Considerations in the surgical management of infantile coarctation of aorta

Surgical management of the infant with coarctation of the aorta and ventricular septal defect

Clinical and cardiac catheterization data were collected from 39 infants with coarctation of the aorta and ventricular septal defect, 31 of whom were initially managed only by surgical repair of coarctation. Data were analyzed to determine mortality, morbidity, outcome and factors that might predict survival or the need for septal defect closure. Of the eight patients who did not require surgical treatment before 3 months of age, seven underwent coarctation repair alone at a mean age of 2.3 years. Of the 23 infants managed with coarctation repair alone, before age 3 months, 9 needed no additional surgical treatment and 6 required early and 8 required late repair of the ventricular septal defect. Seven infants underwent coarctation repair and simultaneous pulmonary artery banding and one eventually required debanding after spontaneous closure of the septal defect. The overall mortality rate in this series was 10.3% (mean follow-up time 5.7 years). Of 39 infants, 16 (41%) never required a second operation for ventricular septal defect closure. For patients who had only coarctation or coarctation repair with pulmonary artery banding at less than 3 months of age, ventricular septal defect size was categorized as small (less than 0.5 cm/m2), moderate (less than 1 cm/m2) or large (greater than 1 cm/m2) on the basis of defect size at operative repair or echocardiographic or angiographic assessment. Defect size did not necessarily correlate with the need for operative repair.(ABSTRACT TRUNCATED AT 250 WORDS)

Operative repair of coarctation of the aorta in infancy: results with and without ventricular septal defect

Coarctation of the aorta (CA) presenting in infancy is a life-threatening condition, especially if associated with intracardiac left-to-right shunts. Between 1971 and 1980, 51 infants with symptomatic CA have been diagnosed and treated. Ventricular septal defect (VSD) was present in 18 patients and patent ductus arteriosus in 24. End-to-end repair was performed in 20 patients, 17 (85%) of whom were long-term survivors. Subclavian flap angioplasty repair was used in 28 patients, of whom 25 (89%) were long-term survivors. During long-term follow-up 6 patients (35%) who underwent end-to-end repair had recurrent CA, whereas only 3 patients (12%) who underwent subclavian flap angioplasty had recurrent CA (p less than 0.05). The mortality rate in patients with associated VSD was higher (4 of 18, 22%). Pulmonary trunk banding with subsequent VSD repair was associated with a better survival (13 of 14 patients, 90%) than when banding was not performed (2 of 5 patients) (p less than 0.05). These results suggest subclavian flap angioplasty is the preferred treatment for symptomatic CA occurring in infancy. Concomitant pulmonary trunk banding in patients with VSD can be performed with the expectation of a lower mortality at subsequent VSD repair.

Coarctation of the aorta in the newborn: a clinical study

The clinical findings and presentation in nine consecutive neonates in whom coarctation of the aorta was diagnosed over a period of two years were reviewed. Coarctation of the aorta constituted 16% of all infants with congenital cardiovascular malformations admitted to the Neonatal Intensive Care Nursery. The mean age on admission was 8.3 days. The admission findings included absent femoral pulses, 5; feeble femoral pulses, 4; differential blood pressure between upper and lower extremities, 9; congestive heart failure, 8; hypertension, 2; and failure to thrive, 1. Five of the infants died owing to refractory congestive heart failure at the mean age of 10.2 days. It is emphasized that palpation of the femoral pulse should be a routine examination in the neonatal period in order to detect coarctation of the aorta and that surgical intervention may be considered in cases refractory to medical management.

Surgical management of coarctation of aorta with ventricular septal defect. Multivariate analysis

Optimal management of coarctation with ventricular septal defect is difficult. Should one treat the coarctation, the ventricular septal defect, or both? This dilemma was investigated by reviewing 39 successive patients, aged less than 4 months, undergoing coarctation repair without pulmonary artery banding. Twelve hospital deaths occurred. Ventricular septal defect size was graded "blind" according to preoperative angiocardiographic and haemodynamic findings. Of 14 patients classified as having a large ventricular septal defect, necropsy and operative findings in eight showed defects 7 to 12 mm in diameter. Factors associated univariately with significantly increased mortality were young age, raised atrial and ventricular end-diastolic pressures, low weight, high admission blood urea, preoperative ventilation, and a large ventricular septal defect. All but the last two were also closely associated with each other. A jack-knifed discriminant function based upon ventricular septal defect size, blood urea, pulmonary venous oxygen content, and inferior caval oxygen saturation correctly predicted outcome in 78.9% of patients. Combinations of these four giving a probability greater than 0.9 of survival were rare with blood ureas above 8 mmol/litre. Raised blood urea was associated with low descending aortic pressure and subsequent dialysis. Only patients with a large ventricular septal defect stand to benefit from pulmonary artery banding at initial operation. Preoperative treatment to increase renal blood flow (prostaglandins, dopamine) may improve overall survival.

Surgical management of neonates with complex preductal aortic coarctation

Neonates having repair of aortic coarctation commonly have associated ventricular septal defect and patent ductus arteriosus. Prostaglandin E1 is used to dilate the ductus and improve the patient's preoperative condition. An operative technique that maintains ductal patency until the final stages of anastomosis is presented. We believe it has contributed to our present improved results.

Methods of management and results following surgery for coarctation of the aorta in infancy

There were 30 infants, under 1 yr of age, in refractory congestive heart failure, who underwent surgical correction for coarctation of the aorta. The series was divided into two groups, depending on the type of surgical procedure performed: Group 1, 17 patients end-to-end anastomosis; Group 2, 13 patients aortic angioplasty. Aortic angioplasty was carried out by three methods. Ten patients had a subclavian flap angioplasty as described by Waldhausen in 1966. In two patients a carotid artery flap angioplasty was used to enlarge a severely hypoplastic aortic arch distal to the left carotid artery. In one patient an onlay patch of pericardium was used to relieve obstruction across a coarcted segment. Mortality rates in this series and other series from the literature are primarily dependent upon associated cardiac anomalies. Mortality rates approach zero in infants operated on for coarctation who have no associated intracardiac anomalies. While the mortality rate was slightly lower in those patients treated by some type of angioplasty, the figures are too small to be significant. In this series and other series recoarctation is far less likely to occur after subclavian flap angioplasty in comparison to those patients undergoing end-to-end anastomosis. We would advise that in infants 1 yr of age, a subclavian or carotid flap angioplasty be used as a primary method of repair.

Critical aortic coarctation: patch aortoplasty in infants less than age 3 months

Twenty-three infants less than age 3 months (mean age 31 days) underwent patch aortoplasty for relief of coarctation of the aorta. All had intractable congestive heart failure, despite aggressive medical therapy. Each infant had other cardiac anomalies, including patent ductus arteriosus (83 percent) and ventricular septal defect (74 percent). All patients underwent closure of the ductus arteriosus and patch angioplasty of the aorta to produce a luminal diameter of at least 16 mm. In addition, 9 of the 17 patients (53 percent) with a large shunt ventricular septal defect underwent pulmonary arterial banding. There was one hospital death 42 days after operation secondary to bowel perforation and sepsis. Hospitalization beyond 21 days postoperatively was always due to other unrepaired cardiac lesions. The three late deaths at 3, 9 and 18 months after operation were associated with additional major anomalies. Fourteen patients have had postoperative catheterization. No gradient was found across the site of coarctation repair, but one patient had a gradient between the left carotid and left subclavian arteries. Surgical repair of critical coarctation of the aorta in infants can safely be offered despite the presence of other cardiac anomalies.

Congenital heart disease in the first month of life

During the years 1963--73, 276 children with congenital heart disease were admitted to this hospital during their first month of life. Ventricular septal defect was the most common cardiac anomaly and this lesion, together with transposition of the great arteries, comprised 35% of all cardiovascular malformations. Extracardiac malformations were found in 86 patients. The cumulative survival rate for all patients was 66% in the first month of life and 33% in the first year. Forty-three patients were operated upon, but it is estimated from necropsy reports and available clinical data that another 74 patients, who died without operation, would have been suitable candidates for total corrective surgery.

Real-time cross-sectional echocardiographic diagnosis of coarctation of the aorta: a prospective study of echocardiographic-angiographic correlations

Real-time cross-sectional echocardiographic sector scan examinations were performed from a suprasternal notch location to image aortic anatomy in 15 children (ages 1 day to 21 years) who were subsequently shown at cardiac catheterization to have coarctation of the descending thoracic aorta. The resulting echocardiographic images of the ascending, transverse and descending aorta imaged juxtaductal coarctation in all 15 patients. Echocardiography predicted discrete coarctation of the aorta in eight, isthmic hypoplasia in two, hourglass type coarctation deformities in three and longer segment coarctation in four patients. Catheterization and angiography confirmed all of these anatomic observations. The control group, 100 patients with congenital heart disease but without angiographic coarctations, included four patients with right-sided aortic arch and six patients with dextrocardia. The ascending, transverse and descending aorta were adequately imaged in 94 of these and no descending aortic abnormalities were noted. This study shows the potential utility of cross-sectional echocardiography for the noninvasive precatheterization or preoperative assessment of coarctation of the aorta in children and critically ill newborns.

Coarctation of the aorta

Coarctation of the aorta is a cause of hypertension that can present dramatically in the severely ill infant or appear incidentally in the asymptomatic young adult. Coarctation is easily detected and there is good evidence that the extremely poor natural history can be altered favorably by surgical correction. The elevated blood pressure can be lowered in the majority of patients, and there is every expectation that the incidence of known complications of coarctation can be decreased. However, in about three fourths of the patients, significant residual cardiovascular defects persist, with their potential for future problems as yet incompletely defined. For this reason, patients who have undergone surgery for coarctation will need to be followed carefully for an indefinite period.

Coarctation of the aorta with ventricular septal defect

From 1965 to 1974, 53 children with coarctation of the aorta (COA) and an associated ventricular septal defect (VSD) underwent cardiac catheterization. Thirty-one patients presented with congestive heart failure. Twenty-five of 27 patients (92%) who underwent cardiac catheterization under age 3 months had either systemic hypertension, a systolic gradient across the coarctation greater than 20 mm Hg or both. Pulmonary hypertension was present in all 25 patients. COA repair was performed in 39 patients and there were seven deaths. Of the 32 survivors, 23 have no residual gradient; six are normotensive but have a mild residual gradient; three are hypertensive or have a gradient greater than 20 mm Hg. Repair of the VSD or pulmonary artery banding has been performed in 11 of 44 patients who survived infancy. Spontaneous closure of the VSD has occurred in three cases and 25 patients have a small VSD that does not warrant surgical repair. Surgical repair of COA during infancy may be unavoidable but conservative medical management of the associated VSD is often successful.