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Stephens EH, Feins EN, Karamlou T, Anderson BR, Alsoufi B, Bleiweis MS, d'Udekem Y, Nelson JS, Ashfaq A, Marino BS, St Louis JD, Najm HK, Turek JW, Ahmad D, Dearani JA, Jacobs JP. The Society of Thoracic Surgeons Clinical Practice Guidelines on the Management of Neonates and Infants With Coarctation. Ann Thorac Surg 2024; 118:527-544. [PMID: 38904587 DOI: 10.1016/j.athoracsur.2024.04.012] [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] [Received: 03/05/2023] [Revised: 04/06/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Although coarctation of the aorta without concomitant intracardiac pathology is relatively common, there is lack of guidance regarding aspects of its management in neonates and infants. METHODS A panel of experienced congenital cardiac surgeons, cardiologists, and intensivists was created, and key questions related to the management of isolated coarctation in neonates and infants were formed using the PICO (Patients/Population, Intervention, Comparison/Control, Outcome) Framework. A literature search was then performed for each question. Practice guidelines were developed with classification of recommendation and level of evidence using a modified Delphi method. RESULTS For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications. For patients with risk factors for surgery, medical management before intervention is reasonable. For those stable off prostaglandin E1, the threshold for intervention remains unclear. Thoracotomy is indicated when arch hypoplasia is not present. Sternotomy is preferable when arch hypoplasia is present that cannot be adequately addressed through a thoracotomy. Sternotomy may also be considered in the presence of a bovine aortic arch. Antegrade cerebral perfusion may be reasonable when the repair is performed through a sternotomy. Extended end-to-end, arch advancement, and patch augmentation are all reasonable techniques. CONCLUSIONS Surgery remains the standard of care for the management of isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach as opposed to a thoracotomy approach. Significant opportunities remain to better delineate management in these patients.
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Affiliation(s)
| | - Eric N Feins
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Bahaaldin Alsoufi
- Cardiovascular Surgery, Norton Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Mark S Bleiweis
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Yves d'Udekem
- Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Awais Ashfaq
- Division of Cardiovascular Surgery, Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | | | - James D St Louis
- Departent of Surgery, Children's Hospital of Georgia, Augusta, Georgia; Departent of Surgery, Inova L.J. Murphy Children's Hospital, Falls Church, Virginia
| | - Hani K Najm
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph W Turek
- Duke Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Danial Ahmad
- Cardiac Surgery Research Laboratory, Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida.
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Yoneyama F, Kalustian AB, McKenzie ED, Heinle JS, Doan TT, Binsalamah Z. Long-Term Outcomes of Ascending Sliding Arch Aortoplasty. World J Pediatr Congenit Heart Surg 2024; 15:432-438. [PMID: 38465582 DOI: 10.1177/21501351241232071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background: Coarctation of the aorta can be associated with significant hypoplasia of the aortic arch. In contrast to patch aortoplasty, ascending sliding arch aortoplasty uses viable autologous tissue for potential growth in children. We reviewed the mid- to long-term outcomes of this technique. Methods: Between 2002 and 2023, 28 patients underwent ascending sliding arch aortoplasty for the patients with coarctation of the aorta (n = 22) and interrupted aortic arch (n = 2). Four patients underwent previous surgical coarctation repair at other institutions. The median patient age and body weight were 28.5 months (3 weeks to 15.6 years) and 13.4 kg (3.7-70 kg), respectively. Results: Although one patient had a recurrent nerve injury postoperatively, there were no other major morbidities or mortalities. The last follow-up echocardiography demonstrated that the mean peak velocity improved from 3.9 ± 0.6 to 0.9 ± 0.8 m/s, and the pressure gradient improved from 63.6 ± 21.5 to 7.1 ± 7.7 mm Hg. The postoperative diameters of the ascending aorta, proximal arch, distal arch, and isthmus all increased significantly. The mean postoperative length of stay was 5.9 ± 2.1 days, and the median follow-up time was 7.3 years (10 days to 20.5 years). No reoperation or catheterization-based intervention was performed for residual coarctation. Conclusions: Ascending sliding arch aortoplasty is safe and effective for treating coarctation of the aorta with aortic arch hypoplasia. This technique is applicable for children ranging in size from neonates to older children (or adolescents), recurrent coarctation cases, and provides complete relief of narrowing by utilizing viable native aortic tissue.
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Affiliation(s)
- Fumiya Yoneyama
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Alyssa B Kalustian
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - E Dean McKenzie
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey S Heinle
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Tam T Doan
- Department of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ziyad Binsalamah
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Yilmaz M, Turkcan BS, Ecevit AN, Şahan YÖ, Atalay A. Comparative analysis of the effectiveness of coarctation surgery between neonates and infants. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20231626. [PMID: 38775513 PMCID: PMC11110970 DOI: 10.1590/1806-9282.20231626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/29/2023] [Indexed: 05/24/2024]
Abstract
OBJECTIVE This study aimed to compare the effectiveness of resection and extended end-to-end anastomosis between neonate and infant patients with coarctation. METHODS This study was designed retrospectively and included 41 neonate (<30 days) and infant (30 days to 1 year) patients who were operated on using the resection and extended end-to-end anastomosis technique for aortic coarctation. Preoperative aortic annulus diameters and Z scores, all aortic arch diameters and Z scores, the presence of hypoplastic aortic segment, and the presence of prematurity were reviewed in both groups. Subsequently, we investigated whether these parameters were statistically related to the residual gradient in the operation area, whether there was a need for early re-intervention, and what was the incidence of mortality in the early postoperative period. In addition, the aortic arch Z scores of the patients at 6 months postoperatively were examined. RESULTS While the mean age (p<0.001), body weight (p<0.001), and proximal arch Z score (p=0.029) were found to be significantly lower in the neonate group than in the infant group, the total length of the intensive care unit stay (p=0.013) and the total length of hospital stay (p=0.017) were found to be significantly higher. In addition, significant enlargement was detected in the proximal arch, distal arch, and isthmus segments in both patient groups. CONCLUSION The resection and extended end-to-end anastomosis is an equally effective technique that can provide a marked decrease in gradient in the coarctation area and a significant enlargement of the aortic arch segments in the early period after coarctation repair in both neonate and infant patients.
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Affiliation(s)
- Mustafa Yilmaz
- Ankara Bilkent City Hospital, Department of Pediatric Cardiovascular Surgery – Ankara, Turkey
| | - Başak Soran Turkcan
- Ankara Bilkent City Hospital, Department of Pediatric Cardiovascular Surgery – Ankara, Turkey
| | - Ata Niyazi Ecevit
- Ankara Bilkent City Hospital, Department of Pediatric Cardiovascular Surgery – Ankara, Turkey
| | | | - Atakan Atalay
- Ankara Bilkent City Hospital, Department of Pediatric Cardiovascular Surgery – Ankara, Turkey
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Stukov Y, Jacobs JP, Sharaf OM, Peek GJ, Pitkin AD, Cruz Beltrán SC, Lopez-Colon D, Nixon CS, Bleiweis MS. 15-Year Analysis of Surgical Approaches and Outcomes for Coarctation in 132 Neonates and Infants. Pediatr Cardiol 2024:10.1007/s00246-023-03360-1. [PMID: 38557773 DOI: 10.1007/s00246-023-03360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/19/2023] [Indexed: 04/04/2024]
Abstract
A variety of surgical approaches exist to treat aortic coarctation in neonates and infants. Our institutional approach is designed to match the surgical approach to the individual anatomy of the patient. The objective of this study is to evaluate operative characteristics and outcomes of all neonates and infants who underwent surgical repair of coarctation of the aorta or hypoplastic aortic arch at University of Florida from 2006 to 2021, inclusive, either in isolation or with concomitant repair of atrial septal defect (ASD) and/or ventricular septal defect (VSD). A retrospective review was performed of 132 patients aged 0-1 year who underwent surgical repair of aortic coarctation or hypoplastic aortic arch between 2006 and 2021, inclusive, either in isolation or with concomitant repair of ASD and/or VSD. Patients were divided into two groups based on the surgical approach: Group 1 = Median Sternotomy and Group 2 = Left Lateral Thoracotomy. Continuous variables are presented as median (minimum-maximum); categorical variables are presented as N (%). The most common operative technique in Group 1 was end-to-side reconstruction with ligation of the aortic isthmus. The most common operative technique in Group 2 was extended end-to-end repair. Operative Mortality was one patient (1/132 = 0.76%). Transcatheter intervention for recurrent coarctation was performed in seven patients (7/132 = 5.3%). Surgical re-intervention for recurrent coarctation was performed in three patients (3/132 = 2.3%). From these data, one can conclude that a strategy of matching the surgical approach to the anatomy of neonates and infants who underwent surgical repair of aortic coarctation or hypoplastic aortic arch, either in isolation or with concomitant repair of ASD and/or VSD, is associated with less than 1% Operative Mortality and less than 3% recurrent coarctation requiring reoperation.
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Affiliation(s)
- Yuriy Stukov
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Omar M Sharaf
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Andrew D Pitkin
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Susana C Cruz Beltrán
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Dalia Lopez-Colon
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Connie S Nixon
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Mark S Bleiweis
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA.
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Winder MM, Ware A, Husain A, Griffiths E, Swink JM, Ou Z, Eckhauser A. Interdigitating Technique for Repair of Aortic Arch Obstruction to Reduce Reintervention Rates. Ann Thorac Surg 2024; 117:387-394. [PMID: 37414382 PMCID: PMC10764635 DOI: 10.1016/j.athoracsur.2023.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND The incidence of reintervention for aortic arch obstruction is 5% to 14% after coarctation or hypoplastic aortic arch repair and 25% after the Norwood procedure. Institutional practice review indicated higher than reported reintervention rates. Our aim was to assess the impact of an interdigitating reconstruction technique on reintervention rates for recurrent aortic arch obstruction. METHODS Children (<18 years) were included if they had undergone aortic arch reconstruction by sternotomy or the Norwood procedure. Three surgeons participated in the intervention with staggered rollout dates between June 2017 and January 2019, with the study ending December 2020 and review for reinterventions ending February 2022. Preintervention cohorts represented patients who underwent aortic arch reconstructions with patch augmentation, and postintervention cohorts represented patients who underwent an interdigitating reconstruction technique. Reinterventions by cardiac catheterization or operation were measured within 1 year of initial operation. Wilcoxon rank sum and χ2 tests were used to compare preintervention and postintervention cohorts. RESULTS Overall, 237 patients were included for participation in this study, with 84 patients in the preintervention cohort and 153 in the postintervention cohort. Patients undergoing the Norwood procedure represented 30% (n = 25) of the retrospective cohort and 35% (n = 53) of the intervention cohort. Overall reinterventions were significantly decreased after the study intervention from 31% (n = 26/84) to 13% (n = 20/153; P < .001). Reintervention rates were decreased for each intervention cohort: aortic arch hypoplasia (24% [n = 14/59] vs 10% [n = 10/100]; P = .019) and Norwood procedure (48% [n = 12/25] vs 19% [n = 10/53]; P = .008). CONCLUSIONS The interdigitating reconstruction technique for obstructive aortic arch lesions was successfully implemented and is associated with a decrease in reinterventions.
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Affiliation(s)
- Melissa M Winder
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah; Heart Center, Primary Children's Hospital, Salt Lake City, Utah.
| | - Adam Ware
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Adil Husain
- Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Aaron Eckhauser
- Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
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Masaki N, Tatewaki H, Kumae M, Ochiai T, Koizumi T, Ono T, Sonota K, Kimura M, Ozawa A, Sai S. Clinical Prognosis of Vocal Cord Paralysis After Cardiothoracic Surgery in Infants. Pediatr Cardiol 2024; 45:40-47. [PMID: 38070026 DOI: 10.1007/s00246-023-03341-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/30/2023] [Indexed: 01/10/2024]
Abstract
We aimed to clarify the long-term outcomes and prognosis of vocal cord paralysis (VCP) after cardiothoracic surgery in infants as well as the usefulness of laryngeal ultrasound (LUS) as screening for VCP. Overall, 967 infants aged 1-year-old or younger who underwent cardiothoracic surgery between 2008 and 2022 were included in this study. We divided the patients into two groups based on the period on whether they underwent screening without or with LUS and compared the incidence of VCP between the groups. There were no differences in the patients' preoperative characteristics between the two periods, whereas the incidence of VCP was significantly higher in period 2 than in period 1 (11.0% vs. 3.2%, p < 0.0001). The incidence of VCP among the procedures, including aortic arch repair, was > 50% and significantly increased from period 1 to period 2. The sensitivity and specificity of LUS was 87% and 90%, respectively. Symptoms of VCP improved in 92% of patients. Repeated flexible laryngoscopy revealed that the residual rate of VCP was 68%, 52%, and 48% at 6, 12, and 24 months, respectively. In conclusion, symptoms of postoperative VCP improved in most cases; however, paralysis persisted in half of the patients. As a screening method, LUS is useful for evaluating postoperative VCP. A more accurate understanding of VCP is needed to improve postoperative outcomes.
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Affiliation(s)
- Naoki Masaki
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Hideki Tatewaki
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Masaru Kumae
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Tomonori Ochiai
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan
| | - Taku Koizumi
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Tanomo Ono
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Kenji Sonota
- Department of Intensive Care Medicine, Miyagi Children's Hospital, Sendai, Japan
| | - Masato Kimura
- Department of Cardiology, Miyagi Children's Hospital, Sendai, Japan
| | - Akira Ozawa
- Department of Cardiology, Miyagi Children's Hospital, Sendai, Japan
| | - Sadahiro Sai
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, 4-3-17 Ochiai, Aoba-ku, Sendai, 989-3126, Japan.
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Choi KH, Kim H, Sung SC, Lee HD, Ko H, Byun JH, Kim T, Chung C. Outcomes of surgery for coarctation of the aorta based on a new classification system. Cardiol Young 2023; 33:2644-2648. [PMID: 37127753 DOI: 10.1017/s104795112300104x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES To evaluate early- and long-term outcomes of the surgical treatment for coarctation of the aorta based on a new classification system. METHODS A retrospective clinical review of 111 patients with coarctation of the aorta who underwent surgery (March 2011 to August 2020) was performed. We categorised coarctation of the aorta into type I, with all three head vessels tightly packed; type II, with the left subclavian artery separated from the two other head vessels; and type III, with all three head vessels separated from one another. Each type included subtype a, with a short isthmic portion, and subtype b, with a long isthmic portion. RESULTS The median patient age and weight at operation were 8 (range, 1-1490) days and 3.2 (range, 1.9-18.5) kg, respectively. Extended end-to-end anastomosis was performed via sternotomy in 54, via thoracotomy in 12, end-to-side anastomosis in 31, autologous main pulmonary artery patch augmentation in 12, and modified end-to-end anastomosis combined with subclavian artery flap aortoplasty in two patients. There was one (0.9%) case of early mortality and 12 (10.8%) cases of post-operative complications. Two (1.8%) late deaths occurred during follow-up. Five (4.5%) patients underwent balloon dilatation and three (2.7%) underwent reoperation for restenosis of coarctation of the aorta. All patients with type Ia (21 patients, 18.9%) underwent extended end-to-end anastomosis via sternotomy or thoracotomy. CONCLUSIONS According to the early and late outcomes observed in this study, surgical treatment of coarctation of the aorta using the new classification system could be safe and low risk.
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Affiliation(s)
- Kwang Ho Choi
- Department of Thoracic and Cardiovascular Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Hyungtae Kim
- Department of Thoracic and Cardiovascular Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Si Chan Sung
- Department of Thoracic and Cardiovascular Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Hyoung Doo Lee
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Hoon Ko
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Joung-Hee Byun
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Taehong Kim
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
| | - Chanyoung Chung
- Department of Pediatrics, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Yangsan, Republic of Korea
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Hui C, Ren Q, Zhuang J, Chen J, Li X, Cui H, Cen J, Xu G, Wen S. Bronchus compression is a predictor for reobstruction in coarctation with hypoplastic arch repair. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad186. [PMID: 37991842 PMCID: PMC10681811 DOI: 10.1093/icvts/ivad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/13/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES The surgical treatment of coarctation of aorta with hypoplastic aortic arch (CoA/HAA) was challenging to achieve long-lasting arch patency. We reviewed early and late outcomes in our centre and identified predictors for arch reobstruction. METHODS A retrospective analysis of medical records was performed to identify CoA/HAA patients who underwent primary arch reconstruction via median sternotomy between 2011 and 2020. Preoperative aortic arch geometry was analysed with cardiac computed tomographic angiography. Bedside flexible fibre-optic bronchoscopy was routinely performed after surgery in intensive care unit. RESULTS There were 104 consecutive patients (median age 39.5 days) who underwent extended end-to-end anastomosis, extended end-to-side anastomosis and autograft patch augmentation. Early mortality was 3.8% and overall survival was 94.1% [95% confidence interval (CI) 89.6-98.8%] at 1, 3 and 5 years. Reobstruction-free survival was 85.1% (95% CI 78.4-92.3%) at 1 year, 80.6% (95% CI 73.1-88.9%) at 3 years and 77.4% (95% CI 69.2-86.6%) at 5 years. Preoperative aortic arch geometric parameters were not important factors for reobstruction. Nineteen patients (18.3%) were detected with left main bronchus compression (LMBC) on flexible fibre-optic bronchoscopy. Cardiopulmonary bypass time [P < 0.001, hazard ratio (95% CI): 1.02 (1.01-1.03)] and postoperative LMBC [P = 0.034, hazard ratio (95% CI): 2.99 (1.09-8.23)] were independent predictive factors on multivariable Cox regression analysis of reobstruction-free survival. CONCLUSIONS Aortic arch can be satisfactorily repaired by extended end-to-end anastomosis, extended end-to-side anastomosis and autograft patch augmentation via median sternotomy in CoA/HAA. Cardiopulmonary bypass time and postoperative LMBC detected by flexible fibre-optic bronchoscopy are significant predictors for long-term arch reobstruction.
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Affiliation(s)
- Chengyi Hui
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Qiushi Ren
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Department of Cardiac Surgery, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Department of Cardiac Surgery, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jimei Chen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xiaohua Li
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Hujun Cui
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jianzheng Cen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Gang Xu
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
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Influence of Bovine Arch Anatomy on Surgical Outcomes of Coarctation of the Aorta. Pediatr Cardiol 2022; 44:933-939. [PMID: 36538051 DOI: 10.1007/s00246-022-03072-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
This study aimed to evaluate the outcome of coarctation of the aorta (CoA) repair with a special interest in bovine arch anatomy. Fifty-six patients who underwent CoA repair between 2010 and 2021 were included in this retrospective study. Of these, 11 patients had bovine arch anatomy. Surgical outcomes were reviewed. Computed tomography was used to analyze aortic arch geometry for all cases preoperatively. The gap between anastomotic sites was calculated at the linear region of the lesser curvature of the aortic arch between the distal ascending aorta and the proximal descending aorta. CoA repair was performed at a median age of 39 days (median body weight 3.3 kg). Thirty-two patients underwent extended direct anastomosis, 22 patients underwent direct anastomosis, and two patients underwent lesser curvature patch augmentation. The median follow-up period was 47 months. There were no early deaths. In patients who underwent direct and extended direct anastomosis, nine recoarctation and one left pulmonary venous obstruction events occurred. Moreover, freedom from these adverse events was 81% in normal arch and 50% in bovine arch patients at 10 years (P = 0.04). Two patients with a bovine arch anatomy who underwent lesser curvature patch augmentation had good outcomes. The distal arch was narrower and longer, and the gap between anastomotic sites was longer in patients with a bovine arch anatomy than with a normal arch (P < 0.01). In CoA with a bovine arch anatomy, the gap between anastomotic sites was long. This adversely influenced the outcomes of the CoA repairs.
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Kenny L, McIntosh A, Jardine K, Suna J, Versluis K, Slee N, Lloyd G, Justo R, Merlo G, Wilson M, Reddan T, Powell J, Venugopal P, Betts K, Alphonso N. Vocal cord dysfunction after pediatric cardiac surgery: A prospective implementation study. JTCVS OPEN 2022; 11:398-411. [PMID: 36172446 PMCID: PMC9510869 DOI: 10.1016/j.xjon.2022.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 05/18/2022] [Accepted: 06/01/2022] [Indexed: 11/09/2022]
Abstract
Objective To determine the incidence, outcomes, and evaluate diagnostic modalities for postoperative vocal cord dysfunction (VCD) following cardiothoracic surgery in children. Methods A prospective mixed-methods study using principles of implementation science was completed. All patients undergoing surgery involving the aortic arch, ductus, or ligamentum arteriosum and vascular rings from September 2019 to December 2020 were enrolled. Patients underwent speech pathology assessment, laryngeal ultrasound, and flexible direct laryngoscopy. Results Ninety-five patients were eligible for inclusion. The incidence of VCD ranged from 18% to 56% and varied according to procedure group. VCD occurred in 42% of neonates. Repair of hypoplastic aortic arch was associated with increased risk of VCD (57%; P = .002). There was no significant difference in duration of intubation, pediatric intensive care unit stay, or hospital stay. Forty percent children were able to achieve full oral feeding. Children with VCD were more likely to require nasogastric supplementary feeding at discharge (60% vs 36%; P = .044). Sixty-eight percent of patients demonstrated complete resolution of VCD at a median of 97 days postoperatively. Laryngeal ultrasound and speech pathology assessment combined had a sensitivity of 91% in comparison to flexible direct laryngoscopy. Conclusions VCD occurred in one-third and resolved in two-thirds of patients at a median of 3 months following cardiac surgery. Aortic arch repair carried the highest risk of VCD. VCD adversely influenced feeding. Forty percent of patients achieved full oral feeding before discharge. VCD did not delay intensive care unit or hospital discharge. Speech pathology assessment and laryngeal ultrasound combined was reliable for diagnosis in most patients and was more patient friendly than flexible direct laryngoscopy.
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11
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Patukale A, Shikata F, Marathe SS, Patel P, Marathe SP, Colen T, Venugopal P, Suna J, Betts K, Karl TR, Johnson J, Versluis K, Alphonso N. A single-centre, retrospective study of mid-term outcomes of aortic arch repair using a standardized resection and patch augmentation technique. Interact Cardiovasc Thorac Surg 2022; 35:6594494. [PMID: 35640134 PMCID: PMC9419687 DOI: 10.1093/icvts/ivac135] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/19/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to evaluate the mid-term outcomes after the repair of aortic arch using a standard patch augmentation technique.
METHODS
The study included all patients who underwent repair of a hypoplastic/interrupted aortic arch (IAA) in a single institute from June 2012 to December 2019 by a standardized patch augmentation (irrespective of concomitant intra-cardiac lesions). End points evaluated were reintervention for arch obstruction and persistent/new-onset hypertension.
RESULTS
The study included 149 patients [hypoplastic aortic arch, n = 92 (62%), IAA, n = 9 (6%), Norwood procedure, n = 48 (32%)]. The patch material used for augmentation of the aortic arch included pulmonary homograft (n = 120, 81%), homograft pericardium (n = 18, 12%), CardioCel® (n = 9, 6%) and glutaraldehyde-treated autologous pericardium (n = 2, 1%). The median age and weight at surgery were 7 days [interquartile range (IQR) 5–17 days] and 3.5 kg (IQR 3–3.9 kg), respectively. The median follow-up was 3.27 years (IQR 1.28, 5.08), range (0.02, 8.76). Freedom from reintervention at 1, 3 and 5 years was 95% [95% confidence interval (CI) = 89%, 98%], 93% (95% CI = 86%, 96%) and 93% (95% CI = 86%, 96%) respectively. One patient (0.6%) had persistent hypertension 8 years after correction for interrupted arch with truncus arteriosus.
CONCLUSIONS
Repair of hypoplastic/IAA by transection and excision of all ductal tissue and standardized patch augmentation provide good mid-term durability. The freedom from reintervention at 5 years is >90%. The incidence of persistent systemic hypertension following arch reconstruction is low. The technique is reproducible and applicable irrespective of underlying arch anatomy.
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Affiliation(s)
- Aditya Patukale
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland , Brisbane, QLD, Australia
| | | | - Shilpa S Marathe
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland , Brisbane, QLD, Australia
| | - Pervez Patel
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
| | - Supreet P Marathe
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland , Brisbane, QLD, Australia
- Children’s Health Research Centre, University of Queensland , Brisbane, QLD, Australia
| | - Timothy Colen
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland , Brisbane, QLD, Australia
| | - Prem Venugopal
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland , Brisbane, QLD, Australia
- Children’s Health Research Centre, University of Queensland , Brisbane, QLD, Australia
| | | | | | | | | | | | - Nelson Alphonso
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital , Brisbane, QLD, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland , Brisbane, QLD, Australia
- Children’s Health Research Centre, University of Queensland , Brisbane, QLD, Australia
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12
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Arya B, Maskatia SA. Coarctation of the aorta: Prenatal assessment, postnatal management and neonatal outcomes. Semin Perinatol 2022; 46:151584. [PMID: 35422354 DOI: 10.1016/j.semperi.2022.151584] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coarctation of the aorta (Coa) is a potentially life threatening diagnosis. It occurs in 0.3 per 1000 live births and accounts for 6-8% of all infants with congenital heart defects. Neonates with severe Coa may be completely asymptomatic at birth, as the ductus arteriosus can provide flow to the lower body. Those who are not diagnosed prenatally may be diagnosed only after constriction of the ductus arteriosus, when they present in cardiogenic shock. This group has a higher risk for mortality and morbidity relative to those diagnosed prenatally. Despite the increasing practice of universal pulse oximetry screening, many cases with significant coarctation of the aorta still go undiagnosed in the newborn period. In this article, we present the pathophysiology, diagnosis, presentation, treatment and outcomes of Coa.
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Affiliation(s)
- Bhawna Arya
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, United States.
| | - Shiraz A Maskatia
- Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, United States
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13
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Bhatt AB, Lantin-Hermoso MR, Daniels CJ, Jaquiss R, Landis BJ, Marino BS, Rathod RH, Vincent RN, Keller BB, Villafane J. Isolated Coarctation of the Aorta: Current Concepts and Perspectives. Front Cardiovasc Med 2022; 9:817866. [PMID: 35694677 PMCID: PMC9174545 DOI: 10.3389/fcvm.2022.817866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal diagnosis, high survival and improved understanding of long-term complication. Isolated CoA has heterogenous presentations, complex etiologic mechanisms, and progressive pathophysiologic changes that influence outcome. End-to-end or extended end-to-end anastomosis are the favored surgical approaches for isolated CoA in infants and transcatheter intervention is favored for children and adults. Primary stent placement is the procedure of choice in larger children and adults. Most adults with treated isolated CoA thrive, have normal daily activities, and undergo successful childbirth. Fetal echocardiography is the cornerstone of prenatal counseling and genetic testing is recommended. Advanced 3D imaging identifies aortic complications and myocardial dysfunction and guides individualized therapies including re-intervention. Adult CHD program enrollment is recommended. Longer follow-up data are needed to determine the frequency and severity of aneurysm formation, myocardial dysfunction, and whether childhood lifestyle modifications reduce late-onset complications.
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Affiliation(s)
- Ami B. Bhatt
- Departments of Internal Medicine and Pediatrics and Division of Cardiology, Harvard Medical School, Boston, MA, United States
| | - Maria R. Lantin-Hermoso
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Curt J. Daniels
- Departments of Pediatrics and Internal Medicine, The Ohio State University Medical Center, Columbus, OH, United States
| | - Robert Jaquiss
- Department of Cardiovascular and Thoracic Surgery and Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Benjamin John Landis
- Department of Pediatrics and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, United States
| | - Rahul H. Rathod
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Robert N. Vincent
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States
| | - Bradley B. Keller
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Bradley B. Keller
| | - Juan Villafane
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
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14
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Comparison of cases with and without additional lower body perfusion in newborns undergoing aortic arch reconstruction with antegrade selective cerebral perfusion method. TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2022; 30:192-198. [PMID: 36168563 PMCID: PMC9473591 DOI: 10.5606/tgkdc.dergisi.2022.22805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/27/2022] [Indexed: 11/21/2022]
Abstract
Background
The aim of this study was to analyze the effect of additional lower body perfusion, compared to antegrade selective cerebral perfusion, on early postoperative outcomes after aortic arch repair in neonates with biventricular morphology.
Methods
Between January 2017 and April 2020, a total of 46 neonates (34 males, 12 females; median age: 10 days; range, 7 to 14 days) with biventricular morphology underwent an aortic arch reconstruction were retrospectively analyzed. The effects of antegrade selective cerebral perfusion and additional lower body perfusion techniques on vital organ preservation and mortality were evaluated in these patients who underwent arch reconstruction.
Results
In the univariate analysis of the whole cohort, postoperative creatinine level was lower in the additional lower body perfusion group, while there was no significant difference between the other parameters. In the multivariate analysis, intraoperative highest lactate level (odds ratio: 1.7; 95% confidence interval: 1.07-2.68; p=0.02) and postoperative 4th t o 6 th h lactate levels (odds ratio: 2.34; 95% confidence interval: 1.08-5.09; p=0.03) were independent predictors of early mortality. Mortality rate was higher in the antegrade selective cerebral perfusion group (22% vs. 7%), although it did not reach statistical significance. In the receiver operating characteristic curve analysis, the cut-off value for intraoperative lactate was 6.2 mmol/L (sensitivity: 85.7%, specificity: 71.1%) and the cut-off value for the lactate level at the postoperative 4th to 6th h was 4.9 mmol/L (sensitivity: 85.7%, specificity: 73.7%). Above these lactate levels were found to be associated with mortality.
Conclusion
Additional lower body perfusion may have a role in vital organ protection in aortic arch repair of neonates, compared to antegrade selective cerebral perfusion.
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15
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Li C, Ma J, Yan Y, Chen H, Shi G, Chen H, Zhu Z. Surgical options for proximal and distal transverse arch hypoplasia in infants with coarctation. Transl Pediatr 2022; 11:330-339. [PMID: 35378967 PMCID: PMC8976682 DOI: 10.21037/tp-21-557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/18/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Although various surgical techniques have been reported for aortic arch reconstruction for proximal and distal transverse arch (PDTA) hypoplasia, no consensus has been reached on a surgical option for initial arch reconstruction. This study was undertaken to review various arch reconstruction options for PDTA hypoplasia in Chinese infants. METHODS A retrospective review of 121 infants who underwent initial arch reconstruction of the proximal and distal aortic arches between 2010 and 2020 was performed. Freedom from recoarctation was analyzed using Kaplan-Meier analysis. Univariate and multivariable Cox regression analyses were performed to determine perioperative data associated with an increased risk of recoarctation after surgery. RESULTS Aortic arch reconstruction was performed by end-to-side anastomosis (ESA) (n=37) or patch repair [autologous pericardial patch (APP), n=53; bovine pericardial patch (BPP), n=20; autologous pulmonary artery patch (APAP), n=11]. The relative diameter of the proximal arch was 0.51±0.07, and the relative diameter of the distal arch was 0.43±0.07. The median follow-up time was 679 (range, 388-1,362) days. Recoarctation was observed in 44 (36.4%) patients. ESA was an independent risk factor for further development of recoarctation after the initial aortic arch reconstruction [hazard ratio (HR) =2.13; P=0.020]. CONCLUSIONS Aortic arch reconstruction via ESA was an independent risk factor for late recoarctation of the proximal and distal aortic arches in patients who underwent the initial surgery in infancy. TRIAL REGISTRATION Chinese Clinical Trials Registry ChiCTR2100048212.
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Affiliation(s)
- Cong Li
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jidan Ma
- Department of Pediatric Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yichen Yan
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongtong Chen
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guocheng Shi
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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16
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Miwa K, Iwai S, Nagashima T. Coarctation of Aorta with Circumflex Aorta: Risk of Bronchial Compression and Recoarctation. Ann Thorac Surg 2022; 114:e461-e463. [DOI: 10.1016/j.athoracsur.2022.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/26/2022] [Accepted: 02/06/2022] [Indexed: 11/01/2022]
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17
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Pivirotto M, Swartz MF, McGreevy MB, Atallah-Yunes N, Cholette JM, Lipshultz SE, Alfieris GM. Factors Associated With an Abnormal Blood Pressure Response During Exercise After Coarctation Repair. World J Pediatr Congenit Heart Surg 2021; 13:53-59. [PMID: 34919481 DOI: 10.1177/21501351211060351] [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: 11/17/2022]
Abstract
BACKGROUND Although resting blood pressures following aortic arch repair or the extended end-to-end anastomosis (EEA) repair for coarctation can be physiologic, factors associated with an abnormal blood pressure response after exercise are unknown. We measured blood pressure gradients following exercise in children who had undergone previous repair in accordance with a surgical selection algorithm and sought to identify factors associated with an abnormal blood pressure response. METHODS In accordance with our practice's surgical algorithm for repair of coarctation, infants were stratified to aortic arch repair when the distal transverse arch-to-left carotid artery ratio (DTA:LCA) ≤ 1.0, or when a brachiocephalic trunk or intra-cardiac lesion requiring repair was present. A thoracotomy and EEA were otherwise used. A follow-up exercise stress test (EST) measured the arm:leg blood pressure gradient after exercise, and a gradient ≥ 20 mm Hg was defined as an abnormal blood pressure response. RESULTS Thirty-seven infants who had previously undergone coarctation repair (aortic arch repair-19, EEA-18) completed an EST at 12.3 ± 2.2 years of age. Thirteen (35%) children (aortic arch repair-5, EEA-8; p = .3) exhibited an abnormal blood pressure response. Factors associated with an abnormal blood pressure response included: smaller DTA:LCA ratios prior to repair (1.0 ± .2 vs. 1.2 ± .3; p = .04) and greater body weight at the time of EST (57.5 ± 19.1 vs. 40.9 ± 15.6 kg; p = .03). CONCLUSION An abnormal blood pressure response following exercise is associated with smaller DTA:LCA ratios at the time of repair and increased weight during follow-up suggesting that patients with these factors warrant close observation.
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Affiliation(s)
- Mia Pivirotto
- Pediatric Cardiac Consortium of Upstate New York, USA.,12291University at Buffalo Jacobs School of Medicine and Biomedical Sciences and Oishei Children's Hospital, Buffalo, New York, USA
| | - Michael F Swartz
- Pediatric Cardiac Consortium of Upstate New York, USA.,6923University of Rochester School of Medicine and Dentistry and University of Rochester Medical Center, Rochester, New York, USA
| | - Megan B McGreevy
- Pediatric Cardiac Consortium of Upstate New York, USA.,12291University at Buffalo Jacobs School of Medicine and Biomedical Sciences and Oishei Children's Hospital, Buffalo, New York, USA
| | - Nader Atallah-Yunes
- Pediatric Cardiac Consortium of Upstate New York, USA.,12291University at Buffalo Jacobs School of Medicine and Biomedical Sciences and Oishei Children's Hospital, Buffalo, New York, USA
| | - Jill M Cholette
- Pediatric Cardiac Consortium of Upstate New York, USA.,6923University of Rochester School of Medicine and Dentistry and University of Rochester Medical Center, Rochester, New York, USA
| | - Steven E Lipshultz
- Pediatric Cardiac Consortium of Upstate New York, USA.,12291University at Buffalo Jacobs School of Medicine and Biomedical Sciences and Oishei Children's Hospital, Buffalo, New York, USA
| | - George M Alfieris
- Pediatric Cardiac Consortium of Upstate New York, USA.,6923University of Rochester School of Medicine and Dentistry and University of Rochester Medical Center, Rochester, New York, USA
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18
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Jiang Q, Hu R, Dong W, Guo Y, Zhang W, Hu J, Zhang H. Outcomes of Arch Reintervention for Recurrent Coarctation in Young Children. Thorac Cardiovasc Surg 2021; 70:26-32. [PMID: 34521137 DOI: 10.1055/s-0041-1731825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To evaluate the outcomes of reintervention for postrepair recoarctation in young children. METHODS Between January 2011 and December 2020, all consecutive patients aged ≤3 years who were treated for postrepair recoarctation were included. Recoarctations were classified into two morphological types by three-dimensional imaging. Two methods, namely, surgical repair and balloon angioplasty (BA), were used to treat recoarctation. RESULTS This study included 50 patients with a median age of 10.5 months (range, 2.0-36.0 months) and a mean weight of 9.3 ± 3.1 kg. Hypoplastic recoarctation occurred most frequently in patients who had undergone patch aortoplasty at initial repair (p = 0.001). No hospital mortality occurred, and all patients achieved an increased diameter (p < 0.001) and a decreased pressure gradient (p < 0.001) at the recoarctation site immediately after reintervention. The median follow-up time after reintervention was 3.5 years (range, 16.0 days-9.6 years). Late mortality occurred in four patients (8.0%): two in the surgical group and two in the BA group (chi-square test= 0.414, p = 0.520). There was no difference in arch reobstruction after reintervention between the surgical and BA groups (chi-square test = 1.383, p = 0.240). Recoarctation with a hypoplastic morphology was the leading risk factor for arch reobstruction after reintervention (hazard ratio, 6.552; 95% confidence interval, 2.045-20.992; p = 0.002). CONCLUSION Reintervention for recoarctation has favorable early outcomes in young children. However, late mortality is not rare, and arch reobstruction is common during close follow-up. For young children, recoarctation with hypoplastic morphology is the leading risk factor for reobstruction, while the choice of reintervention method exerts little effect on the outcomes of arch reintervention.
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Affiliation(s)
- Qi Jiang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Renjie Hu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Wei Dong
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Ying Guo
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Wen Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Jie Hu
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
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19
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Parikh KJ, Fundora MP, Sasaki N, Rossi AF, Burke RP, Sasaki J. Use of aortic arch measurements in evaluating significant arch hypoplasia in neonates with coarctation. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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20
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Iwaki R, Matsuhisa H, Minamisawa S, Akaike T, Hoshino M, Yagi N, Morita K, Shinohara G, Kaneko Y, Yoshitake S, Takahashi M, Tsukube T, Oshima Y. Evaluation of Ductal Tissue in Coarctation of the Aorta Using X-Ray Phase-Contrast Tomography. Pediatr Cardiol 2021; 42:654-661. [PMID: 33403434 DOI: 10.1007/s00246-020-02526-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/18/2020] [Indexed: 10/22/2022]
Abstract
We assessed the histological accuracy of X-ray phase-contrast tomography (XPCT) and investigated three-dimensional (3D) ductal tissue distribution in coarctation of the aorta (CoA) specimens. We used nine CoA samples, including the aortic isthmus, ductus arteriosus (DA), and their confluences. 3D images were obtained using XPCT. After scanning, the samples were histologically evaluated using elastica van Gieson (EVG) staining and transcription factor AP-2 beta (TFAP2B) immunostaining. XPCT sectional images clearly depicted ductal tissue distribution as low-density areas. In comparison with EVG staining, the mass density of the aortic wall positively correlated with elastic fiber formation (R = 0.69, P < 0.001). TFAP2B expression was consistent with low-density area including intimal thickness on XPCT images. On 3D imaging, the distances from the DA insertion to the distal terminal of the ductal media and to the intima on the ductal side were 1.63 ± 0.22 mm and 2.70 ± 0.55 mm, respectively. In the short-axis view, the posterior extension of the ductal tissue into the aortic lumen was 79 ± 18% of the diameter of the descending aorta. In three specimens, the aortic wall was entirely occupied by ductal tissue. The ductal intima spread more distally and laterally than the ductal media. The contrast resolution of XPCT images was comparable to that of histological assessment. Based on the 3D images, we conclude that complete resection of intimal thickness, including the opposite side of the DA insertion, is required to eliminate residual ductal tissue and to prevent postoperative re-coarctation.
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Affiliation(s)
- Ryuma Iwaki
- Department of Cardiovascular Surgery, Kobe Children's Hospital, 1-6-7, Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan.
| | - Hironori Matsuhisa
- Department of Cardiovascular Surgery, Kobe Children's Hospital, 1-6-7, Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
| | - Susumu Minamisawa
- Department of Cell Physiology, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Toru Akaike
- Department of Cell Physiology, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Masato Hoshino
- Japan Synchrotron Radiation Research Institute (SPring-8), 1-1-1, Kouto, Sayo-cho, Sayo-gun, Hyogo, 679-5198, Japan
| | - Naoto Yagi
- Japan Synchrotron Radiation Research Institute (SPring-8), 1-1-1, Kouto, Sayo-cho, Sayo-gun, Hyogo, 679-5198, Japan
| | - Kiyozo Morita
- Department of Cardiac Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Gen Shinohara
- Department of Cardiac Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yukihiro Kaneko
- Division of Cardiovascular Surgery, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Syuichi Yoshitake
- Division of Cardiovascular Surgery, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Masashi Takahashi
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, 8050, Ikarashi 2 Nocho, Nishi-ku, Niigata, 950-2102, Japan
| | - Takuro Tsukube
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital, 1-3-1, Wakinohamakaigandori, Chuo-ku, Kobe, Hyogo, 651-0073, Japan
| | - Yoshihiro Oshima
- Department of Cardiovascular Surgery, Kobe Children's Hospital, 1-6-7, Minatojimaminamimachi, Chuo-ku, Kobe, Hyogo, 650-0047, Japan
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21
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Mishima A, Nakai Y, Asano M, Suda H. Aortic Arch Enlargement and Coarctation Repair of Preserving the Lesser Curvature of the Aortic Arch Through a Left Thoracotomy in Neonates. Pediatr Cardiol 2020; 41:1492-1500. [PMID: 32638042 DOI: 10.1007/s00246-020-02401-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/12/2020] [Indexed: 11/28/2022]
Abstract
The aim of this study was to analyze the aortic arch repair technique for preserving the lesser curvature without cardiopulmonary bypass through a left thoracotomy in neonates with coarctation of the aorta (CoA) and a hypoplastic distal aortic arch (HDAA). HDAA was defined as z-score of the aortic arch < - 2.5. Twenty-four neonates with CoA and HDAA were retrospectively studied. Patients underwent enlargement of the HDAA associated with CoA repair when their z-scores were < - 4. They were divided into 2 groups on the basis of the preoperative z-score of the distal aortic arch: group 1 (n = 14), z-score ≥ - 4; group 2 (n = 10), z-score < - 4. Twenty-two patients had intracardiac defects. Follow-up ranged from 0.9 to 20.1 years (median 11.6 years). The z-scores of the distal aortic arch were significantly smaller in group 2 than group 1 (- 5.09 ± 1.05 vs - 3.19 ± 0.36, p < 0.001). There were no hospital deaths and no hypertension. All dimensions of the aortic arch in both groups revealed significant catch-up growth (p < 0.02). All patients showed a pressure gradient ≤ 5 mmHg across the aortic arch and between the arms and legs at the latest follow-up. Two patients showed an angulated arch deformity over 10 years later. This technique provided good catch-up growth and a low incidence of reobstruction and deformity of reconstructed aortic arch in both groups. These results suggest that this modification might be considered as one choice of technique for CoA and HDAA.
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Affiliation(s)
- Akira Mishima
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan.
| | - Yosuke Nakai
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Miki Asano
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
| | - Hisao Suda
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Nagoya City University, Kawasumi 1, Mizuho-cho, Mizuho-ku, Nagoya, 467-8601, Japan
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Farag ES, Kluin J, de Heer F, Ahmed Y, Sojak V, Koolbergen DR, Blom NA, de Mol BAJM, Ten Harkel ADJ, Hazekamp MG. Aortic coarctation repair through left thoracotomy: results in the modern era. Eur J Cardiothorac Surg 2019; 55:331-337. [PMID: 30165590 DOI: 10.1093/ejcts/ezy241] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 05/31/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Surgical repair of coarctation of the aorta (CoA) is often possible through left thoracotomy and without the use of cardiopulmonary bypass. Recent studies reporting the outcome after CoA repair through left thoracotomy are limited. Therefore, the aim of this study is to evaluate the results of CoA repair through left thoracotomy in children who were operated on in our centre over the past 21 years. METHODS From January 1995 to December 2016, 292 patients younger than 18 years underwent primary CoA repair through left thoracotomy at our 2 institutions. Peri- and postoperative data and follow-up data collected from our hospital and the referring hospitals were retrospectively reviewed. RESULTS Median age at operation was 64 days (range 2 days-17 years). Most patients underwent the resection of the CoA followed by an (extended) end-to-end anastomosis (93%). Six patients died perioperatively and 2 more patients died during the follow-up, of which 7 patients had other major comorbidities. Actuarial survival was 97% at 5 years, 96% at 10 years and 96% at 15 years. Second arch interventions due to recoarctation were performed in 9.9% (n = 29) of patients, consisting of balloon dilatation in all but 2 patients. Recoarctation occurred significantly more often after initial repair in the neonatal period (21%) and could occur as late as 14 years after initial surgery. There were 7 re-recoarctations, and 14% of patients were on hypertensive medication during the follow-up. CONCLUSIONS Repair of CoA through left thoracotomy is a safe procedure with low rates of mortality. The long-term follow-up is necessary due to the significant risk of recoarctation requiring reintervention.
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Affiliation(s)
- Emile S Farag
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Frederiek de Heer
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Yunus Ahmed
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Vladimir Sojak
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - David R Koolbergen
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Nico A Blom
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Bas A J M de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | | | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, Netherlands.,Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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Abstract
Summary
Objectives
Various surgical strategies have been reported for the treatment of aortic coarctation with hypoplastic aortic arch, including simple resection and end-to-end anastomosis as well as various forms of patch augmentation. These techniques are limited by inadequate relief of arch obstruction and use of patch material predisposed to recurrent obstruction or aneurysm formation. We report our experience with autologous aortic arch reconstruction in isolated and combined lesions, a technique that relieves even complex forms of arch reconstruction without patch material.
Methods
We retrospectively analyzed our institutional experience with autologous aortic arch reconstruction in isolated and combined cardiac lesions from November 2009 to December 2016. Study endpoints were procedural success, incidence of procedure-related complications, need for re-interventions, and survival.
Results
In total, 54 patients underwent total autologous aortic arch reconstruction during the study period. Thereof, 13 (24%) had isolated arch obstruction and 41 (76%) had combined cardiac lesions. The majority of procedures were performed in the neonatal period (72%), median age was 8 days (range: 1 day to 4.3 years). Body weight ranged from 2.2 to 16.5 kg (median: 3.7 kg). There was one (1.9%) procedure-related early reoperation for bronchial obstruction. No repeat interventions (dilatation or re-operation) were observed. One patient with syndromic disease died on postoperative day 20 due to sepsis (1.9% in-hospital mortality rate). No late deaths were observed. Median follow-up was 23 months.
Conclusion
Autologous aortic arch reconstruction is a safe and effective surgical technique for the treatment of aortic arch obstruction in isolated and complex cardiac lesions. It is associated with an extremely low re-intervention rate and a low overall complication rate.
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Abstract
OBJECTIVES Surgery of the aortic arch poses risk of recurrent laryngeal nerve injury due to the anatomic proximity and can manifest as vocal cord dysfunction after surgery. We assessed risk factors for vocal cord dysfunction and calculated surgical procedure associated rates in young infants after congenital heart surgery. DESIGN Cross section analysis. SETTING Forty-four children's hospitals reporting administrative data to Pediatric Health Information System. PARTICIPANTS Cardiac surgical patients less than or equal to 90 days old and discharged between January 2004 and June 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 2,319 of 46,567 subjects (5%) had vocal cord dysfunction, increasing from 4% to 7% over the study period. Of those with vocal cord dysfunction, 75% had unilateral partial paralysis. Vocal cord dysfunction was significantly more common in newborn infants (74%), those with aortic arch procedures (77%) and with greater surgical complexity. Rates of vocal cord dysfunction ranged from 0.7% to 22.4% across surgical procedure groups. Vocal cord dysfunction was significantly associated with greater use of: prolonged mechanical ventilation (53% vs 40%), diaphragmatic plication (3% vs 1%), feeding tube use (32% vs 8%), surgical airways (4% vs 2%), and prolonged length of stay (44 vs 21 d). Vocal cord dysfunction testing increased significantly over the study (6-14 %), and vocal cord dysfunction diagnosis increased almost two-fold (odds ratio, 1.9; 95% CI, 1.7-2.1) comparing the last to first study quarters with the increase in vocal cord dysfunction diagnosis occurring predominately in surgeries to the aortic arch supported by cardiopulmonary bypass. However, aortic procedures without cardiopulmonary bypass and nonaortic arch procedures were common surgeries accounting for 27% and 23% of vocal cord dysfunction cases despite low overall vocal cord dysfunction rates (3.7% and 2.6%). CONCLUSIONS Vocal cord dysfunction complicated all cardiac surgical procedures among infants including those without aortic arch involvement. Increased efforts to determine appropriate indications for prevention, screening and treatment of vocal cord dysfunction among young infants after congenital heart surgery are needed.
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Callahan CP, Saudek D, Creighton S, Kuhn EM, Mitchell ME, Tweddell JS, Woods RK. Proximal Arch in Left Thoracotomy Repair of Neonatal and Infant Coarctation-How Small Is Too Small? World J Pediatr Congenit Heart Surg 2019; 10:469-474. [PMID: 31307310 DOI: 10.1177/2150135119852329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We sought to evaluate the relationship between proximal arch hypoplasia and reintervention for left thoracotomy repair of coarctation of the aorta. METHODS This was a retrospective review of 153 consecutive neonates and infants undergoing left thoracotomy and extended end-to-end repair of coarctation from January 1, 2000, to January 1, 2014, at a single center with exclusion of single ventricle-palliated patients. Primary outcome was reintervention evaluated with respect to five definitions of proximal arch hypoplasia. RESULTS Median follow-up was 7.2 years. Reintervention occurred in eight (5.2%) patients, with 50% of patients undergoing re-intervention in the first six months after their index operation. Using Kaplan-Meier analysis and log-rank test, with hypoplasia defined by weight, hypoplasia was not associated with increased reintervention for arch size < patient weight (in kilograms; P = .24) or for arch size < patient weight (in kilograms) +1 (P = .02, higher freedom from reintervention in hypoplasia group). For each of the five comparison groups, freedom from reintervention was similar between the groups with and without proximal arch hypoplasia: (1) z-score < -2 versus ≥-2 (P = .72), (2) z-score < -3 versus ≥-3 (P = .95), and (3) z-score < -4 versus ≥-4 (P = .17). CONCLUSION In our cohort of patients with left thoracotomy and extended end-to-end repair of coarctation, proximal arch hypoplasia, defined by various weight-based or z-score thresholds, was not associated with reintervention. While this may imply value to a more liberal use of thoracotomy, confirmation requires longer term follow-up with a more comprehensive evaluation of the patients and their arches.
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Affiliation(s)
- Connor P Callahan
- 1 Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - David Saudek
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Sara Creighton
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Evelyn M Kuhn
- 3 Department of Business Intelligence and Data Warehousing, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Michael E Mitchell
- 4 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- 5 Department of Cardiothoracic Surgery, University of Cincinnati, Heart Institute, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA
| | - Ronald K Woods
- 4 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Orzell S, Joseph R, Ongkasuwan J, Bedwell J, Shin J, Raol N. Outcomes of Vocal Fold Motion Impairment and Dysphagia after Pediatric Cardiothoracic Surgery: A Systematic Review. Otolaryngol Head Neck Surg 2019; 161:754-763. [DOI: 10.1177/0194599819858594] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective The objective of this study was to systematically review the literature regarding vocal fold motion impairment (VFMI), respiratory outcomes, and swallowing outcomes in children following congenital heart surgery (CHS). Data Sources PubMed, Embase, Medline, and CINAHL databases. Review Methods Data sources were searched from inception to November 30, 2018. Studies that described recovery of VFMI and swallowing function following CHS were included, and a qualitative analysis was performed. Results A total of 1371 studies were identified, of which 8 met inclusion criteria for VFMI and 5 met inclusion criteria for swallowing outcomes. Studies including patients who underwent isolate patent ductus arteriosus ligation were excluded. VFMI was present in 8% to 59% of subjects, and rates of recovery ranged from 9% to 96% at 6 months to 6 years of follow-up. Inability to maintain an oral diet occurred in 14% to 100% of subjects with VFMI and 11% to 61% without VFMI following surgery. Tolerance of an oral diet without tube feeding was present in 66% to 75% of subjects with VFMI and 88% to 100% without VFMI at 24 days to 3.2 years of follow-up. Limited data suggest that time to extubation is longer in VFMI subjects, but overall hospital length of stay and mortality may not be affected by VFMI status. Conclusions Data evaluating dysphagia and VFMI after CHS are limited. Most studies suggest significant improvement in swallowing function, while rate of recovery of VFMI is variable. Future prospective studies with standardized screening and follow-up are needed to better elucidate outcomes to help develop algorithms for identification and management of VFMI after CHS.
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Affiliation(s)
- Susannah Orzell
- Department of Otolaryngology, SUNY Upstate Medical Center, Syracuse, New York, USA
| | - Rahul Joseph
- School of Medicine Emory University, Atlanta, Georgia, USA
| | - Julina Ongkasuwan
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Bedwell
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhila Raol
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
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Simon BV, Swartz MF, Orie JM, Adams HR, Seltzer LE, Angona RE, Atallah-Yunes NH, Alfieris GM. Neurodevelopmental Delay After the Neonatal Repair of Coarctation and Arch Obstruction. Ann Thorac Surg 2019; 108:1416-1422. [PMID: 31207245 DOI: 10.1016/j.athoracsur.2019.04.088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/19/2019] [Accepted: 04/24/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although single ventricle physiology and cyanosis are known risk factors for neurodevelopmental delay (NDD), the impacts of isolated coarctation (Iso CoA) repair or arch reconstruction (AR) are less understood. METHODS The Vineland Adaptive Behavior Scales, third edition, prospectively evaluated children without a genetic syndrome. An overall composite score, normalized to age and sex, was generated from individual domain scores. NDD was defined as a composite or domain score at least 1 SD less than the established mean. Iso CoA was repaired using a left thoracotomy, whereas AR was performed using a sternotomy and cardiopulmonary bypass. Children with a structurally normal heart and without previous surgery were used as control patients. RESULTS Of 60 children, 50 required neonatal repair (12 for Iso CoA, 38 for AR), and 10 were control patients. From the entire cohort of children who required neonatal coarctation repair (Iso CoA + AR) composite (93.9 ± 15.9 vs 105.0 ± 7.4; P = .004) and all domain scores were significantly lower than control patients. NDD was present in 25 of 50 children after repair and in 0 of 10 control patients (P = .003). Similarly, the prevalence of NDD was significantly greater after Iso CoA repair (58.3% vs 0%; P = .005) and AR (47.3% vs 0%; P = .007) than in the control population, but no significant difference was found between the Iso CoA and AR groups (P = .74). CONCLUSIONS In this small cohort, half of the neonates who required either Iso CoA repair or AR exhibit NDD at an intermediate-term follow-up.
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Affiliation(s)
- Bartholomew V Simon
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michael F Swartz
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jennifer M Orie
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Heather R Adams
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Laurie E Seltzer
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ron E Angona
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Nader H Atallah-Yunes
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - George M Alfieris
- Department of Surgery, University of Rochester Medical Center, Rochester, New York.
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Sandoval NF, Acevedo CV, Umaña JB, Pineda I, Guerrero A, Obando C, Umaña JP, Camacho J. Wide Dissection and Intercostal Vessel Division Allows for Repair of Hypoplastic Aortic Arch Through Thoracotomy. World J Pediatr Congenit Heart Surg 2018; 9:659-664. [PMID: 30322367 DOI: 10.1177/2150135118799631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The approach to coarctation of the aorta with hypoplastic aortic arch is controversial. We evaluated the outcomes in patients with coarctation of the aorta with or without hypoplastic aortic arch operated through a posterior left lateral thoracotomy. METHODS A retrospective cohort of patients with aortic coarctation, who underwent repair between January 2009 and October 2017, was analyzed. Preoperative, postoperative, and echocardiographic characteristics were reviewed. Statistical analysis examined survival, freedom from reintervention, and freedom from recoarctation. RESULTS In nine years, 389 patients who underwent surgical treatment for coarctation of the aorta were identified; after exclusion criteria and complete echocardiographic reports, 143 patients were analyzed, of which 29 patients had hypoplastic aortic arch. The modification in the extended end-to-end anastomosis technique was a wide dissection and mobilization of the descending aorta that was achieved due to the ligation and division of 3 to 5 intercostal vessels. In both groups, patients were close to one month of age and had a median weight of 3.6 and 3.4 kg for hypoplastic and nonhypoplastic arch, respectively. In postoperative events, there was no statistically significant difference between the groups ( P = .57 for renal failure, P = .057 for transient, nonpermanent neurologic events, P = .496 for sepsis), as for intensive care unit ( P = .502) and total in-hospital stay ( P = .929). There was one case of postoperative mortality in each group and both were associated with noncardiac comorbidities. Regarding survival (log-rank = 0.060), freedom from reintervention (log-rank = 0.073), and freedom from recoarctation (log-rank = 0.568), there was no statistically significant difference between the groups. CONCLUSION We believe that it is the modified technique that allowed greater mobilization of the aorta and successful repair of hypoplastic arch through thoracotomy, without an increase in paraplegia or other adverse outcomes.
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Affiliation(s)
- Néstor F Sandoval
- 1 Congenital Heart Disease Institute, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | | | - Juan Bernardo Umaña
- 3 Department of Cardiovascular Surgery, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Ivonne Pineda
- 3 Department of Cardiovascular Surgery, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Albert Guerrero
- 1 Congenital Heart Disease Institute, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Carlos Obando
- 1 Congenital Heart Disease Institute, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Juan P Umaña
- 3 Department of Cardiovascular Surgery, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Jaime Camacho
- 3 Department of Cardiovascular Surgery, Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
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Long-Term Outcomes of Coarctation Repair Through Left Thoracotomy. Ann Thorac Surg 2018; 107:157-164. [PMID: 30205114 DOI: 10.1016/j.athoracsur.2018.07.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 07/02/2018] [Accepted: 07/05/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Optimal surgical approach for repair of coarctation of the aorta (CoA) remains controversial. This study aimed to evaluate reintervention rates and its predictors by using a strategy of resection with extended end-to-end anastomosis (REEEA) through left thoracotomy. METHODS A retrospective analysis was performed for all patients who underwent isolated CoA repair or simultaneous repair of CoA and ventricular septal defect repair by REEEA between January 2000 and December 2015 at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. Patients with complex congenital heart disease were excluded. Transverse arch hypoplasia was defined as echocardiographic z-score lower than -2 or by documentation in medical or operative reports. Reintervention was defined as the need for balloon angioplasty or reoperation. Hypertension was defined as antihypertensive medication use or blood pressure greater than or equal to the 95th percentile. RESULTS A total of 251 patients with median age at repair of 14.6 days met inclusion criteria. Repair was by left thoracotomy in 226 (90%). Follow-up data were available for 186 of 251 patients, with median follow-up time of 5.4 years (range, 0.2 to 15.3 years); 169 (91%) of these patients underwent thoracotomy. There were no early deaths or early reoperations. A proximal transverse arch z-score lower than -4.1 or a distal transverse arch z-score of less than -2.8 was predictive of repair through sternotomy. Only 4 (2%) patients required reintervention (2 patients had balloon angioplasties, 2 had reoperations). Transverse arch hypoplasia was a risk factor for reintervention (p = 0.048), but surgical approach was not (p = 0.35). Late hypertension was identified in only 33 of 186 (18%) patients. CONCLUSIONS Repair of CoA, even with associated transverse arch hypoplasia, by REEEA through left thoracotomy has a low mortality, low reintervention rate, and low incidence of late hypertension.
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Binsalamah ZM, Zea-Vera R, Fraser CD. Cervical left aortic arch with distal tortuosity causing coarctation and aneurysmal formation in a child. J Card Surg 2018; 33:466-468. [DOI: 10.1111/jocs.13750] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Ziyad M. Binsalamah
- Congenital Heart Surgery; Texas Children's Hospital − Baylor College of Medicine; Houston Texas
| | - Rodrigo Zea-Vera
- Congenital Heart Surgery; Texas Children's Hospital − Baylor College of Medicine; Houston Texas
| | - Charles D. Fraser
- Congenital Heart Surgery; Texas Children's Hospital − Baylor College of Medicine; Houston Texas
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Gray WH, Wells WJ, Starnes VA, Kumar SR. Arch Augmentation via Median Sternotomy for Coarctation of Aorta With Proximal Arch Hypoplasia. Ann Thorac Surg 2018; 106:1214-1219. [PMID: 29753817 DOI: 10.1016/j.athoracsur.2018.04.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 04/08/2018] [Accepted: 04/11/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Coarctation of the aorta can be associated with hypoplasia of the proximal transverse aortic arch. One approach to manage this condition is via left thoracotomy and extended end-to-end anastomosis with the expectation that the proximal arch will grow over time. Our preferred approach is to augment the aorta via midline sternotomy. We hypothesized that this approach is safe, durable, and allows reliable growth of the aorta. METHODS We identified the records of patients with biventricular anatomy who had coarctation of the aorta, hypoplasia of the proximal transverse arch, and no other cardiac lesion that would mandate cardiopulmonary bypass use and midline sternotomy. The records of 62 such patients operated on between 2005 and 2016 were retrospectively reviewed. Patient demographics, clinical variables and outcome data were collected and analyzed using SAS 9.4. Data are presented as median (interquartile range [IQR]). RESULTS Sixty-two patients (23 girls [37%]) underwent repair at 10 (IQR, 5 to 21) days of life. Forty-nine (79%) patients were on prostaglandin infusion to maintain ductal patency. Fifteen (24%) patients presented in shock with end organ dysfunction, 17 (27%) were on inotropes, and 26 (42%) were mechanically ventilated. The proximal transverse arch was 41% (IQR, 34% to 47%) of the size of ascending aorta as measured by echocardiography (z-score, -5 [IQR, -5.8 to -4.3]). Following median sternotomy, repair was carried out on cardiopulmonary bypass (41 [IQR, 37 to 47] minutes). The arch was reconstructed with (n = 26 [42%]) or without (n = 36 [58%]) coarctectomy usually using homograft patch aortoplasty (n = 58 [94%]). In all but 2 patients, repair was undertaken with circulatory arrest (27 [IQR, 22 to 31] minutes). Patients were extubated 4 (IQR, 3 to 5) days later and discharged home in 12 (IQR, 8 to 18) days. There was no mortality, and 8 morbidity events (3 recurrent nerve injury, 2 chylothorax, 1 phrenic nerve injury, 1 seizure, and 1 superficial wound infection) in 7 (11%) patients. All patients are alive at 41 (IQR, 11 to 64) months of follow-up. Reintervention was required in 6 (10%) patients (5 catheter based and 3 surgical) for recurrent distal coarctation. Reintervention-free survival at 1, 3, and 5 years was 87%. Only 1 child was currently on antihypertensive therapy, and all were in New York Heart Association functional class I symptoms. At last echocardiogram, the proximal transverse arch was 97% (IQR, 84% to 103%) of the diameter of the ascending aorta (z-score, 0.8 (IQR, 0.3 to 1.3]), ejection fraction was 70% (IQR, 60% to 76%), and only 2 patients had significant left ventricular hypertrophy. CONCLUSIONS Arch augmentation via median sternotomy is a safe and effective procedure that can be accomplished with low morbidity and mortality. The reconstructed arch retains excellent growth potential resulting in a very favorable physiologic outcome.
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Affiliation(s)
- W Hampton Gray
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Winfield J Wells
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - Vaughn A Starnes
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California.
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32
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Affiliation(s)
- Scott M Bradley
- Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC.
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33
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Corno AF, Smith P, Bezuska L, Mimic B. Is Decellularized Porcine Small Intestine Sub-mucosa Patch Suitable for Aortic Arch Repair? Front Pediatr 2018; 6:149. [PMID: 29900163 PMCID: PMC5989640 DOI: 10.3389/fped.2018.00149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/04/2018] [Indexed: 12/21/2022] Open
Abstract
Introduction: We reviewed our experience with decellularized porcine small intestine sub-mucosa (DPSIS) patch, recently introduced for congenital heart defects. Materials and Methods: Between 10/2011 and 04/2016 a DPSIS patch was used in 51 patients, median age 1.1 months (5 days to 14.5 years), for aortic arch reconstruction (45/51 = 88.2%) or aortic coarctation repair (6/51 = 11.8%). All medical records were retrospectively reviewed, with primary endpoints interventional procedure (balloon dilatation) or surgery (DPSIS patch replacement) due to patch-related complications. Results: In a median follow-up time of 1.5 ± 1.1 years (0.6-2.3years) in 13/51 patients (25.5%) a re-intervention, percutaneous interventional procedure (5/51 = 9.8%) or re-operation (8/51 = 15.7%) was required because of obstruction in the correspondence of the DPSIS patch used to enlarge the aortic arch/isthmus, with median max velocity flow at Doppler interrogation of 4.0 ± 0.51 m/s. Two patients required surgery after failed interventional cardiology. The mean interval between DPSIS patch implantation and re-intervention (percutaneous procedure or re-operation) was 6 months (1-17 months). While there were 3 hospital deaths (3/51 = 5.9%) not related to the patch implantation, no early or late mortality occurred for the subsequent procedure required for DPSIS patch interventional cardiology or surgery. The median max velocity flow at Doppler interrogation through the aortic arch/isthmus for the patients who did not require interventional procedure or surgery was 1.7 ± 0.57 m/s. Conclusions: High incidence of re-interventions with DPSIS patch for aortic arch and/or coarctation forced us to use alternative materials (homografts and decellularized gluteraldehyde preserved bovine pericardial matrix).
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Affiliation(s)
- Antonio F Corno
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom.,Cardiovascular Research Center, University of Leicester, Leicester, United Kingdom
| | - Paul Smith
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Laurynas Bezuska
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Branko Mimic
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
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Bacha E. Aortic coarctation decision making comes of age. J Thorac Cardiovasc Surg 2017; 155:1184-1185. [PMID: 29224838 DOI: 10.1016/j.jtcvs.2017.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Emile Bacha
- Division of Cardiac, Thoracic and Vascular Surgery, New York-Presbyterian/Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY.
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Murtuza B, Alsoufi B. Current Readings on Surgery for the Neonate With Hypoplastic Aortic Arch. Semin Thorac Cardiovasc Surg 2017; 29:S1043-0679(17)30294-0. [PMID: 29180283 DOI: 10.1053/j.semtcvs.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 11/11/2022]
Abstract
Aortic arch hypoplasia is commonly present in neonates born with ductal-dependent coarctation of the aorta. The ideal surgical repair of neonates with proximal arch hypoplasia continues to be debated. Controversy exists about the fate of the hypoplastic proximal aortic arch following surgical repair and whether that will eventually grow to normal size upon relief of the distal obstruction or will persist as a residual lesion that can affect the long-term outlook of those patients. There is new evidence that residual proximal arch hypoplasia and the shape of the reconstructed arch both have an important impact on vascular remodeling and on the subsequent development of hypertension. Those concerns about late outcomes despite what was originally deemed a successful repair in infancy, coupled with improved cardiopulmonary bypass and cerebral perfusion techniques that allow surgeons to address proximal arch hypoplasia with low morbidity, have rekindled the debate on how to address proximal arch hypoplasia, with the aim to offer a neonatal surgery that would last for a lifetime and provide both optimal early recovery and late freedom from hypertension and related complications.
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Affiliation(s)
- Bari Murtuza
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
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Bovine arch anatomy influences recoarctation rates in the era of the extended end-to-end anastomosis. J Thorac Cardiovasc Surg 2017; 155:1178-1183. [PMID: 29198787 DOI: 10.1016/j.jtcvs.2017.10.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 09/11/2017] [Accepted: 10/14/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Arch branching has never been shown to influence recoarctation after extended end-to-end anastomosis via thoracotomy, yet in each study bovine arch identification is grossly underreported. This study aims to (1) assess chart review reliability in bovine arch identification; (2) determine recoarctation risk with a bovine arch; and (3) explore an anatomic explanation for recurrent arch obstruction based on arch anatomy. PATIENTS A total of 49 consecutive patients underwent thoracotomy with extended end-to-end aortic coarctation repair at a single institution (2007-2012). METHODS Echocardiograms from these patients were reviewed for arch anatomy and compared with the echocardiographic reports. Recurrent arch obstruction was defined as an echocardiographic gradient across the repair of 20 mm Hg or greater. For cases with angiographic images (n = 17), a scaled clamping distance between the left subclavian artery and the maximal proximal clamp location on orthogonal projections was then calculated across arch anatomies. RESULTS Chart review identified 6.1% (3/49) of patients with a bovine arch compared with 28.6% (14/49) on targeted image review. A total of 28.6% (4/14) of patients with a bovine arch had a follow-up gradient of 20 mm Hg or greater. Only 5.7% (2/35) of patients with normal arch branching had a follow-up gradient of 20 mm Hg or greater. The mean clamping index was significantly diminished in patients with bovine arch anatomy. CONCLUSIONS Arch anatomy often goes undocumented on preoperative imaging, yet children undergoing extended end-to-end repair with bovine arch anatomy are at a significantly increased risk of recoarctation. This may be due to a reduced clampable distance to facilitate repair. These results should be considered in the preoperative assessment, parental counseling, and surgical approach for children with discrete aortic coarctation.
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Kim ER, Kim WH, Nam J, Choi K, Jang WS, Kwak JG. Mid-Term Outcomes of Repair of Coarctation of Aorta With Hypoplastic Arch: Extended End-to-side Anastomosis Technique. Semin Thorac Cardiovasc Surg 2017; 29:S1043-0679(17)30289-7. [PMID: 29111297 DOI: 10.1053/j.semtcvs.2017.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2017] [Indexed: 11/11/2022]
Abstract
The optimal surgical repair technique for coarctation associated with aortic arch hypoplasia (CoA-AAH) in neonates and infants is controversial. This study evaluates our current strategy using extended end-to-side anastomosis under selective cerebral and myocardial perfusion in treating this group of patients. Through a retrospective review, we analyzed the outcome of 87 infants who underwent surgical repair of CoA-AAH from January 2004 to December 2015. Patients with functional single ventricle were excluded. There were no early mortalities, and 4 patients (4.6%) experienced early complications. Eighty-five patients (97.7%) were followed up during a mean duration of 6.1 ± 3.53 years. There were 2 late mortalities (2.3%) and 3 reintervention (3.5%) of the aortic arch. Ten-year overall survival and freedom from reintervention for the entire cohort was 97.7% and 96.3%, respectively. At last follow-up, 4 patients (4.5%) showed a peak velocity greater than 2.5 m/s across the repair site. Seven patients (8.2%) were hypertensive. Our strategy with extended end-to-side anastomosis under selective cerebral and myocardial perfusion is safe and effective for repairing CoA-AAH in neonates and infants. Concomitant repair of associated cardiac anomalies can be done without added risk. Mid-term results are excellent with low rates of mortality, reintervention, and late hypertension.
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Affiliation(s)
- Eung Re Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea.
| | - Jinhae Nam
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Kwangho Choi
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Pusan, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Medical Center, Daegu, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, Republic of Korea
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Callahan C, Saudek D, Shillingford A, Creighton S, Hill G, Johnson W, Tweddell JS, Mitchell ME, Woods RK. Single-Stage Repair of Coarctation of the Aorta and Ventricular Septal Defect: A Comparison of Surgical Strategies and Resource Utilization. World J Pediatr Congenit Heart Surg 2017; 8:559-563. [PMID: 28901231 DOI: 10.1177/2150135117727256] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We sought to compare clinical outcomes and resource utilization for two surgical approaches for single-stage repair of coarctation of the aorta and ventricular septal defect (VSD). METHODS This was a retrospective chart review of 21 consecutive neonates and infants undergoing single-stage repair of coarctation of the aorta and VSD. Group 1 included 13 patients with both arch repair and VSD repair completed via sternotomy. Group 2 included eight patients with off-pump arch repair via left thoracotomy followed by repositioning and VSD repair via sternotomy. Primary clinical outcome was arch reintervention. Secondary outcomes included various measures of resource utilization. RESULTS Group 1 patients demonstrated younger age at repair (median of 10 days vs 57 days for group 2; P = .05) and lower proximal arch z scores (-4.2 vs -2.3 for group 2; P = .003). Arch reintervention occurred in 0 of 8 patients in group 2 and 1 (7.7%) of 13 patients in group 1 ( P = nonsignificant). Group 2 was associated with lower total charges (US$68,301 vs US$211,723 for group 1; P = .0007), shorter length of stay (8 days vs 23 days for group 1; P = .004), and shorter duration of postoperative mechanical ventilation (0.5 days vs 4.0 days for group 1; P = .0008). Group 2 was also associated with shorter total cardiopulmonary bypass time (86 minutes vs 201 minutes for group 1; P = .0009). CONCLUSION Single-stage two-incision repair of coarctation and VSD in appropriately selected patients may be associated with higher value of care. Confirmation of this finding will require further study based on larger numbers of patients.
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Affiliation(s)
- Connor Callahan
- 1 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - David Saudek
- 2 Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,3 Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Amanda Shillingford
- 4 Division of Pediatric Cardiology, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Sara Creighton
- 2 Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,3 Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Garick Hill
- 5 Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William Johnson
- 2 Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,3 Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- 6 Division of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael E Mitchell
- 1 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,2 Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,3 Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Ronald K Woods
- 1 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,2 Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,3 Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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De León LE, McKenzie ED. Aortic Arch Advancement and Ascending Sliding Arch Aortoplasty for Repair of Complex Primary and Recurrent Aortic Arch Obstruction. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:63-66. [PMID: 28007067 DOI: 10.1053/j.pcsu.2016.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/14/2016] [Indexed: 11/11/2022]
Abstract
The optimal treatment of patients with complex coarctation of the aorta and hypoplastic aortic arch is controversial. Children undergoing repair of obstructive arch lesions are at lifelong risk of recurrence. Multiple techniques have been described to address complex primary and recurrent coarctation. Our approach at Texas Children's Hospital (Houston, TX) has been to address these lesions in an anatomic fashion via median sternotomy, under cardiopulmonary bypass using the techniques of aortic arch advancement and ascending sliding arch aortoplasty. Anatomic repair of complex primary or recurrent aortic obstruction is safe and produces a favorable repair with a low rate of recurrence. Both operations restore normal arch contour using native aortic tissue. The decision of which particular surgical strategy to use depends on the patient's age, anatomy, and the elasticity of the tissue.
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Affiliation(s)
- Luis E De León
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, TX
| | - E Dean McKenzie
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, TX.
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Modeling Outcomes: Modified Aortic Arch Advancement for Neonatal Hypoplastic Arch. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:109-115. [PMID: 28346262 DOI: 10.1097/imi.0000000000000357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Numerous surgical approaches regarding aortic arch advancement for neonatal arch hypoplasia have been described. These repairs can be classified into two categories: those that incorporate a patch and those that do not. The decision between repairs remains largely experiential, rather than empirical, because of the limited number of reported outcomes. We report early outcomes from neonates undergoing modified aortic arch advancement with an anterior patch and our experience using computational fluid dynamic modeling to better understand the hemodynamic consequences associated with this repair. METHODS A retrospective review of neonates undergoing aortic arch advancement with anterior patch in 2014 at a single institution was performed. Anatomical, perioperative, and follow-up data were collected. Three-dimensional cardiac magnetic resonance images were used to generate computational fluid dynamic models of the modified anterior patch and direct end-to-side repairs. Cardiac waveform inputs were simulated and hemodynamic analyzed. RESULTS Ten neonates underwent modified aortic arch advancement. No hemodynamically significant gradients were observed at a median follow-up of 0.77 (0.30-1.2) years. Asymmetrical flow was observed in the end-to-side repair, whereas more concentric laminar flow was observed throughout the modified model. Spatial variations in velocities immediately distal to the anastomosis were greater in the end-to-side model (0.35 vs 0.17 m/s, P < 0.001). Time-averaged variations in wall shear stress during systole were greater in the end-to-side model at the same location (3.44 vs 1.98 dynes/cm, P < 0.001). CONCLUSIONS Early outcomes after the use of an anterior patch for neonatal hypoplastic aortic arch repair show favorable hemodynamic outcomes.
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41
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Nellis JR, Chung TK, Agarwal N, Torres JE, Holgren SE, Raghavan ML, Turek JW. Modeling Outcomes. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph R. Nellis
- University of Iowa Carver College of Medicine, Iowa City, IA USA
| | | | - Nandita Agarwal
- Department of Radiology, University of Iowa Hospital, Iowa City, IA USA
| | - Jose E. Torres
- Department of Cardiothoracic Surgery, Yavapai Regional Medical Center, Prescott, AZ USA
| | - Sarah E. Holgren
- Department of Pediatric Cardiac Surgery, University of Iowa Children's Hospital, Iowa City, IA USA
| | | | - Joseph W. Turek
- Department of Pediatric Cardiac Surgery, University of Iowa Children's Hospital, Iowa City, IA USA
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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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43
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Urencio M, Dodge-Khatami A, Greenleaf CE, Aru G, Salazar JD. Ascending Aortic Slide for Interrupted Aortic Arch Repair. World J Pediatr Congenit Heart Surg 2016; 7:645-8. [DOI: 10.1177/2150135116655124] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 05/14/2016] [Indexed: 11/16/2022]
Abstract
For repair of interrupted aortic arch, unfavorable anatomy challenges a tension-free anastomosis. We describe a useful alternative surgical technique used in five neonates/infants, involving splitting the ascending aorta from the sinotubular junction to the arch origin, leftward and posterior “sliding” of the flap with anastomosis to the distal arch creating a native tissue bridge, and reconstruction with a patch. With wide interruption gaps between proximal and distal aortic portions, the ascending aortic slide is a safe and reproducible technique, providing a tension-free native tissue bridge with potential for growth, and a scaffold for patch augmentation in biventricular hearts, or for Norwood stage I in univentricular palliation.
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Affiliation(s)
- Miguel Urencio
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ali Dodge-Khatami
- Children’s Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
| | - Chris E. Greenleaf
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Giorgio Aru
- Division of Cardiothoracic Surgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jorge D. Salazar
- Children’s Heart Center, University of Mississippi Medical Center, Jackson, MS, USA
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Horne D, Morris SA, Colquitt JL, Molossi SM, McKenzie ED. Incidental Finding of Right Coronary Artery to Pulmonary Artery Fistula During Surgical Repair of Aortic Arch Atresia in Turner Syndrome. World J Pediatr Congenit Heart Surg 2016; 8:646-649. [DOI: 10.1177/2150135116658016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aortic arch atresia has not been associated with coronary anomalies. We present a unique case of a patient with Turner syndrome and aortic arch atresia with the incidental finding of a right coronary artery to pulmonary artery fistula at the time of surgical repair.
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Affiliation(s)
- David Horne
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shaine A. Morris
- Division of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - John L. Colquitt
- Division of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Silvana M. Molossi
- Division of Pediatric Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - E. Dean McKenzie
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Left Ventricular Outflow Tract Obstruction: Coarctation of the Aorta, Interrupted Aortic Arch, and Borderline Left Ventricle. Pediatr Crit Care Med 2016; 17:S315-7. [PMID: 27490616 DOI: 10.1097/pcc.0000000000000826] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this review are to discuss the perioperative management of coarctation of the aorta, interrupted aortic arch, and the borderline left ventricle. METHODS MEDLINE and PubMed. CONCLUSIONS Successful management of systemic obstructive lesions involves a thorough evaluation of the anatomy and pathophysiology to determine the most effective management strategy.
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46
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Lee H, Yang JH, Jun TG, Cho YH, Kang IS, Huh J, Song J. Augmentation of the Lesser Curvature With an Autologous Vascular Patch in Complex Aortic Coarctation and Interruption. Ann Thorac Surg 2016; 101:2309-14. [PMID: 27021030 DOI: 10.1016/j.athoracsur.2016.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 12/27/2015] [Accepted: 01/04/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Reconstruction of the aortic arch in patients with complex aortic coarctation or interruption continues to be a challenge because of early left main bronchial compression or recoarctation and late Gothic arch formation. We propose a modified arch reconstruction technique augmenting the lesser curvature with an autologous vascular patch, which can relieve tension on the anastomosis without a prosthetic material. METHODS We retrospectively reviewed 33 patients with coarctation and arch hypoplasia (n = 31) or arch interruption (n = 2) who underwent arch reconstruction with an autologous vascular patch from 2007 to 2012. Median age at the operation was 17 days (range, 5 to 200 days). Median body weight was 3.7 kg (range, 2.3 to 7.0 kg). Cardiopulmonary bypass was used for all operations. Median antegrade selective cerebral perfusion time was 35 minutes (range, 23 to 59 minutes). Combined intracardiac anomalies in 29 patients (88%) were corrected simultaneously. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from aortic isthmus (n = 25), pulmonary artery (n = 4), left subclavian artery (n = 2), aberrant right subclavian artery (n = 1), or distal arch (n = 1). RESULTS One patient (3%) died of acute respiratory distress syndrome. All survivors were discharged at 15 days (range, 7 to 58 days) postoperatively without neurologic complications or bronchial obstructions. Median follow-up was 24.8 months (range, 0.2 to 48.5 months). No recoarctation was observed during follow-up, and no patient needed reoperation. CONCLUSIONS Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in excellent midterm outcomes. Not only can a more natural shape of arch and less tension on the anastomosis be obtained, but complications, such as left main bronchial obstruction or recoarctation, can also be minimized. Long-term follow-up is needed to evaluate late development of recoarctation, hypertension, or aneurysm formation.
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Affiliation(s)
- Heemoon Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| | - Tae-Gook Jun
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - I-Seok Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Aguib H, Torii R, Romeih S, Yacoub M. Characterisation of spatiotemporal aortic flow and aortic wall biomechanics in coarctation. Glob Cardiol Sci Pract 2016; 2015:45. [PMID: 26779520 PMCID: PMC4710873 DOI: 10.5339/gcsp.2015.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/27/2015] [Indexed: 11/09/2022] Open
Affiliation(s)
| | - Ryo Torii
- University College London, London, UK
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48
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Swartz MF, Simon B, Atallah-Yunes N, Cholette JM, Orie J, Gensini F, Alfieris GM. Distal Transverse Arch to Left Carotid Artery Ratio Helps to Identify Infants With Aortic Arch Hypoplasia. Ann Thorac Surg 2015. [PMID: 26212512 DOI: 10.1016/j.athoracsur.2015.04.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aortic coarctation (CoA) with concomitant aortic arch hypoplasia (AAH) is associated with an increased risk of hypertension after surgical repair. The differentiation of CoA with or without AAH may be critical to delineate the ideal surgical approach that best ameliorates postoperative hypertension. Since 2000, we have defined CoA with AAH when the diameter of the distal transverse aortic arch is equal to or less than the diameter of the left carotid artery. We hypothesized that, based on our definition, aortic tissue from infants having CoA with AAH would demonstrate distinct genetic expression patterns as compared with infants having CoA alone. METHODS From 6 infants (AAH, 3; CoA, 3), an Affymetrix 1.0 genome array identified genes in the coarctation/arch region that were differentially expressed between infants having CoA with AAH versus CoA alone. Reverse transcription polymerase chain reaction validated genetic differences from a cohort of 21 infants (CoA with AAH, 10; CoA, 11). To evaluate the clinical outcomes based on our definition of CoA with AAH, we reviewed infants repaired using this algorithm from 2000 to 2010. RESULTS Microarray data demonstrated genes differentially expressed between groups. Reverse transcription polymerase chain reaction confirmed that CoA with AAH was associated with an increased expression of genes involved in cardiac and vascular development and growth, including hepsin, fibroblast growth factor-18, and T-box 2. The clinical outcomes of 79 infants (AAH, 26; CoA, 53) demonstrated that 90.1% were free of hypertension at 13 years when managed with this surgical strategy. CONCLUSIONS These findings provide evidence that the ratio of the diameter of the distal transverse arch to the left carotid artery may be helpful to identify CoA with AAH and, when used to delineate the surgical approach, may minimize hypertension.
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Affiliation(s)
- Michael F Swartz
- Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York.
| | - Bartholomew Simon
- University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York
| | - Nader Atallah-Yunes
- Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York
| | - Jill M Cholette
- Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York
| | - Joseph Orie
- Pediatric Cardiac Consortium of Upstate New York, Rochester, New York
| | - Francisco Gensini
- Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York
| | - George M Alfieris
- Pediatric Cardiac Consortium of Upstate New York, Rochester, New York; University of Rochester Medical Center, Strong Memorial Hospital, Rochester, New York
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Mery CM, Guzmán-Pruneda FA, Trost JG, McLaughlin E, Smith BM, Parekh DR, Adachi I, Heinle JS, McKenzie ED, Fraser CD. Contemporary Results of Aortic Coarctation Repair Through Left Thoracotomy. Ann Thorac Surg 2015. [PMID: 26209490 DOI: 10.1016/j.athoracsur.2015.04.129] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Although surgical results for repair of coarctation of the aorta (CoA) have steadily improved, management of this condition remains controversial. The purposes of this study were to analyze the long-term outcomes of patients undergoing CoA repair through left thoracotomy and to define risk factors for reintervention. METHODS All patients who were less than 18 years old and who underwent initial repair of CoA through left thoracotomy from 1995 to 2013 at Texas Children's Hospital (Houston, TX) were included. Patients were classified into 3 groups: 143 (42%) neonates (0 to 30 days old), 122 (36%) infants (31 days to 1 year old), and 78 (23%) older children (1 to 18 years old). Univariate and multivariate analyses were performed. RESULTS A total of 343 patients (129 [38%] girls) with median age of 53 days (interquartile range [IQR],12 days to 9 months) and weight of 4.1 kg (IQR, 3.1 to 8.0) underwent repair with extended end-to-end anastomosis (291 patients [85%]), end-to-end anastomosis (44 patients [13%]), interposition graft (2 patients [0.6%]), or subclavian flap (6 patients [2%]). Concomitant diagnoses included genetic abnormalities (48 patients [14%]), isolated ventricular septal defects (58 patients [17%]), small left-sided structures (53 patients,16%), or other complex congenital heart disease (18 patients [5%]). Perioperative mortality was 1% (n = 4, all neonates). At a median follow-up of 6 years (7 days to 19 years), only 14 (4%) patients required reintervention (10 catheter-based procedures, 6 surgical repairs). A postoperative peak velocity of 2.5 m/s or greater was an independent risk factor for reintervention (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.4 to 11.6). Within the cohort, 95 (33%) patients were hypertensive or remained on cardiac medications a median of 12 years (6 months to 19 years) after the surgical procedure. Development of perioperative hypertension was associated with higher risk of chronic hypertension or cardiac medication dependency (OR, 1.9; 95% CI, 1.1 to 3.3). CONCLUSIONS CoA repair through left thoracotomy is associated with low rates of morbidity, mortality, and reintervention. Aortic arch obstruction should be completely relieved at the time of surgical intervention to minimize the risk of long-term recoarctation.
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Affiliation(s)
- Carlos M Mery
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas.
| | - Francisco A Guzmán-Pruneda
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas
| | - Jeffrey G Trost
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas
| | - Ericka McLaughlin
- Division of Pediatric Cardiology, Texas Children's Hospital; Department of Pediatrics, Baylor College of Medicine; Houston, Texas
| | - Brendan M Smith
- Division of Pediatric Cardiology, Texas Children's Hospital; Department of Pediatrics, Baylor College of Medicine; Houston, Texas
| | - Dhaval R Parekh
- Division of Pediatric Cardiology, Texas Children's Hospital; Department of Pediatrics, Baylor College of Medicine; Houston, Texas
| | - Iki Adachi
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas
| | - E Dean McKenzie
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas
| | - Charles D Fraser
- Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas
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50
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Cirugía neonatal de la coartación aórtica: ¿dónde estamos? CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2015.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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