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Application of Modified Sliding Anastomosis in the Repair of Aortic Coarctation. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3805385. [PMID: 32509857 PMCID: PMC7245663 DOI: 10.1155/2020/3805385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/19/2020] [Accepted: 05/02/2020] [Indexed: 11/17/2022]
Abstract
Objectives To evaluate the early and midterm results of a modified sliding anastomosis technique in patients with aortic coarctation. Materials and Methods In this study, we reported a new repair method and compared the early and midterm outcome(s) with a conventional surgical approach for the management of patients with aortic coarctation. Forty-eight aortic coarctation patients with a narrowed segment length longer than 2 cm were operated at our department's pediatric surgical division. Excision of the coarctation and end-to-end anastomosis was carried out in twenty-five patients (control group). In contrast, a modified sliding technique was used for twenty-three cases in the observation group. Other accompanying cardiac anomalies simultaneously repaired included ventricular septal defect and patent ductus arteriosus. All patients received 1.5-10 years of postoperative echocardiographic follow-up. Results This is a retrospective study carried out between January 2005 and June 2018. The study population consisted of forty-eight patients, which included twenty-six male and twenty-two female patients, with an average age of 5.2 ± 1.9 months (range, 28 days to 1 year). There was no mortality. The operative time, the number of intercostal artery disconnection, the drainage volume, and arm-leg systolic pressure gradient postoperation were less in the observation group as compared to the control group (p < 0.05). Also, cases with an anastomotic pressure gradient exceeding 10 mmHg during follow-up were less in the observation group as compared to the control group (p < 0.05). The postoperative complications encountered were chylothorax (control group 2 cases vs. observation group 0) and pulmonary atelectasis (control group 4 cases vs. observation group 1). They all, however, recovered after conservative treatment. Three patients in the control group underwent balloon angioplasty (reintervention) postoperative 2-4 years due to an increase in the anastomotic pressure gradient (>20 mmHg). After reintervention, the anastomotic pressure gradient reduced to 14 mmHg, 15 mmHg, and 17 mmHg, respectively. Conclusions For long segment aortic coarctation patients (longer than 2 cm), the use of the modified sliding anastomotic technique effectively helps to retain more autologous tissues, enlarge the diameter of the anastomosis, and decrease anastomotic tension and vascular injury. Therefore, this technique provides a new idea for the surgical treatment of aortic coarctations.
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Berset SG, Dave H, Balmer C, Nowacka A, Pfister R, Myers PO, Prêtre R. Muscle-sparing aortic coarctation repair. JTCVS Tech 2020; 3:249-256. [PMID: 34317891 PMCID: PMC8302918 DOI: 10.1016/j.xjtc.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 11/10/2022] Open
Abstract
Objective Surgery for aortic coarctation repair provides excellent hemodynamic results but may be complicated by musculoskeletal issues. The purpose of the study was to determine the midterm results of a muscle-sparing surgical approach to aortic coarctation repair, with special emphasis on the repair and on the musculoskeletal changes associated with a posterior thoracotomy. Methods We included all children with aortic coarctation operated on with our minimally invasive approach between June 2002 and October 2004, with a follow-up of ≥4.5 years. Patients were assessed clinically and echocardiographically. The spine, left chest, and shoulder were assessed clinically and radiographically. Results Thirty-one children were included. The age at operation ranged from 1 day to 15 months and weight ranged from 980 g to 10 kg. All patients underwent an extended end-to-end anastomosis coarctation repair through a minimal (n = 19) or total-muscle sparing (n = 12) or extrapleural (n = 18) approach. Five patients had an additional enlargement procedure on the aortic arch. 27 patients had no residual or recurrent gradient. Four patients exhibited restenosis, for which 1 underwent a percutaneous angioplasty and 2 underwent surgical reintervention. All patients were free of hypertension. One patient had borderline values. The musculoskeletal assessment was normal in all but 3 patients. Two patients who underwent other subsequent thoracic surgeries developed thoracogenic scoliosis of moderate severity. A third patient had a left winged scapula. No rib fusion or intercostal space enlargement was found. Conclusions Compared with a conventional approach, our minimally invasive surgical approach led to excellent musculoskeletal outcomes without compromising the hemodynamic results.
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Affiliation(s)
- Stephanie G Berset
- Department of Internal Medicine, Vaud University Hospital, Lausanne, Switzerland
| | - Hitendu Dave
- Department of Cardiology, Zurich University Children's Hospital, Zurich, Switzerland
| | - Christian Balmer
- Department of Cardiology, Zurich University Children's Hospital, Zurich, Switzerland
| | - Anna Nowacka
- Department of Cardiovascular Surgery, Valais Hospital, Sion, Switzerland
| | - Raymond Pfister
- Department of Cardiovascular Surgery, Vaud University Hospital, Lausanne, Switzerland
| | - Patrick O Myers
- Department of Cardiovascular Surgery, Vaud University Hospital, Lausanne, Switzerland
| | - René Prêtre
- Department of Cardiovascular Surgery, Vaud University Hospital, Lausanne, Switzerland
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Coarctation Index Predicts Recurrent Aortic Arch Obstruction Following Surgical Repair of Coarctation of the Aorta in Infants. Pediatr Cardiol 2017; 38:1241-1246. [PMID: 28608147 DOI: 10.1007/s00246-017-1651-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 06/02/2017] [Indexed: 10/19/2022]
Abstract
Recurrent aortic arch obstruction (RAAO) remains a major cause of morbidity following surgical neonatal repair of coarctation of the aorta (CoA). Elucidating predictors of RAAO can identify high-risk patients and guide postoperative management. The Coarctation index (CoA-I), defined as the ratio of the diameter of the narrowest aortic arch segment to the diameter of the descending aorta, has been used to help diagnose RAAO in neonates following the Norwood Procedure. We sought to assess the predictive value of the CoA-I on RAAO after CoA repair in infants with biventricular circulation. Clinical, surgical, and echocardiographic data of infants with biventricular circulation following neonatal CoA repair between 2010 and 2014 were evaluated. RAAO was defined using a composite quantitative outcome variable: a blood pressure gradient >20, a peak aortic arch velocity >3.5 m/s by echocardiogram, or a catheter-measured peak-to-peak gradient >20 within 2 years of surgery. Univariate and multivariate logistic regression analyses were used. Of the 68 subjects included in the analysis, 15 (22%) met criteria for RAAO. In the multivariate model, only CoA-I (OR 35.89, 95% CI 6.08-211.7, p < 0.0001) and use of patch material (OR 9.26, 95% CI 1.57-54.66, p = 0.014) were associated with increased risk of RAAO. The odds of developing RAAO was higher in patients with a CoA-I less than 0.7 (OR 33.8, 95% CI 5.7-199.5, p < 0.001). Postoperative CoA-I may be used to predict RAAO in patients with biventricular circulation after repair of CoA. Patients with a CoA-I less than 0.7 or patch aortoplasty warrant close follow-up.
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Whiteside W, Hancock HS, Pasquali SK, Yu S, Armstrong AK, Menchaca A, Hadley A, Hirsch-Romano J. Recurrent Coarctation After Neonatal Univentricular and Biventricular Norwood-Type Arch Reconstruction. Ann Thorac Surg 2016; 102:2087-2094. [DOI: 10.1016/j.athoracsur.2016.04.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 04/27/2016] [Accepted: 04/28/2016] [Indexed: 11/30/2022]
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Abstract
Aortic coarctation is a congenital narrowing of the descend ing thoracic aorta at or near the connection of the ductus arteriosus. It is the sixth most common congenital heart disease in the pediatric age group and constitutes 8% of congenital heart anomalies. Delivering anesthesia care to children undergoing coarctation repair is challenging be cause the anesthetist and the surgeon do not have the immediate safety net provided by cardiopulmonary bypass. Once the aorta is cross-clamped and the repair begins, the anesthesiologist is at the mercy of the surgeon's technical skill and speed and the child's ability to tolerate aortic cross- clamping. This article addresses the etiology and morphol ogy of this lesion. In addition, the perioperative anesthetic management principles relating to coarctation repair are discussed.
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Affiliation(s)
- Ira S. Landsman
- Departments of Anesthesiology, Children's Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Peter J. Davis
- Departments of Anesthesiology, Children's Hospital of Pittsburgh and the University of Pittsburgh School of Medicine, Pittsburgh, PA
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Antihypertensives. Pediatr Crit Care Med 2016; 17:S101-8. [PMID: 26945324 DOI: 10.1097/pcc.0000000000000621] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypertension remains a common condition in pediatric cardiac intensive care. The physiologic effects of hypertension in this population are complex and are impacted by patient age, comorbidities, and primary cardiac disease. The objective of this study is to review current pharmacotherapies for the management of systemic hypertension in the pediatric cardiac ICU. DATA SOURCES Relevant literature to the treatment of systemic hypertension in children was included. Specific focus was given to literature studying the use of therapies in critically ill children and those with heart disease. Reference textbooks and drug packaging inserts were used for drug-specific pediatric guidelines. STUDY SELECTION A search of MEDLINE, PubMed, and the Cochrane Database was performed to find literature about the management of hypertension in children. Metaanalyses and pediatric-specific studies were primarily considered and cross-referenced. Pertinent adult studies were included. DATA EXTRACTION Once the studies for inclusion were finalized, priority for data extraction was given to pediatric-specific studies that focused on children with heart disease and critical illness. CONCLUSIONS Systemic hypertension is common, and there is significant heterogeneity in the patient population with critical heart disease. There are limited large, prospective analyses of safety and efficacy for pediatric drug antihypertensive agents. Despite patient heterogeneity, most pharmacotherapies are safe and efficacious.
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Grohmann J, Sigler M, Siepe M, Stiller B. A new breakable stent for recoarctation in early infancy: Preliminary Clinical Experience. Catheter Cardiovasc Interv 2016; 87:E143-50. [DOI: 10.1002/ccd.26393] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/14/2015] [Accepted: 12/13/2015] [Indexed: 12/27/2022]
Affiliation(s)
- Jochen Grohmann
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
| | - Matthias Sigler
- Department of Pediatric Cardiology and Intensive Care; University Hospital Göttingen; Göttingen Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery; Heart Center, University of Freiburg; Freiburg Germany
| | - Brigitte Stiller
- Department of Congenital Heart Defects and Pediatric Cardiology; Heart Center, University of Freiburg; Freiburg Germany
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Gorbatykh IN, Sinel'nikov IS, Soĭnov IA, Kornilov IA, Kshanovskaia MS, Gorbatykh AV, Ivantsov SM, Omel'chenko AI. [Surgical treatment of aortic arch malformations in infants under cardiopulmonary bypass]. Khirurgiia (Mosk) 2015:18-21. [PMID: 26356054 DOI: 10.17116/hirurgia2015818-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate long-term results and the causes of complications in congenital obstructive pathology of the aortic arch. MATERIAL AND METHODS Retrospective study enrolled 62 patients aged 55 ± 14 days who underwent aortic arch surgery under cardiopulmonary bypass. It was compared two methods of aortic archplasty: use of xenopericardial material in group 1 and Rajasinghe's autoplastic method in group 2. RESULTS Follow-up was 42 ± 14 months. In the long-term recoarctation occurred in 7 (13.7%) cases including 6 (18.75%) patients in group 1 and one (3.3%) patient in group 2. Residual hypertension was observed in 12 (23.5%) cases including 10 (37%) patients in group 1 and 2 (8.3%) patients in group 2. Six (50%) patients receive antihypertensive therapy, 5 (41.6%) patients who receive antihypertensive drugs have persistent increase of blood pressure without evidence of anatomic aortic obstruction. Hypertensive response to functional tests was observed in one patient. CONCLUSIONS Aortic arch reconstruction using autoplasty is associated with lower risk of recoarctationand residual hypertension compared with xenopericardial patch application.
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Affiliation(s)
- Iu N Gorbatykh
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - Iu S Sinel'nikov
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - I A Soĭnov
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - I A Kornilov
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - M S Kshanovskaia
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - A V Gorbatykh
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - S M Ivantsov
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
| | - A Iu Omel'chenko
- Acad. E.N. Meshalkin Novosibirsk Research Institute of Circulation Pathology
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Choudhary P, Canniffe C, Jackson DJ, Tanous D, Walsh K, Celermajer DS. Late outcomes in adults with coarctation of the aorta. Heart 2015; 101:1190-5. [PMID: 25810155 DOI: 10.1136/heartjnl-2014-307035] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 02/25/2015] [Indexed: 12/15/2022] Open
Abstract
AIMS Previous cohort studies of patients with coarctation of the aorta (CoA) demonstrate reduced long-term survival. Improved surgical outcomes in children and evolution of adult congenital heart disease (ACHD) services have resulted in improved survival in patients with other CHDs. We hypothesise that for young adult patients with CoA long-term outcomes have improved in the contemporary era. METHODS 151 patients (58% men) with simple CoA followed up at a tertiary ACHD service in Sydney, Australia, from 1993 to 2013 were included. We documented mortality and major morbidity such as the need for re-intervention for re-coarctation or aneurysms. RESULTS 140 patients (mean age 35±15 years) underwent CoA repair at median age of 5 (IQR 0-10) years. Initial surgical strategy included end-to-end repair in 43, subclavian flap aortoplasty in 28 and patch aortoplasty in 31 patients (and was not documented in 28 cases). 6 patients had endovascular repair, 4 had interposition tube grafts and 11 were unrepaired. There were a total of seven deaths at a median age of 60 years. Actuarial survival was 98% at 40, 98% at 50 and 89% at 60 years of age. Re-coarctation occurred in 34% and descending aortic aneurysms were noted in 18%. Patients with end-to-end repair had lower rates of significant re-coarctation or descending aortic aneurysms (p=0.026 and <0.001, respectively). 66% had bicuspid aortic valve and 44% were hypertensive. CONCLUSIONS Patients with CoA who reach adolescence demonstrate very good long-term survival up to age 60 years. Long-term morbidity is common, however, related largely to aortic complications and late hypertension.
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Affiliation(s)
- P Choudhary
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Discipline of Medicine, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - C Canniffe
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Department of Cardiology, Mater Misericordiae Hospital, Dublin, Ireland
| | - D J Jackson
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Discipline of Medicine, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - D Tanous
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - K Walsh
- Department of Cardiology, Mater Misericordiae Hospital, Dublin, Ireland
| | - D S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Discipline of Medicine, Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Chen SSM, Dimopoulos K, Alonso-Gonzalez R, Liodakis E, Teijeira-Fernandez E, Alvarez-Barredo M, Kempny A, Diller G, Uebing A, Shore D, Swan L, Kilner PJ, Gatzoulis MA, Mohiaddin RH. Prevalence and prognostic implication of restenosis or dilatation at the aortic coarctation repair site assessed by cardiovascular MRI in adult patients late after coarctation repair. Int J Cardiol 2014; 173:209-15. [PMID: 24631116 DOI: 10.1016/j.ijcard.2014.02.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 02/04/2014] [Accepted: 02/13/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cardiovascular magnetic resonance (CMR) is ideal for assessing patients with repaired aortic coarctation (CoA). Little is known on the relation between long-term complications of CoA repair as assessed by CMR and clinical outcome. We examined the prevalence of restenosis and dilatation at the repair site and the long-term outcome in patients with repaired CoA. METHODS AND RESULTS CMR imaging and clinical data for adult CoA patients (247 patients aged 33.0 ± 12.8 years, 60% male), were analyzed. The diameter of the aorta at the repair site was measured on CMR and its ratio to the aortic diameter at the diaphragm (repair site-diaphragm ratio, RDR) was calculated. Restenosis (RDR≤70%) was present in 31% of patients (and significant in 9% [RDR<50%]), and dilatation (RDR>150%) in 13.0%. A discrete aneurysm at the repair site was observed in 9%. Restenosis was more likely after resection and end-end anastomosis, whereas dilatation after patch repair. Systemic hypertension was present in 69% of patients. Of the hypertensive patients, blood pressure (133 ± 20/73 ± 10 mm Hg) was well controlled in 93% with antihypertensive therapy. Mortality rate over a median length of 5.9 years was low (0.69% per year, 95% CI: 0.33-1.26), but significantly higher than age-matched healthy controls (standardised mortality ratio 2.86, CI 1.43-5.72, p<0.001). CONCLUSION Restenosis or dilatation at the CoA repair site as assessed by CMR is not uncommon. Medium term survival remains good, however, albeit lower than in the general population. Life-long follow-up and optimal blood pressure control are likely to secure a good longer term outlook in these patients.
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Affiliation(s)
- S S M Chen
- Royal Brompton Hospital, London SW36NP, UK
| | - K Dimopoulos
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK
| | | | - E Liodakis
- Royal Brompton Hospital, London SW36NP, UK
| | | | | | - A Kempny
- Royal Brompton Hospital, London SW36NP, UK
| | - G Diller
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK
| | - A Uebing
- Royal Brompton Hospital, London SW36NP, UK
| | - D Shore
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK
| | - L Swan
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK
| | - P J Kilner
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK
| | - M A Gatzoulis
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK
| | - R H Mohiaddin
- Royal Brompton Hospital, London SW36NP, UK; Imperial College, London SW36LY, UK.
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Egan M, Holzer RJ. Comparing balloon angioplasty, stenting and surgery in the treatment of aortic coarctation. Expert Rev Cardiovasc Ther 2014; 7:1401-12. [DOI: 10.1586/erc.09.111] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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12
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Whiteside W, Hirsch-Romano J, Yu S, Pasquali SK, Armstrong A. Outcomes associated with balloon angioplasty for recurrent coarctation in neonatal univentricular and biventricular norwood-type aortic arch reconstructions. Catheter Cardiovasc Interv 2014; 83:1124-30. [DOI: 10.1002/ccd.25318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/15/2013] [Accepted: 11/28/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Wendy Whiteside
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
| | - Jennifer Hirsch-Romano
- Section of Pediatric Cardiac Surgery Department of Cardiac Surgery; University of Michigan; Ann Arbor Michigan
| | - Sunkyung Yu
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
| | - Sara K. Pasquali
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
| | - Aimee Armstrong
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
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Acevedo-Bañuelos I, González-Peña J, Chagolla-Santillán MÁ, Hernández-Morales G, Farías-Serratos CV. [Surgery repair of aortic coarctation in infancy]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2013; 83:159-64. [PMID: 23906749 DOI: 10.1016/j.acmx.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 03/16/2013] [Accepted: 03/25/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE The study's purpose is to present our experience with surgical correction of aortic coarctation in infants, at short and medium term, particularly morbidity and mortality. METHOD This is a retrospective observational and descriptive trial. We included all infant patients undergoing surgical correction of AC. All data were obtained from the clinical database of the hospital. RESULTS We included 20 patients with AC. The surgical technique was extended coarctectomy in 19 patients and, in one patient, a subclavian artery flap was performed. In all patients, the average time of aortic clamping was 18min. The residual gradient measured by echocardiography was in average of 12.2mmHg. One patient died of sepsis secondary to pneumonia. The main cause of immediate postoperative morbidity was systemic hypertension in seven patients, nosocomial infection in four patients with development of sepsis, one patient had to be reoperated due to high gradient. One patient had cholestatic syndrome. Eighteen patients required a transfusion at some time during their hospital stay. Average in-hospital stay was of 12 days. CONCLUSION The aortic coarctation surgery has had favorable results so far and we can conclude that the program has been successful. The surgical technique has shown low mortality and complications and midterm follow-up shows low rate of recoarctation.
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Affiliation(s)
- Iliana Acevedo-Bañuelos
- Cirugía Cardiotorácica, Cardiotorácicos, Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, México.
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Adams EE, Davidson WR, Swallow NA, Nickolaus MJ, Myers JL, Clark JB. Long-Term Results of the Subclavian Flap Repair for Coarctation of the Aorta in Infants. World J Pediatr Congenit Heart Surg 2013; 4:13-8. [DOI: 10.1177/2150135112466878] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background: Coarctation is a congenital narrowing of the aorta that often requires repair during infancy. The subclavian flap aortoplasty was once widely favored for its avoidance of a circumferential suture line and low incidence of recoarctation. The aim of this study is to report the long-term results of the subclavian flap repair for coarctation of the aorta in infants. Methods: Our operative database was queried for infants with coarctation who underwent subclavian flap aortoplasty from 1966 to 1991. Medical records were reviewed for patient characteristics and outcomes. Survivors were identified for additional phone interview. Results: Fifty-five patients met the inclusion criteria. There were 7 early deaths (in hospital), 11 late deaths, 5 patients lost to follow-up, and 32 known long-term survivors with a mean follow-up of 22.0 years (range 2.4-34.9). Hospital mortality was not associated with patient characteristics but was associated with earlier year of surgery ( P = .015). A trend toward decreased overall survival was seen in patients with coarctation with associated cardiac defects ( P = .072). Reintervention for recoarctation was required in 3 (6.6%) patients and was not related to the patient characteristics. There were no apparent complications related to subclavian artery sacrifice. Conclusions: Subclavian flap aortoplasty provides excellent long-term results for the repair of coarctation in infants. The incidence of recoarctation requiring reintervention is low and compares favorably with other techniques. Compromise of growth or function of the left arm was not appreciated. The subclavian flap technique remains a viable surgical option for the repair of coarctation in infants.
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Affiliation(s)
- Elizabeth E. Adams
- Department of Pediatrics, Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - Nicole A. Swallow
- Department of Medicine, Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - John L. Myers
- Department of Pediatrics, Penn State Hershey Medical Center, Hershey, PA, USA
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Joseph B. Clark
- Department of Pediatrics, Penn State Hershey Medical Center, Hershey, PA, USA
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
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Neonatal Interventions for Left-Sided Obstructive Lesions: Alternatives to Surgery. Interv Cardiol Clin 2013; 2:11-22. [PMID: 28581977 DOI: 10.1016/j.iccl.2012.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Percutaneous neonatal cardiac interventions are effective in management strategies. Aortic valve dilation has become a first line therapy with excellent outcomes and low morbidity equivalent to surgery. Percutaneous intervention for coarctation of the aorta can safely postpone surgical intervention in small unwell neonates, allowing stabilization and growth. Stent implantation can provide a stable and predictable relief of obstruction; however, care should be taken to implant stents so that they can be removed subsequently. As experience increases, the role of percutaneous techniques in the management of high-risk neonates with coarctation of the aorta will become better defined and improve the outcomes.
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Sakurai T, Stickley J, Stümper O, Khan N, Jones TJ, Barron DJ, Brawn WJ. Repair of isolated aortic coarctation over two decades: impact of surgical approach and associated arch hypoplasia. Interact Cardiovasc Thorac Surg 2012; 15:865-70. [PMID: 22833510 DOI: 10.1093/icvts/ivs265] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES A variety of surgical approaches and techniques are used for isolated coarctation repair. We have retrospectively reviewed our results of isolated repair of coarctation over the last 20 years, to establish whether the approach affects clinical outcome and the need for re-intervention. METHODS Two hundred and eighty-eight patients who underwent isolated repair for coarctation of the aorta at Birmingham Children's Hospital between 1991 and 2010 were enrolled in this study. Chart review and the Departmental database were used to determine demographics, operative details and complications. RESULTS The majority of patients (n = 237, 82%) underwent surgical repair via thoracotomy techniques, whereas median sternotomy was used in patients where there was associated arch hypoplasia (n = 51, 18%). For all 288 patients, median age at operation was 24 days (range 0-14 years). Between 1991 and 2000, ten patients (6%) underwent repair through midline sternotomy, increasing to 41 patients (36%) between 2001 and 2010. Overall early mortality was 1% and late mortality was 3%. There was a statistically higher re-intervention rate (16%) in the decade 1991-2000, compared to 5% in the period 2001-10 (P = 0.02). In patients with hypoplastic arch, the midline approach has a lower re-intervention rate than thoracotomy (P < 0.001). CONCLUSIONS In our institution, there has been a trend in recent years towards increased use of median sternotomy to repair the aortic arch, which has been associated with a reduced rate of re-intervention. The midline sternotomy approach for coarctation with arch hypoplasia significantly reduces the risk of re-coarctation.
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Affiliation(s)
- Takahisa Sakurai
- Department of Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
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Kaushal S, Backer CL, Patel JN, Patel SK, Walker BL, Weigel TJ, Randolph G, Wax D, Mavroudis C. Coarctation of the Aorta: Midterm Outcomes of Resection With Extended End-to-End Anastomosis. Ann Thorac Surg 2009; 88:1932-8. [DOI: 10.1016/j.athoracsur.2009.08.035] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 08/10/2009] [Accepted: 08/13/2009] [Indexed: 12/15/2022]
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Burch PT, Cowley CG, Holubkov R, Null D, Lambert LM, Kouretas PC, Hawkins JA. Coarctation repair in neonates and young infants: is small size or low weight still a risk factor? J Thorac Cardiovasc Surg 2009; 138:547-52. [PMID: 19698833 DOI: 10.1016/j.jtcvs.2009.04.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 03/25/2009] [Accepted: 04/27/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Previous reports of neonatal coarctation repair demonstrate a high rate of recurrent arch obstruction in small neonates. This study assesses the effect of patient size on reintervention and survival in neonates and infants undergoing repair of simple aortic coarctation. METHODS From 1996 to 2006, 167 neonates and infants younger than 90 days with simple coarctation underwent repair. Median patient age was 16 days (range, 1-85 days). Median patient weight was 3.4 kg (range, 0.8-6.0 kg), with 29 patients weighing less than 2.5 kg. All 167 patients included in the study underwent repair through a left thoracotomy. RESULTS There was 1 early death (1/167, 0.6%). Median follow-up of 4.8 years (range, 0-11.8 years) demonstrated 2 late deaths unrelated to recurrent coarctation. Eighteen patients underwent intervention for recurrent arch obstruction a median of 0.48 years postoperatively (range, 0.14-9.8 years). All were treated with balloon angioplasty and have required no additional intervention. Actuarial freedom from reintervention was 90% at 1 year and 89% at 5 years for infants weighing more than 2.5 kg and 89% at 1 year and 86% at 5 years (P = .31) for infants weighing less than 2.5 kg. There was no difference between survival or reintervention for neonates 30 days of age or younger compared with infants 31 to 90 days of age. Use of polypropylene sutures and female sex did correlate with increased reintervention. CONCLUSIONS Low weight does not affect survival or reintervention rates after coarctation repair in neonates and infants less than 3 months of age. Balloon angioplasty is an effective treatment for recurrent obstruction after coarctation repair in infancy. In the current era, timing of the operation should be based on clinical status.
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Affiliation(s)
- Phillip T Burch
- Division of Cardiothoracic Surgery, Primary Children's Medical Center and the University of Utah, Salt Lake City, Utah, USA.
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Pekkan K, Dasi LP, Nourparvar P, Yerneni S, Tobita K, Fogel MA, Keller B, Yoganathan A. In vitro hemodynamic investigation of the embryonic aortic arch at late gestation. J Biomech 2008; 41:1697-706. [PMID: 18466908 PMCID: PMC3805112 DOI: 10.1016/j.jbiomech.2008.03.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2007] [Revised: 03/10/2008] [Accepted: 03/11/2008] [Indexed: 10/22/2022]
Abstract
This study focuses on the dynamic flow through the fetal aortic arch driven by the concurrent action of right and left ventricles. We created a parametric pulsatile computational fluid dynamics (CFD) model of the fetal aortic junction with physiologic vessel geometries. To gain a better biophysical understanding, an in vitro experimental fetal flow loop for flow visualization was constructed for identical CFD conditions. CFD and in vitro experimental results were comparable. Swirling flow during the acceleration phase of the cardiac cycle and unidirectional flow following mid-deceleration phase were observed in pulmonary arteries (PA), head-neck vessels, and descending aorta. Right-to-left (oxygenated) blood flowed through the ductus arteriosus (DA) posterior relative to the antegrade left ventricular outflow tract (LVOT) stream and resembled jet flow. LVOT and right ventricular outflow tract flow mixing had not completed until approximately 3.5 descending aorta diameters downstream of the DA insertion into the aortic arch. Normal arch model flow patterns were then compared to flow patterns of four common congenital heart malformations that include aortic arch anomalies. Weak oscillatory reversing flow through the DA junction was observed only for the Tetralogy of Fallot configuration. PA and hypoplastic left heart syndrome configurations demonstrated complex, abnormal flow patterns in the PAs and head-neck vessels. Aortic coarctation resulted in large-scale recirculating flow in the aortic arch proximal to the DA. Intravascular flow patterns spatially correlated with abnormal vascular structures consistent with the paradigm that abnormal intravascular flow patterns associated with congenital heart disease influence vascular growth and function.
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Affiliation(s)
- Kerem Pekkan
- Department of Biomedical and Mechanical Engineering, Carnegie Mellon University, PA, USA.
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Barreiro CJ, Ellison TA, Williams JA, Durr ML, Cameron DE, Vricella LA. Subclavian flap aortoplasty: still a safe, reproducible, and effective treatment for infant coarctation. Eur J Cardiothorac Surg 2007; 31:649-53. [PMID: 17276693 DOI: 10.1016/j.ejcts.2006.12.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Revised: 12/04/2006] [Accepted: 12/11/2006] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE Subclavian flap repair of infant coarctation has been criticized and in many centers abandoned in favor of resection with end-to-end anastomosis. The goal of this study was to examine intermediate and long-term results of infant subclavian flap aortoplasty, which has been the preferred technique at our institution over the last two decades. METHODS Our patient database identified all infants (age<1 year) who underwent repair of isthmic coarctation via thoracotomy between January 1984 and December 2004. Procedure details and late results were collected by retrospective review of hospital and clinic data. Follow-up was 95.8% complete at a mean of 6.7 years. RESULTS Between January 1984 and December 2004, 119 infants underwent isolated subclavian flap repair of coarctation. Mean age and weight at operation were 35+/-52 days (range 1-269 days) and 3.5+/-1.3kg (range 0.7-9.3kg), respectively. Concomitant pulmonary artery banding was performed in 22% (26/119). In-hospital mortality was 4% (5/119) and cumulative late mortality was 6% (7/114) of patients with long-term follow-up. Actuarial survival at 1, 5, and 10 years was 91, 85, and 85%, respectively. Overall re-intervention rate for re-stenosis was 11% (12/114); 10 patients (9%) underwent balloon angioplasty while 3 patients (3%) required operative revision. All re-stenoses occurred in the descending aorta, and all occurred in patients who had undergone neonatal repair. At late follow-up, there were no significant neurologic events (left recurrent laryngeal nerve injury, stellate ganglion dysfunction, or paraplegia), no clinically significant ischemic arm complications, and no flap aneurysms. CONCLUSIONS Subclavian flap aortoplasty remains our procedure of choice for isthmic coarctation, as it is a simple, technically straightforward technique with a low incidence of re-stenosis and serious early and late morbidity. Furthermore, subclavian flap re-stenoses are easily treated with percutaneous intervention and seldom require surgical re-intervention via thoracotomy.
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Affiliation(s)
- Christopher J Barreiro
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA
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Eichhorn JG, Fink C, Delorme S, Hagl S, Kauczor HU, Ulmer HE. Magnetic resonance blood flow measurements in the follow-up of pediatric patients with aortic coarctation – A re-evaluation. Int J Cardiol 2006; 113:291-8. [PMID: 16377005 DOI: 10.1016/j.ijcard.2005.11.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Revised: 10/25/2005] [Accepted: 11/04/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous studies have suggested the feasibility of a non-invasive quantification of vascular trans-stenotic pressure gradients (DeltaP) by phase-contrast MR imaging (PC-MRI). Our purpose was to assess the value of MRI estimated pressure gradients as a screening tool for assessing hemodynamically significant (re-)coarctation of the aorta (CoA) in pediatric patients. METHODS Forty-three patients (median age (range), 16 (5-25) years) with CoA (38 postoperative and 5 native) and clinically suspected hemodynamically significant stenosis underwent quantitative and semi-quantitative PC-MRI blood flow measurements and 3D MR-angiography, Doppler ultrasound (US) and conventional catheter angiography (CCA, n=20). Estimated DeltaP for each modality was correlated with percent stenosis. RESULTS The percent stenosis correlated only moderately with DeltaP(MRI) (r=0.55, p<0.001) and DeltaP(CCA) (r=0.48, p<0.001). Only moderate correlations were observed between DeltaP(MRI) vs. DeltaP(CCA) (r=0.54, p=0.02) and vs. DeltaP(US) (r=0.40, p=0.01). In contrast, semi-quantitative analysis of PC-MRI flow profiles predicted with good sensitivity (88%) and specificity (88%) who would be operated on. Thirteen patients met hemodynamic and percent stenosis criteria by CCA for surgical intervention. CONCLUSION Measured pressure gradients using PC-MRI should be used cautiously when assessing patients for recoarctation of the aorta. The analysis of blood flow profiles by PC-MRI might be a promising alternative in assessing the hemodynamic significance of CoA.
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Affiliation(s)
- Joachim G Eichhorn
- Department of Paediatric Cardiology, University Children's Hospital, Im Neuenheimer Feld 153, 69120 Heidelberg, Germany.
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Wright GE, Nowak CA, Goldberg CS, Ohye RG, Bove EL, Rocchini AP. Extended resection and end-to-end anastomosis for aortic coarctation in infants: results of a tailored surgical approach. Ann Thorac Surg 2006; 80:1453-9. [PMID: 16181886 DOI: 10.1016/j.athoracsur.2005.04.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2004] [Revised: 03/31/2005] [Accepted: 04/01/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND The surgical repair of aortic coarctation in infants has evolved over time. This study evaluates our current approach utilizing extended end-to-end anastomosis without prosthetic material to enlarge all areas of aortic arch hypoplasia. METHODS The Michigan Congenital Heart Center database was reviewed for infants who underwent repair of isolated aortic coarctation from January 1, 1990, to January 1, 2000. RESULTS Eighty-three infants underwent surgical repair of isolated coarctation during this decade. Median age at repair was 21 days (range, 2 to 365). Repair was performed through thoracotomy in 72 patients. Because of severe transverse arch hypoplasia, the remaining 11 infants underwent median sternotomy with circulatory arrest. There were 2 deaths: 1 due to pulmonary hypertension in a patient with alveolar capillary dysplasia and 1 late death due to pneumonia in a patient with noncardiac anomalies. Neither patient had residual coarctation. Technique-related complications of bronchial compression, chylothorax, and vocal cord paralysis were noted in 4 patients. Follow-up data were available for 66 patients (80%) with mean follow-up duration of 4.5 years (SD +/- 3.1). Reintervention was required in 4 patients (6%). One underwent reoperation after 1 month, and 3 underwent balloon angioplasty within 7 months of initial repair. The remaining 61 patients are asymptomatic, on no antihypertensive medications, and have aortic arch gradients less than 15 mm Hg. One developed subaortic stenosis necessitating resection. CONCLUSIONS Tailored surgical repair for aortic coarctation has a low rate (6%) of residual and recurrent coarctation even when performed in infants. Mortality and morbidity are low.
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Affiliation(s)
- Gail E Wright
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Sudarshan CD, Cochrane AD, Jun ZH, Soto R, Brizard CP. Repair of coarctation of the aorta in infants weighing less than 2 kilograms. Ann Thorac Surg 2006; 82:158-63. [PMID: 16798207 DOI: 10.1016/j.athoracsur.2006.03.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2005] [Revised: 02/28/2006] [Accepted: 03/03/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND We retrospectively reviewed our experience in aortic coarctation repair on infants weighing less than 2 kg to evaluate the results and assess the rate of recoarctation in this group of patients. METHODS Twenty-four consecutive babies weighing 2 kg or less were operated on over a period of 15 years. Median gestational age was 33 weeks (range, 30 to 36), and median weight was 1.6 kg (range, 1.0 to 2.0). Seventeen of them had associated cardiac anomalies. The methods of repair undertaken were resection with extended end-to-end anastomosis (n = 13), subclavian flap angioplasty (n = 9), carotid flap angioplasty (n = 1), and patch repair using pulmonary homograft tissue (n = 1). RESULTS Mean follow-up was 52.5 months (range, 0.5 to 151). There were 3 in-hospital deaths and 2 late deaths. Recoarctation developed in 7 babies. Four underwent balloon dilatation; 1 of them required further surgery; 3 others have mild recoarctation, but have not required further intervention. Risk factor analyses revealed that the presence of preoperative congestive cardiac failure, and coexisting noncardiac lesions as well as the duration of descending aortic cross-clamp and postoperative ventilation had a significant influence on mortality after repair. CONCLUSIONS Coarctation repair in infants less than 2 kg can be performed safely. The incidence of recoarctation is acceptable and comparable with that of other pediatric cohorts that have been reported. Preoperative cardiac function and associated noncardiac lesions may influence the incidence of mortality after repair. Delaying the timing of surgical repair to achieve growth is not necessary.
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Pandey R, Jackson M, Ajab S, Gladman G, Pozzi M. Subclavian flap repair: review of 399 patients at median follow-up of fourteen years. Ann Thorac Surg 2006; 81:1420-8. [PMID: 16564285 DOI: 10.1016/j.athoracsur.2005.08.070] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2005] [Revised: 08/22/2005] [Accepted: 08/25/2005] [Indexed: 12/20/2022]
Abstract
BACKGROUND Conflicting results have been obtained for the same operation for repair of coarctation of the aorta by different institutes. The purpose of this study was to assess the results of subclavian flap aortoplasty (SFA) alone, performed on 399 patients in a single institute between 1966 and 1995. METHODS Data were collected retrospectively from the congenital cardiac surgical database at the institute. RESULTS The median age at operation was 22 days (3 days-49 months). One hundred thirty-four patients had isolated coarctation while 265 children had complex coarctation. Maximum follow-up was 24 years (median, 14 years). Overall mortality over the whole duration of follow-up was 24.8%. Mortality for isolated coarctation at first intervention was 7.4% (operative mortality, 2.6%) while it was 12.8% for complex coarctation. At second intervention the mortality for isolated coarctation was 5%. For the second, third, and fourth interventions the mortality for complex coarctation was 25%, 25%, and 27%, respectively. The survival for isolated coarctation at 1, 5, 10, and 20 years was 94%, 93.2%, 92.4%, and 88.4%, respectively, while it was 74.6%, 66.3%, 63%, and 61.4%, respectively, for complex coarctation. Of the total patients, 15.3% had interventions for recoarctation. The incidence of recoarctation was 13.6% on those patients operated on in the first month of life, while it was 3.6% in older children. A percentage of 3.3% of patients continue to be hypertensive and require medication. There was a significant difference between the systolic blood pressure and anthropometric measurements between the arms. Despite this none of the patients complained of effect on lifestyle. CONCLUSIONS Despite improved early results the long-term mortality for coarctation remains high. Mortality is higher for complex coarctation as compared with isolated procedures. The incidence of recoarctation after SFA at long term is acceptable and is higher in patients operated on in the first month of life. The overall incidence of hypertension is quite low. Patients remained normotensive when operated upon at the age of 0.9 months. The SFA, no doubt, effects the limb development; however it does not cause limitation in the lifestyle.
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Affiliation(s)
- Ragini Pandey
- Department of Cardiology and Cardiac Surgery, Royal Liverpool Children's NHS Trust, Liverpool, United Kingdom.
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Haas NA, Lewin MAG, Knirsch W, Nossal R, Ocker V, Uhlemann F. Initial experience using the NuMED Cheatham Platinum (CP) stent for interventional treatment of coarctation of the aorta in children and adolescents. ACTA ACUST UNITED AC 2005; 94:113-20. [PMID: 15674741 DOI: 10.1007/s00392-005-0180-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2004] [Accepted: 10/08/2004] [Indexed: 11/30/2022]
Abstract
We report the immediate results in a group of selected patients with native or recurrent coarctation of the aorta who underwent endovascular stent implantation using the newly designed Cheatham-Platinum (CP)-stent. The balloon-expandable stents were implanted in 6 patients (mean age 12.7 years) with coarctation of the aorta (5 native, 1 recurrent). The maximal systolic peak pressure gradient was decreased from 49 to 3 mmHg (p <0.001). There was a 350% increase in the mean diameter at the original coarctation site (3.8 to 13.8 mm, p <0.01). Although the maximal diameter varied from 8 to 18 mm, there was only a minor reduction in the length of the CP-stents used (max. 11%). The dilatation was successful in all patients and there were no complications during balloon dilatation or stent implantation. All patients were hypertensive prior to stent implantation, with three of them requiring antihypertensive drug therapy. In 2 patients only a moderate dilatation diameter was chosen initially due to the extremely small coarctation site (1 mm) and repeat dilatation after 12 months was performed in order to obtain a maximal aortic diameter. At a mean of 18 months of follow-up, 5 of 6 patients are normotensive. There is no recurrence of coarctation, aortic dissection or aneurysm formation and no stent displacement. These findings suggest that the implantation of CP-stents for coarctation of the aortamay cover a wide spectrum of aortic diameters and consequently hereby offer an effective alternative approach to surgery or ballon dilatation alone even in infancy and childhood. The potential for redilatation of CP-stents in a wide range of diameters without significant shortening adds to the benefit of this device in growing children.
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Affiliation(s)
- N A Haas
- Paediatric Intensive Care Unit, The Prince Charles Hospital, Brisbane Rode Raod, Chermside Old 4032, Austria.
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Puchalski MD, Williams RV, Hawkins JA, Minich LL, Tani LY. Follow-up of aortic coarctation repair in neonates. J Am Coll Cardiol 2004; 44:188-91. [PMID: 15234432 DOI: 10.1016/j.jacc.2004.01.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2003] [Revised: 12/17/2003] [Accepted: 01/19/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purposes of this study were to assess the growth of left heart (LH) structures, to evaluate midterm outcomes, and to define echocardiographic parameters predictive of increased risk of re-intervention in patients born with aortic coarctation and hypoplasia of LH structures that underwent neonatal coarctation repair. BACKGROUND Neonatal coarctation is often associated with hypoplasia of LH structures. Although previous studies have shown that coarctation repair can be performed with good results in these neonates, there are little data regarding growth of the LH structures or outcomes in these patients. METHODS Patients with isolated coarctation and at least one hypoplastic LH valve (mitral or aortic Z-score <-2) who underwent a neonatal coarctation repair were identified. Clinic charts and the latest echocardiograms were reviewed. RESULTS All 55 patients were alive and well, and no patient had clinical evidence of mitral stenosis. Three patients (5%) required re-intervention. Thirty-eight patients had echocardiograms that demonstrated normal left ventricular (LV) size and function with a follow-up duration of 73 +/- 19 months (range 3 to 9 years). Both mitral and aortic annulus Z-scores increased significantly: -3.1 +/- 1.5 to -0.5 +/- 1.6 (p < 0.001) and -3.5 +/- 1.9 to 0.7 +/- 1.6 (p < 0.001), respectively. Nine patients (24%) developed LV outflow tract obstruction by echocardiographic criteria. CONCLUSIONS After neonatal coarctation repair with associated LH hypoplasia, LH structures increase substantially in size, and clinical outcomes are excellent at midterm follow-up. Despite initial annular hypoplasia, the need for intervention for mitral or aortic/subaortic stenosis is uncommon.
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Affiliation(s)
- Michael D Puchalski
- Primary Children's Medical Center, University of Utah, Salt Lake City, Utah 84113, USA.
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Wood AE, Javadpour H, Duff D, Oslizlok P, Walsh K. Is extended arch aortoplasty the operation of choice for infant aortic coarctation? Results of 15 years' experience in 181 patients. Ann Thorac Surg 2004; 77:1353-7; discussion 1357-8. [PMID: 15063265 DOI: 10.1016/j.athoracsur.2003.07.045] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recurrent coarctation is an ever-present complication of surgical treatment of coarctation of aorta (CoA) among infants. No single operation appears to have a clear superiority. METHODS From January 1, 1986, to June 30, 2002, a consecutive series of 181 patients less than 1 year of age (range 1 to 300 days, median 13.5 days) were referred for CoA repair. Neonates accounted for 135 patients, and hypoplastic arch (less than 1 mm/kg plus 1) was present in 107 infants. Coarctation of aorta was simple (group 1) in 71 patients; complicated by ventricular septal defect (group 2) in 62; and complicated by complex congenital heart disease (group 3) in 48. All patients were assessed by right arm/left leg Dynamap pressures and routine follow-up was performed by the cardiologists. Follow-up was complete in all patients (range 6 months to 16 years, median 7.5 years). RESULTS The overall hospital/30-day mortality was 0.5% (group 1 = 0, group 2 = 0, group 3 = 1 [2.0%]). Complications other than recoarctation occurred in 5 patients (2.7%). Late mortality occurred in 15 (11 at intracardiac repair). Recoarctation, ie, a gradient of more than 20 mm Hg, occurred in 4 patients (2.2%). All 4 patients were noted to have a gradient of more than 10 mm Hg (right arm/left leg) postoperatively and as such had residual coarctation. All 4 were successfully treated by balloon aortoplasty. CONCLUSIONS Extended arch aortoplasty in association with ductal and coarctation excision provides excellent coarctation repair with a low incidence of recoarctation. Recoarctation occurred only in proximal aortic arch hypoplasia or low birth weight. Balloon aortoplasty easily and effectively relieved the recoarctation in all cases.
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Affiliation(s)
- Alfred E Wood
- Department of Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland.
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Abstract
Chest pain is common in adolescents and in young adults and usually not associated with a severe underlying cardiovascular disorder. However, in adults with congenital heart disease, residua or sequellae of previous interventions may provoke potential complications. Moreover, chest pain may be the first sign of a life-threatening condition. Basic knowledge is mandatory and will lead to the correct diagnosis and treatment. Data in literature, which focus on this issue, are scarce and motivated to summarize the experience of daily practice from the eye point of the clinician.
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Mavroudis C, Sade RM. The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice. Ann Thorac Surg 2003; 76:S47-67. [PMID: 14596980 DOI: 10.1016/s0003-4975(03)01508-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Members of the Southern Thoracic Surgical Association (STSA) have presented important pediatric cardiothoracic surgery papers at the annual meetings over the last 50 years. In order to determine the influence of these presentations on the practice of surgery, a review was undertaken. Early papers were characterized by emerging advances in open-heart surgery, anatomic congenital heart studies, and electrophysiologic discoveries that extended life with pacemakers. Later years were characterized by innovative myocardial preservation methods, improved cardiopulmonary bypass techniques, expanded homograft availability, emphasis on accurate repairs, intraoperative transesophageal echocardiography, and cardiopulmonary transplantation. METHODS All but one of the scientific programs of the annual meetings (that of 1964) were located. The programs were reviewed and 180 presentations were identified on topics in congenital heart disease, pediatric thoracic disease, and pediatric thoracic wall abnormalities. Of those 180 oral presentations, 155 manuscripts (86%) were eventually published or in press and available for critical review and analysis. Manuscripts were grouped by diagnosis or therapeutic intervention. We determined a "cumulative citation frequency" (CCF), which measures the number of times an article is cited in the bibliography of related papers in the universe of participating journals. The selected manuscripts were compared with the historic landmark contributions and the existing trends at the time, and the number of articles both by individual authors and from institutions were tallied. RESULTS Grouping by authors and institutions showed that 100 of 155 pediatric cardiothoracic manuscripts (65%) originated from 13 institutions. The CCF for the 20 leading articles ranged from 26 to 93. CONCLUSIONS This historical STSA 50-year record of pediatric cardiothoracic advances was accomplished in a milieu of collegial respect and camaraderie. Our annual meetings over the years have provided a venue for thoracic surgeons to share their ideas, innovations, and scientific inquiry. These contributions have significantly affected the practice of pediatric cardiothoracic surgery. The STSA has worked for 50 years and we trust that it will work for another 50 years and beyond.
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Affiliation(s)
- Constantine Mavroudis
- Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA.
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Walhout RJ, Lekkerkerker JC, Oron GH, Hitchcock FJ, Meijboom EJ, Bennink GBWE. Comparison of polytetrafluoroethylene patch aortoplasty and end-to-end anastomosis for coarctation of the aorta. J Thorac Cardiovasc Surg 2003; 126:521-8. [PMID: 12928653 DOI: 10.1016/s0022-5223(03)00030-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Although aneurysm formation and recoarctation after Dacron patch aortoplasty have been reported on extensively, less is known about these outcomes after polytetrafluoroethylene patch repair, which was compared with resection and end-to-end anastomosis in this study. METHODS Two hundred sixty-two children had surgical repair of coarctation of the aorta by means of either resection and end-to-end anastomosis (n = 137; mean age, 1.85 +/- 3.1 years) or polytetrafluoroethylene patch aortoplasty (n = 118; mean age, 1.09 +/- 1.9 years) during a 28-year period. Coarctation was isolated in 109 (41.6%), associated with ventricular septal defect in 77 (29.4%), and associated with complex intracardiac anomalies in 76 (29.0%) patients. Follow-up ranged from 2 days to 29.3 years (median, 11.9 years). Seven patients were lost to follow-up. Kaplan-Meier survival curves were estimated, and multivariable Cox regression analysis was performed for several outcome variables. RESULTS Mortality was 8.2% and was associated with intracardiac pathology in all cases. Recoarctation occurred in 53 patients, 23 after resection and anastomosis and 30 after patch repair, not differing statistically (P =.4, log-rank test). Aneurysm formation occurred in 8 patients after patch repair that included ridge resection in 7 of the 8 patients. Late hypertension occurred in less patients (n = 3) after resection and anastomosis than after patch repair (n = 8) (P <.03). Arch hypoplasia (P <.01) and age less than 1 month (P <.001) were found to be independent risk factors for recoarctation. CONCLUSIONS Polytetrafluoroethylene patch repair including coarctation ridge resection was found to be a risk factor for aneurysm formation and late hypertension. Arch hypoplasia and young age must be considered to predispose to recoarctation.
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Affiliation(s)
- Ronald J Walhout
- Children's Heart Center, Department of Cardiology/Cardiac Surgery, Wilhelmina Children's Hospital UMC, University of Utrecht, 3501 CA Utrecht, the Netherlands
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Shimizu T, Satomi G, Yasukochi S. Intravascular ultrasonic assessment of post-operative remodelling of aortic coarctation repaired by use of a subclavian flap. Cardiol Young 2003; 13:53-7. [PMID: 12691289 DOI: 10.1017/s1047951103000106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND We have used intravascular ultrasound in an attempt to clarify the extent of vascular remodelling of the aortic arch after the repair of aortic coarctation by use of a subclavian flap. METHODS We investigated 13 patients with coarctation of the aorta, ranging in age from 1.4 to 43.0 months, with a mean of 20.8 months, who underwent aortoplasty by incorporation of a subclavian flap. The mean postoperative period was 19.6 months, with a range from 0.03 to 41.2 months. The luminal morphology of the aortic arch was evaluated by intravascular ultrasound at the time of post-operative catheterization. RESULTS We observed 3 cases longitudinally. Over the period of observation, we found three types o f morphology of the aorta at the site of incorporation of the subclavian flap, namely a snowman shape with two inflection points, a pisiform shape with one inflection point, and a round shape without any points of inflection. There was a correlation between the cross-sectional shapes at the site of the subclavian flap in the postoperative period (p < 0.01). In each case, we measured the cross-sectional area at the site of subclavian flap, at the descending aorta, and at the distal aortic arch. The cross-sectional area, and the increment of the cross-sectional area at the site of subclavian flap, was larger. CONCLUSION The shape of the lumen subsequent to repair of aortic coarctation changes progressively from a snowman, to a pisiform, and finally to a round shape. Greater growth of the subclavian flap compared to the native wall of the aorta was observed for at least the first 4 years after repair. This finding may improve our understanding of the remodelling process of the arterial trunks after surgical repair.
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Affiliation(s)
- Takashi Shimizu
- Nagano Children's Hospital, Department of Pediatric, Nagano, Japan.
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Narasinga Rao P, Kumar RNS, Anil Kumar D, Mohmoud HM, Chandran S, Dhir AK, Saxena DK, Azhagappan SP, Pillai VR, Venkitachalam CG, Fikree MA, Nazer YA, Cartmill TB, Mrutyunjaya Rao I. Coarctation of the aorta in neonates and young infants: surgical experience. Asian Cardiovasc Thorac Ann 2002; 10:310-3. [PMID: 12538274 DOI: 10.1177/021849230201000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A retrospective analysis of repair of aortic coarctation in young infants was conducted. Between April 1997 and December 2000, 21 patients under 4 months of age underwent repair of coarctation. Their mean age and weight were 41 42 days (range, 2 to 120 days) and 3.6 0.7 kg (range, 2.6 to 4.9 kg). The indications for surgery were congestive heart failure and/or shock. Diagnosis was made by 2-dimensional echocardiography with Doppler color flow imaging. Preoperative gradients ranged from 25 to 100 mm Hg. Aortic arch hypoplasia was present in 8 patients; 7 patients also had ventricular septal defect. Wide excision of the coarctation segment with extended end-to-end anastomosis was performed in 20 patients, while 1 required a Gore-Tex interposition graft between the left common carotid artery and the descending aorta. Subclavian angioplasty was performed to augment the anastomosis in 1 patient. There was no early mortality. One patient died 2 months after surgery. Follow-up examination revealed recoarctation in 5 patients (23.8%), all of whom underwent successful balloon dilatation. In conclusion, wider excision of the coarctation with extended end-to-end anastomosis reduces the chances of recoarctation. Percutaneous balloon angioplasty for treating recoarctation is effective in immediately reducing pressure gradients.
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Younoszai AK, Reddy VM, Hanley FL, Brook MM. Intermediate term follow-up of the end-to-side aortic anastomosis for coarctation of the aorta. Ann Thorac Surg 2002; 74:1631-4. [PMID: 12440621 DOI: 10.1016/s0003-4975(02)03902-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Classic techniques for repairing coarctation of the aorta, especially in neonates, have a significant incidence of recurrent obstruction. By connecting the descending aorta to the proximal aortic arch, the end-to-side aortic anastomosis isolates hypoplastic distal arch and encroaching ductal tissue from the anastomotic site. METHODS Follow-up data were available for 88 patients (54 male) who underwent an end-to-side aortic anastomosis from November 1992 until November 1999. The median postoperative follow-up was 1.9 years (range, 0.1 to 6.3 years). Fifty-four patients were corrected as neonates. Thirty-four patients were operated on out of the neonatal period (> 1 month of age). A systolic blood pressure gradient > or = 20 mm Hg and a Doppler flow velocity > or = 2.5 ms across the area of repair were considered a recurrent obstruction. RESULTS No patients in the pediatric group had a recurrent obstruction. In the neonatal group, 3 patients (5.5%) had recurrent obstruction. Of those, 2 patients had a reintervention performed; one reintervention was a balloon angioplasty and the other one was a reoperation. Kaplan-Meier analysis of the neonatal group revealed a 95.8% freedom from reintervention at 1 and 2 years. CONCLUSIONS The end-to-side aortic anastomosis is an effective repair for coarctation of the aorta. Even when performed in the neonatal period, recurrence of coarctation is rare.
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Affiliation(s)
- Adel K Younoszai
- Division of Pediatric Cardiology, University of California San Francisco, USA.
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McElhinney DB, Yang SG, Hogarty AN, Rychik J, Gleason MM, Zachary CH, Rome JJ, Karl TR, Decampli WM, Spray TL, Gaynor JW. Recurrent arch obstruction after repair of isolated coarctation of the aorta in neonates and young infants: is low weight a risk factor? J Thorac Cardiovasc Surg 2001; 122:883-90. [PMID: 11689792 DOI: 10.1067/mtc.2001.116316] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Repair of aortic coarctation is often delayed in small infants because of the belief that such patients are at risk of recurrent arch obstruction and that growth will decrease this risk. To determine whether low weight was a risk factor for recurrent arch obstruction, we reviewed our experience with coarctation repair via left thoracotomy in infants less than 3 months of age. METHODS From 1990 to 1999, 103 patients less than 3 months of age underwent repair of aortic coarctation through a left thoracotomy. Median age was 18 days (1-90 days), with 45 patients less than 2 weeks. Median weight was 3.3 kg (1.0-6.4 kg) and 14 patients were less than 2 kg. The method of repair was resection and end-to-end anastomosis in 64 patients, subclavian flap angioplasty in 34, and patch augmentation of the arch in 5. Demographic, echocardiographic, and operative variables were analyzed for correlation with recurrent arch obstruction. RESULTS One early and 1 late death occurred, both in patients who had complications but no evidence of recoarctation. At median follow-up of 24 months, reinterventions for recurrent arch obstruction were performed in 15 patients. The median time to reintervention was 5 months and was less than 1 year in 12 patients. Kaplan-Meier freedom from arch reintervention was 88% at 1 year (95% confidence intervals: 82%-94%) and 82% at 5 years (95% confidence intervals: 72%-92%). Factors associated with shorter duration to arch reintervention by univariable Cox regression included younger age (continuous, P =.01; <2 weeks, P =.005), smaller transverse arch (absolute diameter, P <.001; indexed to weight, P =.03; indexed to ascending aortic diameter, P =.02), and smaller ascending aorta (absolute diameter, P =.02). Smaller absolute transverse arch diameter and younger age were the only independent predictors of shorter time to arch reintervention by multivariable Cox regression analysis. Weight and type of repair did not correlate with risk of recoarctation. CONCLUSIONS Low weight is not a risk factor for recurrent obstruction after repair of coarctation of the aorta in infants less than 3 months of age. Rather, risk of recoarctation is more a function of the anatomy of the arch. Thus, it is not indicated to delay repair in low weight infants with the goal of achieving growth.
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Affiliation(s)
- D B McElhinney
- Division of Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, USA
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Harrison DA, McLaughlin PR, Lazzam C, Connelly M, Benson LN. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up. Heart 2001; 85:561-6. [PMID: 11303011 PMCID: PMC1729735 DOI: 10.1136/heart.85.5.561] [Citation(s) in RCA: 129] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To test the hypothesis that endovascular stents used with dilation of coarctation of the aorta (CoA) improve late outcomes. Balloon dilation for CoA has been limited by concerns over the risk for acute dissection, late restenosis, or aneurysm formation. DESIGN All patients seen with CoA between November 1994 and September 1997 underwent attempted stent implantation. Follow up was obtained for all patients and a subgroup (n = 18) had repeat catheterisation at a mean (SD) of 1.3 (0.5) years to assess residual gradient and stent-CoA morphology. RESULTS Stents were placed in 27 patients (15 male and 12 female patients, mean age 30.1 (13.1) years), of whom seven had prior surgical coarctectomy and one had a prior balloon dilation. Hypertension was present in 26 patients (mean pressure 164 (26)/86 (13) mm Hg), of whom 16 were on antihypertension drugs. CoA gradients were 46 (20) mm Hg (range 18-106 mm Hg) at baseline and 3 (5) mm Hg after the procedure. One patient had a stroke following the procedure; another patient had incomplete dilation and underwent a second procedure. At 1.8 (1) years after the procedure the mean pressure was 130 (14)/74 (11) mm Hg with seven patients on antihypertension treatment. The clinical gradient was 4 (8) mm Hg (range 0-32 mm Hg). At follow up angiography, the mean gradient was 4(6) mm Hg, and two patients had a gradient over 10 mm Hg. Aneurysms formed in three patients at the dilation site; one patient was referred for surgery. CONCLUSION In this age group stent management for CoA appears to be an effective technique and results in sustained reduction in CoA gradients at early term follow up, but aortic aneurysm was detected in 17% of patients who had repeat angiography.
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Affiliation(s)
- D A Harrison
- Department of Medicine, Divisions of Cardiology, The Toronto Hospital and The Hospital for Sick Children, University of Toronto School of Medicine, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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Harrison DA, McLaughlin PR, Lazzam C, Connelly M, Benson LN. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up. BRITISH HEART JOURNAL 2001. [DOI: 10.1136/hrt.85.5.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVESTo test the hypothesis that endovascular stents used with dilation of coarctation of the aorta (CoA) improve late outcomes. Balloon dilation for CoA has been limited by concerns over the risk for acute dissection, late restenosis, or aneurysm formation.DESIGNAll patients seen with CoA between November 1994 and September 1997 underwent attempted stent implantation. Follow up was obtained for all patients and a subgroup (n = 18) had repeat catheterisation at a mean (SD) of 1.3 (0.5) years to assess residual gradient and stent-CoA morphology.RESULTSStents were placed in 27 patients (15 male and 12 female patients, mean age 30.1 (13.1) years), of whom seven had prior surgical coarctectomy and one had a prior balloon dilation. Hypertension was present in 26 patients (mean pressure 164 (26)/86 (13) mm Hg), of whom 16 were on antihypertension drugs. CoA gradients were 46 (20) mm Hg (range 18–106 mm Hg) at baseline and 3 (5) mm Hg after the procedure. One patient had a stroke following the procedure; another patient had incomplete dilation and underwent a second procedure. At 1.8 (1) years after the procedure the mean pressure was 130 (14)/74 (11) mm Hg with seven patients on antihypertension treatment. The clinical gradient was 4 (8) mm Hg (range 0–32 mm Hg). At follow up angiography, the mean gradient was 4(6) mm Hg, and two patients had a gradient over 10 mm Hg. Aneurysms formed in three patients at the dilation site; one patient was referred for surgery.CONCLUSIONIn this age group stent management for CoA appears to be an effective technique and results in sustained reduction in CoA gradients at early term follow up, but aortic aneurysm was detected in 17% of patients who had repeat angiography.
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Bacha EA, Almodovar M, Wessel DL, Zurakowski D, Mayer JE, Jonas RA, del Nido PJ. Surgery for coarctation of the aorta in infants weighing less than 2 kg. Ann Thorac Surg 2001; 71:1260-4. [PMID: 11308171 DOI: 10.1016/s0003-4975(00)02664-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Low- and very low-birth weight infants are now candidates for reparative cardiac surgery. Outcomes after coarctation repair have not been characterized in this patient population. METHODS We performed a retrospective review of 18 consecutive neonates less than 2 kg who underwent repair of aortic coarctation between August 1990 and December 1999. RESULTS Median weight was 1,330 g, and median gestational age was 31 weeks. A ventricular septal defect was present in 5 patients, and Shone's complex in 4. Sixteen patients had resection and end-to-end anastomosis, and 2 had resection and subclavian flap. Median clamp time was 15.5 minutes. One patient died during hospitalization. Two patients died late postoperatively (5-year estimated survival 80%). Mean follow-up was 28.5 months. Eight patients (44%) had a residual or recurrent coarctation, 5 underwent balloon dilation, and 3 underwent reoperation. Freedom from reintervention for recoarctation was 60% at 5 years. Shone's complex or a hypoplastic arch was an independent risk factor for decreased survival (p < 0.001). Very low birth weight was a multivariate predictor for increased risk of recoarctation (p = 0.01). CONCLUSIONS Coarctation repair in less than 2-kg premature non-Shone's infants can be performed with a low mortality. The rate of recoarctation is higher in the very low-birth weight infants, but can be managed with low risk.
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Affiliation(s)
- E A Bacha
- Department of Cardiac Surgery, The Children's Hospital, Boston, Massachusetts, USA.
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Johnson D, Perrault H, Vobecky SJ, Trudeau F, Delvin E, Fournier A, Davignon A. Resetting of the cardiopulmonary baroreflex 10 years after surgical repair of coarctation of the aorta. Heart 2001; 85:318-25. [PMID: 11179275 PMCID: PMC1729634 DOI: 10.1136/heart.85.3.318] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To characterise cardiopulmonary baroreflex responses and examine the effects of a 45 minute cycling bout late after successful repair of coarctation of the aorta. SUBJECTS 10 young adults (mean (SEM) age 18.1 (2.6 years)) operated on for coarctation of the aorta 12.7 (3.5) years earlier, and 10 healthy controls. DESIGN Forearm blood flow (venous occlusion plethysmography) and vascular resistance, left ventricular internal diastolic diameter, and central venous pressure estimated from an antecubital vein were measured in the supine position at baseline and during five minute applications of lower body negative pressure (LBNP) at -15 mm Hg (LBNP(-15)) and -40 mm Hg (LBNP(-40)). Venous samples were obtained at baseline and during LBNP(-40) for noradrenaline (norepinephrine), adrenaline (epinephrine), renin activity, and aldosterone. The tests were repeated after 45 minutes of moderate exercise. RESULTS Baseline heart rate (78 (9) v 64 (6) beats/min), echocardiographic cardiac output (6.9 (1.1) v 5.0 (0.2) l/min), shortening fraction (41.7 (1.8)% v 33.3 (1.3)%), and forearm blood flow (3.4 (0.4) v 2.3 (0.3) ml/100 g/min) were higher in the coarctation group than in the controls (p < 0.05). Changes in forearm blood flow and forearm vascular resistance from baseline to LBNP(-40) were similar in both groups, but the relation between forearm vascular resistance and estimated central venous pressure or left ventricular internal diastolic diameter was shifted downward in the coarctation group. Plasma adrenaline was increased in the coarctation group (baseline: 3.2 (0.6) v 2.4 (0.3) pmol/l in controls; LBNP(-40): 687 (151) v 332 (42) pmol/l) (p < 0.05). Both groups showed a similar downward displacement of forearm vascular resistance (p < 0.05) after exercise. CONCLUSIONS There appears to be resetting of the cardiopulmonary baroreflex to a lower forearm vascular resistance in young adults operated on for coarctation of the aorta, associated with hyperdynamic left ventricular function. Raised circulating adrenaline could contribute to the lower forearm vascular resistance.
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Affiliation(s)
- D Johnson
- Cardiology Unit, Ste-Justine Hospital, Montreal, Quebec, Canada
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Manning N, Archer N. Treatment and outcome of serious structural congenital heart disease. SEMINARS IN NEONATOLOGY : SN 2001; 6:37-47. [PMID: 11162284 DOI: 10.1053/siny.2000.0033] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Serious structural congenital heart disease usually presents to the neonatal paediatrician, although increasingly these conditions are being diagnosed before birth. It is, therefore, important that those dealing with these fetuses and infants have some knowledge of their natural and modified history. The vast majority of lesions can either be corrected or given symptomatic palliation and this review discusses treatment options and provides up-to-date outcome information to enable fetal and neonatal staff to anticipate and to complement information given to families by paediatric cardiologists.
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Affiliation(s)
- N Manning
- Paediatric Cardiology, John Radcliffe Hospital, Oxford OX3 9DU, UK
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40
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Allen BS, Halldorsson AO, Barth MJ, Ilbawi MN. Modification of the subclavian patch aortoplasty for repair of aortic coarctation in neonates and infants. Ann Thorac Surg 2000; 69:877-80; discussion 881. [PMID: 10750776 DOI: 10.1016/s0003-4975(99)01503-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coarctation repair in neonates or small infants, using a subclavian patch, has a relatively high risk of restenosis, especially if complicated by the presence of a short subclavian artery or long coarctation segment. We introduce a technical modification that facilitates the use of a subclavian flap, and decreases the restenosis rate in this subgroup of patients. It consists of a side-to-side transverse aortic anastomosis at the level of the coarctation, which widens the coarctation segment, shortens the isthmus, and pulls the distal end of the aortotomy proximally, allowing a tension-free subclavian flap aortoplasty. METHODS Fifty-three consecutive neonates or infants less than 18 weeks old, with complex coarctation, underwent repair using this technique. Mean age was 26+/-3 days and 36 patients (68%) were less than 28 days old. Weights ranged from 1.4 to 6.4 kg (mean 3.4+/-0.2 kg), and 26 patients had other cardiac anomalies. Preoperative gradient by Doppler measurement ranged from 25 to 90 mm Hg (mean 49+/-2 mm Hg). RESULTS Mean aortic cross-clamp time was 27+/-1 minutes (range 19 to 34 minutes). There were no deaths or surgical complications. Follow-up echocardiogram 4 to 52 months postoperatively (mean 25+/-2 months) demonstrated no significant pressure gradient (less than 20 mm Hg) in 51 of 53 patients (96%), and a significant gradient in 2 patients (4%), which was subsequently corrected with balloon angioplasty. CONCLUSIONS The technical modification described shortens the isthmus, and thus allows for a longer aortotomy distal to the area of coarctation resulting in a tension-free repair especially in patients with a short subclavian artery. It also widens the area of coarctation, and as a result leads to a lower early recoarctation rate in this high-risk group. With increasing emphasis on the need for a longer aortotomy to prevent restenosis, this modification will have increasing application, especially in the neonatal population.
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Affiliation(s)
- B S Allen
- Division of Cardiothoracic Surgery, Heart Institute for Children, Hope Children's Hospital, Oak Lawn, Illinois, 60453, USA
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Pihkala J, Pedra CA, Nykanen D, Benson LN. Implantation of endovascular stents for hypoplasia of the transverse aortic arch. Cardiol Young 2000; 10:3-7. [PMID: 10695533 DOI: 10.1017/s1047951100006302] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Hypoplasia of the transverse aortic arch is commonly associated with aortic coarctation. Persistent or recurrent obstruction can occur at this level after successful repair of the native coarcted segment. The purpose of this report is to present a new technique to treat such lesions, namely with implantation of a balloon-expandable stent. This approach was used successfully in 4 children with such hypoplasia occurring after repair of coarctation. Implantation led to both anatomical and physiological relief of obstruction in all. The patients tolerated the procedure, and there were no major adverse events.
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Affiliation(s)
- J Pihkala
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto School of Medicine, Ontario, Canada
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Daebritz S, Fausten B, Sachweh J, Mühler E, Franke A, Messmer BJ. Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999; 16:519-23. [PMID: 10609902 DOI: 10.1016/s1010-7940(99)00315-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Operation for aortic recoarctation and/or residual hypoplastic arch represents a surgical challenge because of surrounding scar tissue in the coarctation area, hazard of spinal cord ischemia due to aortic cross-clamping, laceration of the recurrent nerve, and the choice of the best approach. We demonstrate the first results of an anatomically guided technique via the prior left thoracotomy approach without establishment of cardiopulmonary bypass. METHODS Since 1989, five patients underwent anatomically positioned ascending-descending bypass grafting for treatment of recoarctation. Indication was a non-dilatable hypoplastic aortic arch segment; in two cases an additional isthmic restenosis was present. Inclusion criteria for our technique was an aorta ascending diameter large enough to allow partial clamping. Primary repair of aortic coarctation was end-to-end anastomosis in four patients and patch angioplasty in one. Mean age at primary repair was 5.5 years and at reoperation 16.1 years. Systolic pressure gradients at rest ranged from 35 to 70 mmHg; upper extremity hypertension was present in all patients. Operative technique consisted of performing a dacron or PTFE aorta ascending-descending bypass graft parallel to the aortic arch, size 18 or 20 mm in diameter, via the prior left thoracotomy. RESULTS There were no intraoperative complications and all patients survived. Postoperative complications were left lung atelectasis with necessity of reintubation, pericardial effusion, and transient left diaphragm elevation, each in one patient. After 7-90 months all patients are free of symptoms, have normal blood pressure (with two patients being under anti-hypertensive medication), and have no echocardiographically measurable pressure gradients. CONCLUSIONS Anatomically positioned aorta ascending-descending bypass grafting via the prior left posterolateral thoracotomy without cardiopulmonary bypass is a safe and efficient method for operation of complex recoarctation in patients with an acceptable size of the aorta ascendens.
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Affiliation(s)
- S Daebritz
- Department of Thoracic and Cardiovascular Surgery, Klinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum der RWTH, Aachen, Germany.
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Abstract
Patients with LVOT obstruction require lifelong follow-up because the obstruction may be progressive or recurrent. Several procedures are usually required, either by surgery or by interventional cardiac catheterization, to repair or palliate the obstructive lesion. The treatment of these patients continues to evolve, and, despite the complexity of these patients' lesions, the morbidity and mortality rates have decreased and are expected to decrease further in the future.
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Affiliation(s)
- R T Fedderly
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, USA
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Backer CL, Mavroudis C, Zias EA, Amin Z, Weigel TJ. Repair of coarctation with resection and extended end-to-end anastomosis. Ann Thorac Surg 1998; 66:1365-70; discussion 1370-1. [PMID: 9800834 DOI: 10.1016/s0003-4975(98)00671-7] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Our surgical strategy for infant coarctation changed from subclavian flap aortoplasty to resection with extended end-to-end anastomosis in 1991. The purpose of this review was to evaluate the results of that strategy. METHODS From 1991 through 1997, 55 infants underwent repair of coarctation of the aorta using resection with extended end-to-end anastomosis. Isolated coarctation of the aorta was present in 26 patients, 20 patients had a ventricular septal defect, and 9 patients had other associated intracardiac lesions. Mean age at surgery was 0.20+/-0.24 years (median, 21 days). In 34 patients (62%), arch reconstruction was performed through a left thoracotomy. Twenty patients (36%) had median sternotomy with simultaneous repair of coarctation of the aorta and intracardiac repair of associated lesions. One patient had recoarctation repair through a median sternotomy. All coarctation and ductal tissue was resected and the anastomosis was constructed starting opposite the left carotid artery with running polypropylene suture. RESULTS There was one early death 26 days after coarctation of the aorta and ventricular septal defect repair in a child on extracorporeal membrane oxygenation for meconium aspiration and 2 late deaths owing to pneumonia and pulmonary hypertension (1) and interventricular hemorrhage (1). There were no instances of paraplegia. Follow-up in survivors ranges from 10 to 76 months (mean, 39.8+/-17.2 months). Recoarctation has developed in 2 patients, who have had successful balloon dilation 6 and 14 months after the operation. This yields a low recoarctation rate of 3.6%. CONCLUSIONS Resection with extended end-to-end anastomosis yields a low mortality and particularly a low recoarctation rate and is our procedure of choice for infants with coarctation of the aorta.
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Affiliation(s)
- C L Backer
- Children's Memorial Hospital, and Department of Surgery, Northwestern University Medical School, Chicago, Illinois 60614, USA.
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Asano M, Mishima A, Yamamoto S, Saito T, Manabe T. Modified subclavian flap aortoplasty for coarctation repair in patients less than three months of age. Ann Thorac Surg 1998; 66:588-9. [PMID: 9725421 DOI: 10.1016/s0003-4975(98)00553-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Subclavian flap aortoplasty is one of the best procedures for coarctation repair, but recoarctation still remains a problem in neonates and infants. We employed subclavian flap aortoplasty with resection of the whole layer of aortic ductal tissue in 9 patients less than 3 months of age with coarctation of the aorta and obtained satisfactory results.
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Affiliation(s)
- M Asano
- Division of Cardiovascular Surgery, Nagoya City University Medical School, Nagoya, Japan.
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Cobanoglu A, Thyagarajan GK, Dobbs JL. Surgery for coarctation of the aorta in infants younger than 3 months: end-to-end repair versus subclavian flap angioplasty: is either operation better? Eur J Cardiothorac Surg 1998; 14:19-25; discussion 25-6. [PMID: 9726610 DOI: 10.1016/s1010-7940(98)00142-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Recurrent coarctation is a complication which is seen at a consistent rate following all types of repair for coarctation of the aorta. Particularly disappointing late results are reported in younger infants, under 3 months of age. This retrospective analysis was undertaken to compare the outcomes on late follow-up between subclavian flap angioplasty and resection and end-to-end repair, in this age group. METHODS Over a 12-year period, between 1982 and 1994, 86 infants under 3 months of age underwent surgical repair of coarctation (39 resections and end-to-end repair, and 47 subclavian flap angioplasty procedures). Operative mortality was not significantly different (P = 0.6) between resection and end-to-end repair (5.1%) and subclavian flap angioplasty (8.5%). All operative deaths (six patients) were in infants with associated ventricular septal defects. The mean follow-up for all patients was 7.95 years +/- 4.10 (range 0-14.5 years). The 5-year survival for resection and end-to-end repair was 87 +/- 5%, compared to 75 +/- 7% for subclavian flap angioplasty (P = 0.2). RESULTS Recurrent coarctation occurred in nine patients who needed reoperation. The reoperation-free rates at both 5 and 10 years for resection and end-to-end anastomosis, and subclavian flap repair were 86 +/- 6% and 90 +/- 5%, respectively. The recurrence in the resection and end-to-end anastomosis group were due to constrictive scarring at the anastomosis, whereas periductal tissue and growth of posterior aortic ridge caused recurrence in the subclavian flap angioplasty group. There were no deaths during reoperation for recurrence. CONCLUSIONS Both procedures are extremely effective for coarctation repair in young infants and run a similar risk of recurrence, which are due to completely different mechanisms. The surgeon's expertise is the major determinant of outcome.
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Affiliation(s)
- A Cobanoglu
- Division of Cardiopulmonary Surgery, Oregon Health Sciences University, Portland 97201-3098, USA
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Affiliation(s)
- A Rothman
- Division of Pediatric Cardiology, University of California-San Diego, USA
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Van Son JA, Falk V, Schneider P, Smedts F, Mohr FW. Repair of coarctation of the aorta in neonates and young infants. J Card Surg 1997; 12:139-46. [PMID: 9395942 DOI: 10.1111/j.1540-8191.1997.tb00114.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
In repair of coarctation in neonates or young infants, inadequate removal of ductal tissue, failure to address hypoplasia of the aortic arch, and suture line tension have been reported to be important factors of residual or early recurrent stenosis at the coarctation repair site. In a consecutive series of neonates and young infants with coarctation, who were all operated without delay with extended resection, the clinical outcome regarding the development of restenosis and hypertension was studied. In addition, the resected specimens were investigated regarding the completeness of resection of ductal tissue. Twenty-five consecutive neonates and young infants (median age 22 days, range 5 to 39 days) who underwent surgical correction of coarctation were reviewed; the resected specimens were examined histologically to document the extent of ductal tissue in the aortic wall. Fifteen patients had a preductal coarctation with associated cardiovascular anomalies including a hypoplastic aortic arch (n = 11). The remaining 10 patients had a paraductal coarctation without associated intracardiac anomalies. In all patients, the isthmus was bypassed and an end-to-side anastomosis was constructed between the descending aorta and the undersurface of the proximal aortic arch (n = 13) or the distal ascending aorta (n = 12). In 13 patients without marked hypoplasia of the aortic arch, the coarctation repair was performed through a left thoracotomy. In the remaining 12 patients, the coarctation was repaired through a median sternotomy with CPB and hypothermic circulatory arrest, on the basis of an associated hypoplastic aortic arch (n = 4), hypoplastic aortic arch with intracardiac anomalies (n = 7), or a "bovine" innominate artery (n = 1). There was no perioperative or late mortality. At a median follow-up of 15 months, 1 patient (4%) developed a recurrent stenosis at the coarctation repair site; in the remaining 24 patients, echocardiography showed a widely patent anastomosis with no evidence of a hemodynamically significant gradient. None of the patients had hypertension. Histologic examination of the resected specimens demonstrated the presence of ductal tissue in the descending aorta with maximal extension into its lateral wall (mean 5.2 mm). In all specimens of the paraductal subtype, there was also extension of ductal tissue into the lateral wall of tbe isthmus (mean 3.9 mm). We conclude that: (1) in the absence of marked hypoplasia of the proximal aortic arch, coarctation can be repaired with low mortality and morbidity via a left thoracotomy; (2) in the presence of marked hypoplasia of the proximal aortic arch and/or if associated intracardiac defects also need to be repaired, we advocate repair of the coarctation and associated defects through a median sternotomy with circulatory arrest; (3) in view of the absence of postoperative hypertension in this series, early repair of aortic coarctation is recommended; and (4) because ductal tissue may extend not only into the descending aorta but also into the isthmus, complete excision of the coarctation and bypass of the isthmus are valuable techniques to avoid secondary constriction of the aorta by ductal tissue.
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Lange R, Thielmann M, Schmidt KG, Bauernschmitt R, Jakob H, Hasper B, Ulmer H, Hagl S. Spinal cord protection using hypothermic cardiocirculatory arrest in extended repair of recoarctation and persistent hypoplastic aortic arch. Eur J Cardiothorac Surg 1997; 11:697-702. [PMID: 9151040 DOI: 10.1016/s1010-7940(96)01114-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE In recurrent coarctation collateral circulation may not be sufficient to maintain adequate perfusion of the lower body during the period of surgical repair. Different techniques such as interposition of a Gott-shunt, use of left heart bypass or hypothermic cardiocirculatory arrest are used to prevent spinal cord injury. METHODS Twenty-eight operations for recurrent coarctation were performed in 26 patients following end-to-end anastomosis (58%), patch plasty (21%), subclavian flap aortoplasty (14%) and graft interposition (7%). Associated cardiac defects were present in 77% of the patients. Eleven patients who had adequate (> 50 mmHg) distal perfusion pressure during a test occlusion were operated on using simple cross-clamping (group I, mean age 8.5 +/- 3.8 years). In group I, end-to-end anastomosis was performed in nine patients and graft interposition in two patients. In 17 cases (including two patients from group I) with insufficient collateral circulation and with persistent hypoplasia of the arch, hypothermic cardiocirculatory arrest was used (group II, mean age 12.8 +/- 9.6 years). In group II end-to-end anastomosis was performed in three patients and graft interposition in 14 patients. Mean bypass-time was 116 +/- 36 min and arrest-time 33 +/- 16 min. Hypothermic cardiocirculatory arrest was begun when nasopharyngeal temperature was below 20 degrees C, corresponding to a rectal temperature of 24 +/- 3 degrees C. RESULTS Hypothermic cardiocirculatory arrest allowed open reconstruction of the arch and/or complete or partial replacement of the arch and the coarctation segment. In-hospital mortality was 0 and 5.9% in group I and II, respectively. The one patient who died in group II had simultaneous correction of an anomalous pulmonary venous connection and death was unrelated to the method of coarctation repair. Reversible laryngeal nerve paresis was observed in two patients in group II, no other neurologic complications were observed in either group. Postoperative gradients over the repair site were less than 20 mmHg by Doppler-echocardiography. Two patients of group I had to have a second, early reoperation because of stenosis at the anastomotic site. Reconstruction of the distal aortic arch was then performed during hypothermic cardiocirculatory arrest. CONCLUSIONS The use of hypothermic cardiocirculatory arrest in this special indication is a safe method which allows open reconstruction of the coarctation site and the aortic arch and protection of the spinal cord. The need for early reoperation because of inadequate repair may be reduced.
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Affiliation(s)
- R Lange
- Department of Cardiac Surgery, University of Heidelberg, Germany
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Pfammatter JP, Ziemer G, Kaulitz R, Heinemann MK, Luhmer I, Kallfelz HC. Isolated aortic coarctation in neonates and infants: results of resection and end-to-end anastomosis. Ann Thorac Surg 1996; 62:778-82; discussion 782-3. [PMID: 8784008 DOI: 10.1016/s0003-4975(96)00502-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Operative resection is the treatment of choice for native aortic coarctation in most institutions. The ideal timing for elective repair is still a matter of debate. This study evaluated one institution's results with resection and end-to-end anastomosis in the first year of life. METHODS Between January 1987 and December 1993, 46 neonates and infants with functionally isolated aortic coarctation underwent operative resection and end-to-end anastomosis. For the patients included in the study, all hospital records, catheterization data, and operative protocols were evaluated for retrospective analysis. To obtain valid follow-up information, all patients were systematically seen on an outpatient basis during 1994. RESULTS After a mean follow-up of 49 +/- 24 months (range, 13 to 95 months), recoarctation (arm-leg blood pressure gradient > 20 mm Hg) occurred in 5 of 26 patients with neonatal operations (19%) and in 1 of 20 patients with operations in infancy (5%, p = not significant). Four of these 6 children with recoarctation needed reintervention. The other 2 patients had only mild recoarctation (gradients of 22 and 30 mm Hg, respectively) and were not treated. In all 6 patients, recoarctation was diagnosed within the first 6 months postoperatively. During the whole follow-up period, right arm systolic blood pressures slightly above the 90th percentile of normal developed in 11 of the patients (24%) (7 in the group with neonatal operation and 4 after operation in infancy; p = not significant). CONCLUSIONS Resection with end-to-end anastomosis was shown to be an adequate therapeutic strategy for isolated aortic coarctation in neonates and infants. The results indicate that already beyond the neonatal age, there is a relatively low incidence of recoarctation.
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Affiliation(s)
- J P Pfammatter
- Division of Pediatric Cardiology, Children's Hospital, Berne, Switzerland
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