Anterograde stent implantation for treatment of recurrent coarctation after Norwood operation

Recoarctation of the aorta after the Norwood procedure may be treated during the second stage of the surgical palliation

OBJECTIVES

Recoarctation of the aorta (re-CoA) after the Norwood procedure is traditionally treated during catheter-based aortoplasty (CB-A) performed as a separate procedure preceding stage II surgical palliation (S II SP). Our goal was to determine the efficacy of the protocol according to which re-CoA after the Norwood procedure in patients with hypoplastic left heart syndrome is treated during S II SP using hybrid catheter-based aortoplasty.

METHODS

We compared 2 groups of infants who developed re-CoA after the Norwood procedure and were treated at the same institution: In group I (n = 18), CB-A was traditionally performed before S II SP; in group II (n = 15), CB-A was performed during S II SP using a hybrid procedure (catheter access was through an aortic cannula routinely used for cardiopulmonary bypass). The right ventricular fractional area change was analysed.

RESULTS

The CB-A was performed effectively in both groups. S II SP was performed at a younger age in group II (5.4 ± 0.3 vs 6.0 ± 0.4 months; P = 0.003), with lower body weight (5.6 ± 0.5 vs 6.0 ± 0.4; P = 0.03, respectively). The duration of hospital stay did not differ between the groups (10.6 ± 6.2 vs 11.6 ± 6.4 days; P = 0.91). The right ventricular fractional area change measured before S II SP was higher in group I (39.7 ± 4.2% vs 36.8 ± 3.6%, respectively; P = 0.009), but the difference was not seen 1 month after S II SP (41.0 ± 5.6 vs 39.8 ± 4.1; P > 0.05). The total radiation dose was significantly lower in group II.

CONCLUSIONS

re-CoA after the Norwood procedure in patients with hypoplastic left heart syndrome can be treated effectively during S II SP using a hybrid procedure. The strategy allows for reduction of the total radiation dose and of the number of procedures and does not prolong the postoperative course, even in patients with decreased right ventricular systolic function.

Experience of stent implantation for recurrent aortic arch obstruction following Norwood or Damus-Kaye-Stansel operation over the last decade

BACKGROUND

Recurrent aortic arch obstruction following the Norwood procedure is recognised as an important complication. Balloon arch angioplasty is associated with a high recoarctation rate.

METHODS

We sought to evaluate the prevalence and outcome of stent implantation for recoarctation in children following Norwood or Damus-Kaye-Stansel procedure over the past decade at a single national cardiology centre.

RESULTS

Of 114 children who underwent Norwood procedure or Damus-Kaye-Stansel procedure between January 2003 and June 2013, 80 patients survived. Of these 15 children underwent stent implantation for recoarctation. Six of these patients had previous balloon angioplasty. The median age at stent implantation was 4.4 months (range 2-82 months). The median peak aortic arch gradient at catheterisation decreased from 26mmHg (range 10-70mmHg) to 2mmHg (range 0-20mmHg). The median luminal diameter increased from 4.7 mm (range 3.2-7.9 mm) to 8.6 mm (range 6.2-10.9 mm). The median coarctation index increased by 0.49 (range = 0.24-0.64). A Valeo stent was employed in 11 children, a Palmaz Genesis stent in 2 patients, a MultiLink stent in 1 child, and a Jomed covered stent in 1 child. Two factors were associated with the need for stent placement: previous arch angioplasty (p valve < 0.001, χ-square 11.5) and borderline left ventricle (p = 0.04, χ-square = 4.1). Stent migration occurred in one child. There were two deaths related to poor right ventricular systolic function and severe tricuspid regurgitation. Six patients underwent redilation of the stent with no complications.

CONCLUSIONS

The prevalence of recurrent aortic arch obstruction following Norwood/Damus-Kaye-Stansel procedure was 18%. Stent implantation is safe and reliably eliminates the aortic obstruction. Redilation can be successfully achieved to accommodate somatic growth or development of stent recoarctation.

"Intraoperative hybrid stenting of recurrent coarctation and arch hypoplasia with large stents in patients with univentricular hearts"

BACKGROUND

Obstruction of the reconstructed aortic arch, tubular hypoplasia and recurrent coarctation (RC) is an important risk factor in univentricular physiology. For the past two years we have adopted the concept of intraoperative hybrid stenting of RC and arch hypoplasia with large stents in patients with univentricular hearts as standard care procedure.

METHOD/RESULT

Retrospective analysis of the anatomy and procedural outcome of 14 patients was scheduled for intraoperative stenting of the aortic arch (12 during surgery for BCPS, 2 during Fontan completion). The median age was 5.3 months, weight 5.5 kg, height 62 cm. Five patients had tubular hypoplasia and 9 patients had distal stenosis of the aortic arch. Nine patients had a previous balloon dilatation. The mean diameter of the distal arch was 11.0mm, at the coarctation 5.1mm, at the level of the diaphragm 8.2mm (CoA-index 0.62). Intraoperative stenting was performed in 13/14 patients. Stents were implanted with a mean balloon diameter of 10.8mm (SD 3.4mm). The achieved final mean diameter was 9.8mm (mean, SD 2.8mm) with an oversized Coa-index of 1.2. There was no re-coarctation at a mean follow-up of 7.3 months (range 3 to 24), the maximum flow velocity of 2m/s across the stented lesion assessed by ECHO.

CONCLUSION

This hybrid approach is an easy and safe concept to manage recurrent aortic arch hypoplasia and stenosis. The use of large stents allows redilatation to adult size diameters later on.

Pseudoaneurysm following percutaneous balloon angioplasty for aortic arch recoarctation after the Norwood procedure

We experienced a rare case of 5-month-old male infant presenting with a pseudoaneurysm following percutaneous balloon angioplasty for aortic arch recoarctation after undergoing the Norwood procedure. The pseudoaneurysm, which measured 1 cm in diameter, was located between the left carotid artery and the left subclavian artery. Under deep hypothermic circulatory arrest, resection of the pseudoaneurysm and reconstruction of the neoaortic arch were performed successfully.

Pathology of the aortic arch in hypoplastic left heart syndrome: surgical implications

Aortic arch reconstruction plays an important role in the success of the Norwood procedure (NP) for hypoplastic left heart syndrome (HLHS). This study investigated the cardiac specimens to determine the etiology of distal aortic arch obstruction after the NP for HLHS and to locate coarctation of the aorta in HLHS untreated by surgery. This study examined 17 cardiac specimens: 9 that had NP and 8 not treated by surgery. The findings after NP showed frequent failure to resect the coarctation segment completely and failure to extend the augmentation patch into the descending aorta. Five (62.5%) of the eight hearts not treated by surgery had significant periductal coarctation of the aorta. After NP for nine patients, three (33%) had residual coarctation of the aorta. To minimize the risk of recurrent or persistent aortic arch obstruction after NP and to improve the long- and short-term outcome, the ductal tissue and the coarctation segment encircling the aortic lumen should be resected. The distal wall incision should be extended at least 5 mm beyond the distal aspect of the ductal tissue. These steps could avoid major aortic arch obstruction, promote growth of the native aortic tissue, and avoid ventricular dysfunction.