Comparison of surgical and interventional therapy of native and recurrent aortic coarctation regarding different age groups during childhood

Coarctation of the Aorta: Modern Paradigms Across the Lifespan

While coarctation of the aorta varies greatly in both severity and age at presentation, all patients are at increased risk of hypertension both before and after repair. Despite advances in knowledge about genetic etiologies, pathophysiologic mechanisms, and optimal repair strategies, patients with repaired coarctation of the aorta remain at increased risk of acquired cardiovascular disease. The aims of this review are to describe the management of coarctation of the aorta at all ages before and after repair, highlight pathophysiologic mechanisms of hypertension, and review long-term follow-up considerations.

Long-term outcomes of surgical repair of isolated coarctation of the aorta in different age groups

BACKGROUND

Coarctation of the aorta (CoA) is one of the most common congenital heart defects (5-8% of all CHD). Treatment of native CoA may be accomplished surgically, or through an interventional approach. Surgical repair of CoA remains an important option for treatment of aortic coarctation during childhood, although it is mostly performed in neonates and young infants.

OBJECTIVES

In this retrospective study, we sought to share the long-term outcomes of different surgical techniques for repair of coarctation of the aorta in different age groups.

MATERIALS AND METHODS

This is a retrospective single-center clinical study that included 228 consecutive patients (age: 1 day- 41years) in whom surgical repair of isolated native coarctation of the aorta was performed with different surgical techniques.

RESULTS

Immediate results were excellent; however, the mortality rate were higher in the infants. Complications rate and incidence of recoarctation, both were comparable between different age groups and different surgical techniques.

CONCLUSIONS

Surgical repair of CoA remains an important option for treatment of aortic coarctation in different age groups with low morbidity and mortality. We did not find any significant difference between different surgical techniques regarding the development of recoarctation.

Recovery of Biventricular Function After Catheter Intervention or Surgery for Neonatal Coarctation of the Aorta

Background

Critical coarctation of the aorta (CoA) is a life-threatening condition in newborns that is associated with biventricular dysfunction.

Objectives

The purpose of this study was to examine clinical outcome and echocardiographic changes in isthmus diameter and biventricular function in newborns with critical CoA treated with balloon dilation/stent placement or surgery.

Methods

This is a retrospective single-center cohort study of 26 consecutive neonates with isolated critical CoA, who underwent transcatheter intervention (balloon angioplasty/stent; n = 10) or surgical CoA-repair (n = 16) (2012-2021). Isthmus dimensions and biventricular function at baseline and at hospital discharge were examined by echocardiography, including strain analysis of systolic and diastolic function using 2-dimensional speckle tracking.

Results

Cardiogenic shock at hospital admission was more frequent in the interventional vs the surgical cohort (50% vs 25% of neonates). Echocardiographic isthmus diameter increased with therapy by 0.9 ± 0.1 mm and 1.0 ± 0.1 mm, respectively. Severe systolic left ventricular (LV) dysfunction was more common in interventional patients pre-therapy (LV ejection fraction <50% in 90% vs 38% of surgical patients), resulting in strongly reduced longitudinal strain (LV: -12.3% vs -16.3%; right ventricle:-13.8% vs -16.1% in the interventional and surgical patients, respectively). Prior to hospital discharge, all 26 patients had full recovery of biventricular systolic function, including normalization of longitudinal, radial, and circumferential LV strain and longitudinal right ventricular free wall strain. Improvement of LV diastolic function by strain analysis was evident in both cohorts pre-hospital discharge.

Conclusions

Initial treatment of isolated CoA by percutaneous transcatheter intervention or surgical repair results in recovery of biventricular systolic function, making transcatheter treatment particularly suitable as rescue therapy for neonates with critical CoA.

Computed Tomographic Evaluation of Congenital Left Ventricular Outflow Obstruction

Congenital left ventricular outflow obstruction represents a multilevel obstruction with several morphological forms. It can involve the subvalvular, valvar, or supravalvular portion of the aortic valve complex, and may coexist. Computed tomography (CT) plays an important supplementary role in the evaluation of patients with congenital LVOT obstruction. Unlike transthoracic echocardiography and cardiovascular magnetic resonance (CMR) imaging, it is not bounded by a small acoustic window, needs for anaesthesia or sedation, and metallic devices. Current generations of CT scanners with excellent spatial and temporal resolution, high pitch scanning, wide detector system, dose reduction algorithms, and advanced 3-dimensional postprocessing techniques provide a high-quality alternative to CMR or diagnostic cardiac catheterization. Radiologists performing CT in young children should be familiar with the advantages and disadvantages of CT and with the typical morphological imaging features of congenital left ventricular outflow obstruction.

Transient Recurrent Laryngeal Nerve Palsy after Interventional Therapy

BACKGROUND

 Hoarseness due to laryngeal nerve injury is a known complication after cardiothoracic surgery involving the aortic arch. However, this complication is only rarely reported after catheter interventions.

RESULTS

 In this article we present the unusual case of a left-sided vocal cord paralysis in four patients after primary stenting of a re-coarctation, re-dilatation of a stented coarctation, a primary stenting of the left pulmonary artery (LPA), and prestenting for percutaneous pulmonary valve implantation with dilation of the LPA. After implanting bare metal stents, it is common practice, whilst contemplating the diameters of the adjacent structures, to optimize the stent diameter in a two-step procedure and dilate the stent until a maximum diameter is achieved and there is no residual gradient after applying this technique. Four of our patients experienced hoarseness after the intervention and a vocal cord paralysis was diagnosed. Angiography revealed no signs of extravasation or dissection. Clinical symptoms improved over the course of the following 6 months; patients with interventions at the aortic arch showed a complete remission, patients with procedures involving the LPA showed only mild regression of the symptoms.

CONCLUSION

 To our knowledge, this complication (Ortner's syndrome, cardiovocal syndrome) after such interventions has rarely been reported before. Although a rare complication, the recognition of these symptoms may support colleagues in managing affected patients. In addition, awareness for hoarseness after interventional therapies and systematic screening for this complication might help to identify patients at risk in the future.

Surgery for aortic recoarctation in children less than 10 years old: A single-center experience in Siberia, Russia

BACKGROUND

Persistence or recurrence of stenosis is a complication of initial coarctation repair. This study aims to report short-term outcomes of surgical management of recurrent coarctation and initial repair analysis.

METHODS

We retrospectively reviewed our experience with 51 patients undergoing recoarctation surgical repair between 2008 and 2019 using antegrade cerebral perfusion (ACP) technique.

RESULTS

Surgical correction included prosthetic patch aortoplasty in 23 (45%), resection with wide end-to-end anastomosis in 15 (29%), and a tube interposition graft in 13 (25%) patients. The median age at initial correction and reintervention was 12 months and 9 years. The median interval from primary repair to reintervention was 60 months. Initial repair analysis revealed 33% of patients had initial correction in the neonatal period, 72.5% of patients were done via a left thoracotomy approach and 63% of patients had end-to-end anastomosis at initial surgery.

CONCLUSION

Our study demonstrates that surgical repair of recurrent coarctation of the aorta using ACP technique can be performed safely and with excellent results.

Prospective multicenter study of the breakable babystent for treatment of aortic coarctation in newborns and infants

To assess the efficacy and safety of a breakable BabyStent to treat complex aortic coarctation (CoA) in early childhood. Although recommended in several guidelines, there is no approved aortic stent for young infants, because of the dilemma between two mandatory requirements: expandable up to adult size on the one hand, and small enough to fit through a baby's femoral artery on the other. Prospective interventional, multi-center clinical trial with the breakable Osypka BabyStent® (OBS). The OBS is a low-profile, 15-mm long cobalt-chromium stent, pre-mounted on a 6 mm balloon and inserted via a 4 Fr sheath. After implantation, its diameter is adjustable from 6 to 12 mm by balloon dilation. Further dilation opens predefined joints enabling unrestricted growth. Nineteen patients (9 male), median age 112 days (range: 7-539), median body weight 5.6 kg (range: 2.4-8.4) were deemed high risk and underwent stent implantation. Of those, 74% suffered from re-CoA following surgery, 53% had additional cardiac and 21% noncardiac malformations. Our primary combined endpoint was fulfilled: All stents were implanted in the desired region, and a >50% intrastenotic diameter-extension was achieved in 15 patients (78.9%, 80% confidence interval [62.2; 90.5], 95% confidence interval [54.4; 93.9]). Secondary endpoint confirmed that the OBS fits the baby's femoral vessel diameter. All children survived the procedure and 12-month follow-up. This stent enables percutaneous stenting of complex aortic coarctation to treat high-risk newborns and infants.

Two decades of aortic coarctation treatment in children; evaluating techniques

OBJECTIVE

This study focuses on the evolution of treatment techniques for aortic coarctation in children and assesses long-term morbidity.

METHODS

This retrospective cohort study evaluates patients treated for native aortic coarctation, with at least 7 years of follow-up. To assess time-related changes, three time periods were distinguished according to year of primary intervention (era 1, 2 and 3). Operative and long-term follow-up data were collected by patient record reviews.

RESULTS

The study population consisted of 206 patients (177 surgical and 29 catheter-based interventions), with a median follow-up of 151 months. Anterior approach with simultaneous repair of aortic arch and associated cardiac lesions was more common in the most recent era. Median age at intervention did not change over time. Reintervention was necessary in one third of the cohort with an event-free survival of 74% at 5‑year and 68% at 10-year follow-up. Reintervention rates were significantly higher after catheter-based interventions compared with surgical interventions (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.04-3.00, p = 0.04) and in patients treated before 3 months of age (HR 2.1, 95% CI 1.27-3.55, p = 0.003). Hypertension was present in one out of five patients.

CONCLUSION

Nowadays, complex patients with associated cardiac defects and arch hypoplasia are being treated surgically on bypass, whereas catheter-based intervention is introduced for non-complex patients. Reintervention is common and more frequent after catheter-based intervention and in surgery under 3 months of age. One fifth of the 206 patients remained hypertensive.

Management of adults with coarctation of aorta

Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.

Muscle-sparing aortic coarctation repair

Objective

Surgery for aortic coarctation repair provides excellent hemodynamic results but may be complicated by musculoskeletal issues. The purpose of the study was to determine the midterm results of a muscle-sparing surgical approach to aortic coarctation repair, with special emphasis on the repair and on the musculoskeletal changes associated with a posterior thoracotomy.

Methods

We included all children with aortic coarctation operated on with our minimally invasive approach between June 2002 and October 2004, with a follow-up of ≥4.5 years. Patients were assessed clinically and echocardiographically. The spine, left chest, and shoulder were assessed clinically and radiographically.

Results

Thirty-one children were included. The age at operation ranged from 1 day to 15 months and weight ranged from 980 g to 10 kg. All patients underwent an extended end-to-end anastomosis coarctation repair through a minimal (n = 19) or total-muscle sparing (n = 12) or extrapleural (n = 18) approach. Five patients had an additional enlargement procedure on the aortic arch. 27 patients had no residual or recurrent gradient. Four patients exhibited restenosis, for which 1 underwent a percutaneous angioplasty and 2 underwent surgical reintervention. All patients were free of hypertension. One patient had borderline values. The musculoskeletal assessment was normal in all but 3 patients. Two patients who underwent other subsequent thoracic surgeries developed thoracogenic scoliosis of moderate severity. A third patient had a left winged scapula. No rib fusion or intercostal space enlargement was found.

Conclusions

Compared with a conventional approach, our minimally invasive surgical approach led to excellent musculoskeletal outcomes without compromising the hemodynamic results.

The Challenges of Redo Aortic Coarctation Repair in Adults

PURPOSE OF REVIEW

Aortic coarctation is a common congenital abnormality causing significant morbidity and mortality if not corrected. Re-coarctation or restenosis of the aorta following treatment is a relatively common long-term problem and the optimal therapy has not been elucidated. In this review, we identify the challenges associated with and the optimal management for recurrent aortic coarctation and the most appropriate therapy for different patient cohorts.

RECENT FINDINGS

Open surgery provides a durable long-term aortic repair, however, given the complex nature of the procedure, has a somewhat higher rate of serious complications. Endovascular repair, although less invasive and relatively safe, has limitations in treated complex anatomy and is more likely to require repeat intervention. Open surgical repair is more appropriate for infants that have not been intervened on and endovascular therapy should be reserved for older children and adults and those that require repeat intervention.

Coarctation of Aorta in Children

Coarctation of aorta (CoA) is a discrete narrowing in aorta causing obstruction to the flow of blood. It accounts for 6–8% of all congenital heart diseases. With advances in fetal echocardiography rate of prenatal diagnosis of coarctation of aorta has improved but it still remains a challenging diagnosis to make prenatally. Transthoracic echocardiography is mainstay of making initial diagnosis and routine follow-up. Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) are great advanced imaging tools for two-dimensional and three-dimensional imaging of aortic arch in complex cases. Based on type of coarctation, size of patient, severity of lesion, and associated abnormalities various management options like surgical treatment, transcatheter balloon angioplasty and transcatheter stent implantation are available. There is significant improvement in long-term survival from pre-surgical era to post-surgical era. But, among the postsurgical era patients, the long-term survival has not significantly changed between older and contemporary cohort. Patients with coarctation of aorta need lifelong follow-up event after successful initial intervention.

Coarctation repair-redo challenges in the adults: what to do?

Aortic coarctation is one of the most common congenital cardiac pathologies. Repair of native aortic coarctation is nowadays a common and safe procedure. However, late complications, including re-coarctation and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both endovascular and conventional open repair play important roles in the treatment of late complications after previous coarctation repair. This article will review the incidence of late complications after coarctation repair and will discuss the treatment options for redo coarctation repair in adult patients.

Diagnosis, imaging and clinical management of aortic coarctation

Coarctation of the aorta (CoA ) is a well-known congenital heart disease (CHD) , which is often associated with several other cardiac and vascular anomalies, such as bicuspid aortic valve (BAV), ventricular septal defect, patent ductus arteriosus and aortic arch hypoplasia. Despite echocardiographic screening, prenatal diagnosis of C o A remains difficult. Most patients with CoA present in infancy with absent, delayed or reduced femoral pulses, a supine arm-leg blood pressure gradient (> 20 mm Hg), or a murmur due to rapid blood flow across the CoA or associated lesions (BAV). Transthoracic echocardiography is the primary imaging modality for suspected CoA. However, cardiac magnetic resonance imaging is the preferred advanced imaging modality for non-invasive diagnosis and follow-up of CoA. Adequate and timely diagnosis of CoA is crucial for good prognosis, as early treatment is associated with lower risks of long-term morbidity and mortality. Numerous surgical and transcatheter treatment strategies have been reported for CoA. Surgical resection is the treatment of choice in neonates, infants and young children. In older children (> 25 kg) and adults, transcatheter treatment is the treatment of choice. In the current era, patients with CoA continue to have a reduced life expectancy and an increased risk of cardiovascular sequelae later in life, despite adequate relief of the aortic stenosis. Intensive and adequate follow-up of the left ventricular function, valvular function, blood pressure and the anatomy of the heart and the aorta are , therefore, critical in the management of CoA. This review provides an overview of the current state-of-the-art clinical diagnosis, diagnostic imaging algori thms, treatment and follow-up of patients with CoA.

Antegrade transvenous balloon angioplasty for coarctation of the aorta in infants with ventricular septal defect

For a newborn, surgical correction has been the primary treatment of native coarctation at most centers; however, there has been an increased use of balloon angioplasty (BA). The anterograde transvenous (AT) technique is another alternative way for coarctation (AoC) angioplasty in low weight patients with large ventricular septal defect (VSD).

Four, 5-day-old to 7-month-old, infants weighing 2500, 2700, 2800, and 3400 g, respectively presented to emergency unit (EU) with cyanosis, tachypnea, and loss of weight. Echocardiography demonstrated AoC and VSD. All four children were admitted to the EU with hemodynamic compromise and critically ill status. We used femoral vein for sheath and used VSD to enter left ventricle from right antegrade route, and performed BA without any complication.

AT described in this report is another alternative way for coarctation angioplasty in patients with large VSD. We suggest that AT BA can be applied to small infants in situations where surgery might have been hazardous.

Effectiveness of Balloon Angioplasty in Children With Recurrent Aortic Coarctation Depends on the Type of Aortic Arch Pathology

OBJECTIVES

The aim of this study was to evaluate the effectiveness of balloon angioplasty (BAP) for recurrent aortic coarctation (ReCoA) in infants comparing simple and complex type of aortic arch pathology (Norwood I procedure).

BACKGROUND

ReCoA is a known complication after cardiovascular surgery for coarctation of the aortic arch.

METHODS AND RESULTS

In a single center case study, we analyzed 20 infants undergoing BAP for ReCoA comparing simple (n = 10) and complex type of aortic arch pathology (n = 10). At catherization diameter of ReCoA stenosis was 3.2 ± 0.7 mm (mean ± SD) with short localized (11/20) or long hypoplastic stenosis (9/20) before and 4.8 ± 1.2 mm after BAP (P < 0.001). Invasive systolic pressure gradient was reduced from 27.5 ± 16.2 mmHg before to 5.1 ± 6.6 mmHg after BAP (P < 0.001), comparable in simple and complex type of ReCoA. At day 1 after catherization noninvasive systolic arterial blood pressure gradient was reduced from 20.2 ± 23.1 to 6.7 ± 9.9 mmHg (P < 0.001), respectively, calculated continuous wave Doppler echo gradient from 36.3 ± 22 to 16.8 ± 9.6 mmHg (P < 0.01). Complications were aortic arch dissection (1/20), discrete aortic arch aneurysm formation (1/20), pericardial effusion (1/20), and peripheral arterial thrombosis (4/20). At a mid-term follow up of 9.5 months (1-40) after BAP, 3 infants needed early surgical reintervention due to secondary ReCoA, all with long hypoplastic aortic arch segments, but simple type of aortic arch pathology.

CONCLUSIONS

At mid-term follow up, BAP remains an effective catheter intervention for ReCoA for infants with localized ReCoA, but not with long hypoplastic aortic arch segments, even in simple type of aortic arch pathology.

Coarctation of the aorta in adolescents and adults: A review of clinical features and CT imaging

Coarctation of the aorta (CoA), while usually identified and treated in the neonatal/infant period, is increasingly seen in adults, either primarily or (more often) following repair. Imaging plays a crucial role in the diagnosis, therapeutic planning, and follow-up of patients with CoA. Clinical management of CoA in adults optimally involves a multidisciplinary team; accordingly, imagers should be familiar with the underlying pathology, associations, and management of CoA in addition to imaging protocoling and interpretation. We will review the relevant clinical and imaging features of CoA, with an emphasis on patients beyond childhood.

Recurrent coarctation: interventional techniques and results

Coarctation of the aorta (CoA) accounts for 5% to 8% of all congenital heart defects. With all forms of interventions for native CoA, repeat intervention may be required due to restenosis and/or aneurysm formation. Restenosis rates vary from 5% to 24% and are higher in infants and children and in those with arch hypoplasia. Although repeat surgery can be done for recurrent CoA, guidelines from a number of professional societies have recommended balloon angioplasty with or without stenting as the preferred intervention for patients with isolated recoarctation. For infants and young children with recurrent coarctation, balloon angioplasty has been shown to be safe and effective with low incidence of complications. However, the rates of restenosis and reinterventions are high with balloon angioplasty alone. Endovascular stent placement is indicated, either electively in adults or as a bailout procedure in those who develop a complication such as dissection or intimal tear after balloon angioplasty. Conventionally bare metal stents are used; these can be dilated later if required. Covered stents, introduced more recently, are best reserved for those who have aneurysm at the site of previous repair or who develop a complication such as aortic wall perforation or tear. Stents produce complete abolition of gradients across the coarct segment in a majority of cases with good opening of the lumen on angiography. The long-term results are better than that of balloon angioplasty alone, with very low rates of restenosis. However, endovascular stenting is a technically demanding procedure and can be associated with serious complications rarely.

Using the Valeo dilatable stent in coarctation stenting for small children: expanding the inclusion criteria for coarctation stenting?

The application of coarctation stenting has grown in paediatric and adult practice in recent years. Stent and delivery sheath technology has improved; however, we remain technically limited when implanting small calibre stents through small sheaths in small children, which then have the potential to be dilated to adult size as time passes. We describe the first reported use of the Valeo Biliary Pre-mounted Re-dilatable Stent (Edwards Life Sciences, California, USA) in aortic coarctation with 1 year follow-up including cross-sectional imaging. This 14 kg 3-year-old girl presented following an intracerebral haemorrhage secondary to severe systemic hypertension. Despite implantation through a 7-French sheath, this stent can be postdilated up to 20 mm, and therefore provides an important new addition to the interventional armamentarium.

A prospective observational multicenter study of balloon angioplasty for the treatment of native and recurrent coarctation of the aorta

OBJECTIVES

Balloon angioplasty (BA) is an important treatment option for coarctation of the aorta. The congenital cardiovascular interventional study consortium (CCISC) represents a multi-institutional and multi-national effort to prospectively investigate congenital cardiac interventions. A prospective observational analysis of the efficacy and safety of balloon aortic angioplasty was conducted.

METHODS

Data were collected prospectively from 36 CCISC sites from 2004 to 2012. One hundred and thirty patients underwent BA for native (n = 76) and recurrent (n = 54) coarctation. Acute, short-term, and intermediate outcomes are described for BA performed in the setting of native and recurrent coarctation of the aorta. Outcome measures included residual upper to lower extremity blood pressure gradient (ULG), use of antihypertensive medications, aortic wall injury, reobstruction, and need for reintervention.

RESULTS

There was no procedural mortality. Acutely in native and recurrent coarctation, BA achieved an ULG less than 15 mm Hg in 73-80% and to less than 10 mm Hg in 54-68% of patients, respectively. At intermediate follow-up, ULG further improved, particularly for those who underwent initial reintervention for recurrent coarctation. No significant differences in aortic wall complications were seen and intervention free survival was similar for both groups. Following angioplasty, there was no significant difference in aortic wall complications; however follow up integrated imaging decreased over time.

CONCLUSIONS

BA is a safe and effective treatment for coarctation of the aorta acutely and at intermediate term. Although aortic injury occurred in patients with both native and recurrent coarctation, at intermediate follow-up, aneurysm was noted more often in those with initial intervention for native coarctation.

Continuous cerebral and myocardial perfusion during one-stage repair for aortic coarctation with ventricular septal defect

Controversy still exists concerning the use of deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (SACP) for repair of aortic coarctation (CoA) with ventricular septal defect (VSD). This report therefore describes outcomes of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia compared with DHCA and SACP. Retrospective analysis was performed for 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Patients repaired under CCMP with mild hypothermia (32 °C) (group A, n = 60) were compared with those repaired under DHCA (18 °C) and SACP (group B, n = 50). In group A, the single arterial cannula perfusion technique was used for 15 patients (25 %), and the dual arterial cannula perfusion technique was used for 45 patients (75 %). The preoperative data were similar in the two groups. Group A had no hospital mortalities, compared with two mortalities (4 %) in group B. Group A had shorter myocardial ischemic and cardiopulmonary times, fewer delayed sternal closures, a shorter time to extubation, lower postoperative lactate levels, and fewer patients with low cardiac output requiring extracorporeal membrane oxygenation or with multiorgan failure than group B. During the postoperative course, no clinical or electrical neurologic events occurred in either group. The mean follow-up period was 5.2 ± 3.2 years for group A and 7.5 ± 3.1 years for group B (P = 0.048). One late death occurred in group B and no late deaths in group A. The actuarial survival for the two groups was similar (100 % for group A vs 96 % for group B; P = 0.264). The freedom from all types of cardiac reintervention was 96.7 % in group A and 89.6 % in group B (P = 0.688). All the patients were free of neurologic symptoms. The authors' perfusion strategy using CCMP with mild hypothermia for repair of CoA with VSD is feasible, safe, and associated with improved postoperative recovery and should be the method of choice.

Repair of isolated aortic coarctation over two decades: impact of surgical approach and associated arch hypoplasia

OBJECTIVES

A variety of surgical approaches and techniques are used for isolated coarctation repair. We have retrospectively reviewed our results of isolated repair of coarctation over the last 20 years, to establish whether the approach affects clinical outcome and the need for re-intervention.

METHODS

Two hundred and eighty-eight patients who underwent isolated repair for coarctation of the aorta at Birmingham Children's Hospital between 1991 and 2010 were enrolled in this study. Chart review and the Departmental database were used to determine demographics, operative details and complications.

RESULTS

The majority of patients (n = 237, 82%) underwent surgical repair via thoracotomy techniques, whereas median sternotomy was used in patients where there was associated arch hypoplasia (n = 51, 18%). For all 288 patients, median age at operation was 24 days (range 0-14 years). Between 1991 and 2000, ten patients (6%) underwent repair through midline sternotomy, increasing to 41 patients (36%) between 2001 and 2010. Overall early mortality was 1% and late mortality was 3%. There was a statistically higher re-intervention rate (16%) in the decade 1991-2000, compared to 5% in the period 2001-10 (P = 0.02). In patients with hypoplastic arch, the midline approach has a lower re-intervention rate than thoracotomy (P < 0.001).

CONCLUSIONS

In our institution, there has been a trend in recent years towards increased use of median sternotomy to repair the aortic arch, which has been associated with a reduced rate of re-intervention. The midline sternotomy approach for coarctation with arch hypoplasia significantly reduces the risk of re-coarctation.