pressure normalized immediately after surgery, in 7 patients it remained slightly elevated (systolic blood pressure between 140-160 mm Hg), and 1 patient suffered from prolonged arterial hypertension. Preoperatively, all patients were treated with antihypertensive drugs. Eleven of 20 patients received long-term medication during follow- up. In the remaining 4 patients, medication lists were unobtainable in retrospect. The mean follow-up was 7.1 years (min. 1.0 years; max. 16.6 years). One patient (5%) died from cardiac failure 12.4 years after the operation. On average, the New York Heart Association (NYHA) class was improved by 0.92.

CONCLUSIONS

The surgical repair of aortic coarctation in adults can be performed with low surgical risk. Surgery reduces hypertension and permits more effective medical treatment.

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.

Surgical repair of coarctation of the aorta in infants less than six months of age: including the question of pulmonary artery banding

High mortality rates (20% to 60%) have been reported in the repair of coarctation of the aorta in infancy. During a 4 year period, 34 infants less than 6 months of age had coarctation repair (two prior to 1976). Eleven were less than 2 weeks of age, nine were 2 weeks to 1 month, eight were 1 to 2 months, and six were 2 to 6 months. Associated lesions were patent ductus arteriosus (PDA) (82%), ventricular septal defect (VSD) (53%), and other intracardiac lesions (35%). Twenty-three patients (67%) had emergency operations; the other procedures were semielective. The indications for operation included congestive cardiac failure (91%), acidosis (32%), hypertension (29%), cardiogenic shock (26%), and cardiac arrest (18%). There was one operative death (2.9%) in a patient with severe pulmonary valve insufficiency and multiple VSDs. There was one late death a 4 months (Taussig-Bing complex). Primary repair was used in 15, patch-graft angioplasty in 19 (left subclavian artery in nine, left common carotid in one, and Dacron or pericardial patch in nine). Two (6%) required reoperation for recurrent coarctation (follow-up 3 to 36 months with a mean of 25.8). Of 15 patients with a large VSD, six had pulmonary artery banding with two deaths (one operative and one late), two had debanding plus VSD repair, and two are awaiting operation. The remaining nine patients did not have banding (no operative or late deaths), four patients required late VSD closure, two VSDs closed spontaneously, two VSDs became smaller, and one patient is awaiting VSD closure. The infrequent need for pulmonary artery banding may be partly due to "physiological banding" seen at Denver's high altitude. The VSD spontaneously closed or became smaller in 44% of nonbanded patients. The low operative mortality can be ascribed to (1) aggressive medical therapy, (2) emergency catheterization and repair, (3) avoidance of hypothermia, and (4) adequate relief of the coarctation.

Evaluation of optimum time for surgical repair of coarctation of the aorta

The results of 182 patients operated upon for coarctation of the aorta from 1953 to 1976 were reviewed. The youngest patient was three weeks old, the eldest, 60 years. One hudnred and twenty-three patients had coarctation without complications, while 59 had other cardiovascular lesions. An end-to-end anastomosis was carried out in 144 patients. Artificial grafts were inserted in 33 patients, while individual techniques were applied in five patients. There were four peroperative deaths, five postoperative deaths and four late deaths. All of these patients had multiple cardiovascular lesions. With respect to the peroperative and postoperative complications and the effect of operation on blood pressure, correction of coarctation of the aorta should be carried out between the ages of five and 15 years.

[Aortic coarctation surgically treated in the 1st year of life. Results in 36 cases]

Thirty-six infants under one year of age underwent surgical repair of coarctation of the aorta between 1968 and 1983 in our institution. Coarctation was isolated or associated to a patent ductus arteriosus in sixteen cases, while in twenty it was associated with significant intracardiac disease. Twenty-nine patients were operated on in the first three months of life and in twenty a severe heart failure was present before the operation. Nine patients (25%) died while in the hospital: all of them were less than three months of age and all but one were affected by major intracardiac anomalies and severe heart failure. Surgical repair was by subclavian flap aortoplasty in twenty-nine cases, resection with end-to-end anastomosis in three, patch aortoplasty in three and Blalock-Park anastomosis in one. Operative mortality was unaffected by the surgical technique. The surviving children were followed-up for 30 +/- 7 months; one late death occurred suddenly, two months after the repair of a ventricular septal defect. An arm/leg pressure gradient, indicative of recoarctation, was detected in five cases: only one had been repaired by the subclavian flap technique, while the others were the only survivors of the end-to-end anastomosis and patch aortoplasty group. Subclavian flap aortoplasty is suggested as the operation of choice for coarctation of the aorta in the first year of life.

Hypoplastic transverse arch and coarctation in neonates. Surgical reconstruction of the aortic arch: a study of sixty-six patients

From Jan. 1, 1983, to Jan. 1, 1988, 66 consecutive neonates with coarctation and severe hypoplasia of the transverse arch underwent coarctation repair by resection of the coarctation and reconstruction of the aortic arch. Mean age at operation was 14 +/- 8 days, ranging from 2 to 30 days; 63% of the newborn infants were less than 2 weeks of age. The coarctation was isolated in 23%, associated with a ventricular septal defect in 39%, and associated with complex anomalies in 38%, including 16 cases of transposition of the great arteries or doublet-outlet right ventricle plus ventricular septal defect, two cases of simple transposition, two of corrected transposition plus ventricular septal defect, and five cases of "hypoplastic" left ventricle. The surgical technique comprises a wide resection of the coarctation extended to the contiguous ductal tissue followed by the reconstruction of the aortic arch in bringing the descending aorta into the concavity of the aortic arch. This technique is able to relieve the obstruction of the aortic arch provided that (1) the descending aorta is widely dissected to allow mobilization and (2) the incision of the transverse arch is extended proximal to the ostium of the left carotid artery. The operation was performed through a left thoracotomy in 62 patients and through a sternotomy in four additional neonates with transposition and ventricular septal defect who underwent a one-stage repair with aortic reconstruction, closure of the defect, and arterial switch. The overall early mortality rate (less than 30 days) was 14% (9/66; 95% confidence limits = 5% to 22%), including four deaths occurring within the first month, at a concomitant or subsequent repair of the associated anomaly. There were six late deaths, all related to the associated lesions. The overall mortality rate was 23% (15/66; 95% confidence limits = 13% to 33%). The mean follow-up was 21 +/- 10 months, ranging from 6 to 66 months. Actuarial survival rates at 5 years are 72% +/- 10% for the overall group; 87% +/- 17% for simple coarctation; 88% +/- 12% for coarctation and ventricular septal defect; and 52% +/- 18% for complex coarctation. The rate of recurrent coarctation was 12.5% (95% confidence limits = 2% to 23%), leading to five reoperations with no deaths. Freedom from reoperation was 89.5% +/- 9% at 5 years. This technique of coarctation repair offers several advantages: low operative mortality, complete relief of the left ventricular obstruction, wide resection of the ductus tissue, absence of prosthetic material, and preservation of the left subclavian artery.

Recurrent obstruction after subclavian flap repair of coarctation of the aorta in infants. Can it be predicted or prevented?

Recoarctation is a problem in some patients after subclavian flap aortoplasty. To investigate the reason for recoarctation, we reviewed the records of 26 infants who underwent subclavian flap repair for symptomatic coarctation of the aorta at less than 3 months of age between June, 1979, and December, 1983. Age at repair ranged from 2 to 65 days (median 16 days) and weight from 2.1 to 4.9 kg (median 3.4 kg). In 14 patients the coarctation was associated with significant intracardiac defects (complex in six). There were two intraoperative deaths and one early death (surgical mortality 12%). The survivors were followed from 6 weeks to 66 months (median 12 months). Five survivors (22%), all operated on at less than 14 days of age, developed severe recoarctation 6 weeks to 6 months (median 5 months) after repair. The obstruction appeared to be due to lumen obliteration by shelf-life posterior wall tissue. Morphometric analysis of preoperative angiograms showed no correlation between recoarctation and distance between the left subclavian artery and the site of coarctation, length of the isthmus, diameter of the isthmus, combined cross-sectional area of the left subclavian artery and isthmus, or the ratio of the combined cross-sectional area of the left subclavian artery and isthmus to the cross-sectional area of the descending thoracic aorta. Recoarctation did not correlate with weight at operation, but it correlated significantly with age at aortoplasty (p = 0.02). The results suggest that intrinsic abnormalities of the periductal aortic wall are responsible for recoarctation after subclavian flap aortoplasty. Particular attention to this abnormal tissue at repair may prevent early recurrence in young infants.

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.

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.

Surgery for coarctation of the aorta in the neonate

Between 1972 and 1984, 100 consecutive neonates (less than or equal to 30 days old) underwent repair of coarctation of the aorta. Mean (+/- SD) age at operation was 12.0 +/- 8.0 days; mean weight was 3.1 +/- 0.5 kg. Simple coarctation was present in 29 patients (group I), 32 patients had additional ventricular septal defects (group II) and 39 patients had additional complex heart disease (group III). An associated patent ductus arteriosus was present in a total of 81 patients. Subclavian flap angioplasty (SFA) was performed in 70 patients, resection and end-to-end anastomosis (E-E) in 24 patients, and miscellaneous procedures in six patients. All SFA procedures were performed after 1977, and 87.5% of E-Es were done before 1977. The early mortality was 33.3% for patients undergoing E-E and 11.4% for those undergoing SFA. Freedom from reintervention for recoarctation after 5 years was 92.9% for patients who underwent E-E and 75.2% for those who underwent SFA. Actuarial survival at 4 years was 85.5% for group I, 79.9% for group II, and 42.9% for group III. Follow-up was 97.7% for a mean (+/- SD) of 41.9 +/- 37.1 months. It is likely that some of the differences between patients undergoing SFA and E-E with respect to early mortality and freedom from reintervention are due to the different time frames during which the procedures were done. However, neonatal ductal tissue after SFA may contract and fibrose causing recoarctation, while disadvantages related to the circumferential suture line after E-E may have been overemphasized in the past. A prospective randomized trial of these two techniques is warranted.

Coarctation and coarctation syndrome. A 5-year review

The management of and results of treatment in 57 children with coarctation of the aorta are presented. In this series, 75% of the patients presented in the 1st year of life and 51% presented as neonates. Among the 50 patients who underwent surgery the total surgical mortality rate was 14%. The higher mortality in young infants is closely related to associated cardiac anomalies. We suggest that neonates with coarctation presenting with heart failure should be operated on early, as this significantly reduces the mortality.