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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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Kulyabin YY, Voitov AV, Nichay NR, Soynov IA, Zubritskiy AV, Bogachev-Prokophiev AV. Single-stage off-pump repair of coarctation of the aorta and ventricular septal defects in children. Interact Cardiovasc Thorac Surg 2022; 35:6618532. [PMID: 35758623 PMCID: PMC9291394 DOI: 10.1093/icvts/ivac186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/26/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The appropriate approach for surgical repair of coarctation of the aorta with a ventricular septal defect (VSD) remains controversial. This study evaluated the outcomes of primary repair of VSDs with periventricular device closure without cardiopulmonary bypass through a left thoracotomy in patients without arch hypoplasia.
METHODS
We selected 21 patients aged <1 year, including 7 neonates, who underwent repair of coarctation of the aorta with periventricular device closure of a VSD.
RESULTS
The median occluder size was 6 (range, 5–8) mm. The median mechanical ventilation time was 14 (range, 2–68) h, and the median duration of hospital stay was 11 (range, 7–16) days. No reoperations were required to correct VSD shunting, and the median residual shunt size was 1 (range, 1–2) mm. The median follow-up period was 13 (range, 4–31) months. No late deaths were reported, and no haemodynamically significant pressure gradient at the anastomotic site was observed. The median distal aortic arch z-score was 0.39 (range, −0.1–to 0.9). Only 1 patient had a permanent pacemaker implanted towards the end of the follow-up period.
CONCLUSIONS
Periventricular device closure can be used safely for closure of VSD in children with coarctation of the aorta without a hypoplastic aortic arch, even in neonates, to reduce the risk of prolonged cardiopulmonary bypass. This hybrid approach can be performed with a low incidence of rhythm disturbances and residual shunting. However, a meticulous assessment of the VSD anatomy is essential to avoid any unfavourable events.
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Affiliation(s)
- Yuriy Y Kulyabin
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center , Novosibirsk, Russian Federation
| | - Alexey V Voitov
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center , Novosibirsk, Russian Federation
| | - Nataliya R Nichay
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center , Novosibirsk, Russian Federation
| | - Ilya A Soynov
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center , Novosibirsk, Russian Federation
| | - Alexey V Zubritskiy
- Department of Pediatric Cardiac Surgery, E. Meshalkin National Medical Research Center , Novosibirsk, Russian Federation
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Lee SO, Shin HJ, Jun TG, Kang IS, Huh J, Song J, Yang JH. Midterm results of arch augmentation with autologous vascular patch in interrupted aortic arch. Eur J Cardiothorac Surg 2022; 62:6506203. [PMID: 35024803 DOI: 10.1093/ejcts/ezab558] [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: 06/21/2021] [Revised: 09/17/2021] [Accepted: 10/17/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Aortic arch reconstruction of interrupted aortic arch remains challenging, and subsequent problems, including arch and airway stenosis, may occur. Thus, we investigated midterm results of an augmentation technique using autologous vascular patch. METHODS This retrospective study included 24 patients who underwent arch reconstruction with an autologous vascular patch for interrupted aortic arch with biventricular physiology from 2006 to 2018. The median age and body weight at operation were 10 days (range 4-77 days) and 3 kg (range 2.5-5.1 kg), respectively. The reconstructed arch was supplemented in the lesser curvature with an autologous vascular patch that was harvested from main pulmonary artery (n = 19), left subclavian artery (n = 3) or aberrant right subclavian artery (n = 1). One patient used patches from both the main pulmonary and left subclavian artery. RESULTS There was 1 early death due to right heart failure. All survivors were discharged 15 days (range 9-58 days) after surgery without residual arch stenosis. Late death occurred in 1 patient with Cri-du-chat syndrome and airway stenosis. Two reoperations and 1 intervention for arch stenosis were performed. The 1-, 5- and 10-year survival was 92%. Freedom from reoperation or intervention for arch stenosis was 86% 1, 5 and 10 years after surgery. No occurrence of arch aneurysm formation, left main bronchial stenosis and significant hypertension was found during a median follow-up period of 5.5 years (range 0.3-13.3 years). CONCLUSIONS Augmenting the lesser curvature with an autologous vascular patch during arch reconstruction resulted in reasonable midterm outcomes.
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Affiliation(s)
- Sang On Lee
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Ju Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Tae-Gook Jun
- 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
| | - Ji-Hyuk Yang
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Kasdi R, Bounader K, Lemdani M. Neonatal management of aortic coarctation with ventricular septal defect: a systematic review and meta-analysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:478-488. [PMID: 32352247 DOI: 10.23736/s0021-9509.20.11075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Neonatal management of aortic coarctation with ventricular septal defect is still under debate between the one-stage full repair by sternotomy versus the staged repair of the coarctation first by thoracotomy (with or without banding the pulmonary artery) followed later by subsequent closure of the ventricular septal defect. EVIDENCE ACQUISITION The aim of this review was to synthesize the evidence in literature since 1980 for the neonatal population. A meta-analysis compared mortality between the two strategies. EVIDENCE SYNTHESIS The analysis did not find a superiority of a strategy over the other regardless of the surgical era studied. Recoarctation rates of both strategies are presented and a management algorithm is suggested. CONCLUSIONS Instead of comparing between the two strategies, a case-adapted management considering the anatomy of the ventricular septal defect and of the aortic arch is discussed to address this association of lesions though presenting with a wide range of settings.
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Affiliation(s)
- Reda Kasdi
- Department of Cardiac Surgery, Rennes University Hospital, Rennes, France - .,Department of Biomathematics, Faculty of Pharmacy and Biology, University of Lille, Lille, France -
| | - Karl Bounader
- Department of Cardiac Surgery, Rennes University Hospital, Rennes, France
| | - Mohamed Lemdani
- Department of Biomathematics, Faculty of Pharmacy and Biology, University of Lille, Lille, France
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Lewis MJ, Johansson Ramgren J, Hallbergson A, Liuba P, Sjöberg G, Malm T. Long-term results of aortic arch reconstruction with branch pulmonary artery homograft patches. J Card Surg 2020; 35:868-874. [PMID: 32160354 DOI: 10.1111/jocs.14494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Homograft tissue is an important reconstructive material used in the surgical correction of a variety of congenital heart defects. The aim of this study is to evaluate the long-term outcome of pulmonary artery (PA) branch patches used in the reconstruction of the thoracic aorta in children. METHODS Retrospective review of 124 consecutive pediatric patients undergoing corrective surgery for their congenital heart defects between 2001 and 2016. Survival, reoperation, and reintervention data were collected, as well as imaging data to assess for presence of recoarctation, dilation, or aneurysm formation in the area of patch reconstruction. RESULTS Overall 15-year survival was 83.9% and 15-year freedom from reintervention in the area of patch reconstruction was 89.2%. Rates of mortality (0%), cardiac transplantation (0%), and reoperation (0.8%) attributable to the area of patch reconstruction were low. The frequency of catheter-based intervention in the area of patch reconstruction was 9.7%; such interventions were successful in all but one patient, who ultimately underwent successful surgical aortoplasty. CONCLUSIONS Homograft patches harvested from PA branches are an effective reconstructive material used for reconstruction of the aorta in small children. Long-term results show no risk of aneurysm formation and low rates of stenosis formation.
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Affiliation(s)
- Michael J Lewis
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University Hospital, Lund, Sweden
| | - Jens Johansson Ramgren
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University Hospital, Lund, Sweden
| | - Anna Hallbergson
- Division of Cardiology, Pediatric Heart Center, University Hospital, Lund, Sweden
| | - Petru Liuba
- Division of Cardiology, Pediatric Heart Center, University Hospital, Lund, Sweden
| | - Gunnar Sjöberg
- Division of Cardiology, Pediatric Heart Center Stockholm/Uppsala, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Malm
- Division of Pediatric Cardiac Surgery, Pediatric Heart Center, University Hospital, Lund, Sweden.,Division of Tissue Bank, University Hospital, Lund, Sweden
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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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7
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Seo DM, Park J, Goo HW, Kim YH, Ko JK, Jhang WK. Surgical modification for preventing a gothic arch after aortic arch repair without the use of foreign material. Interact Cardiovasc Thorac Surg 2015; 20:504-9. [PMID: 25583648 DOI: 10.1093/icvts/ivu442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Systemic hypertension is the main late complication after arch reconstruction in patients with arch obstruction. Gothic arch geometry is suspected to be one of its possible causes. Accordingly, we evaluated here if a modified arch repair technique using an autologous pulmonary patch is effective in preventing gothic arch development. METHODS Fifty infants who underwent arch repair with either a modified (n = 17) or conventional (n = 33) technique between January 2006 and August 2012 by a single surgeon were retrospectively reviewed. Arch geometry was compared using three categories (gothic, crenel or roman), classified by the height/width (H/W) ratio and the arch angle measured in computed tomography. RESULTS No gothic arch geometry was observed in the modified group, whereas it was observed in 9 cases in the conventional group (P = 0.005). Moreover, reintervention for arch restenosis was performed only in the conventional group (n = 4; P = 0.29). No associated complications were observed, although the selective cerebral perfusion time was longer in the modified group than in the conventional group (28.5 ± 6.2 vs 17.1 ± 9.9 min; P < 0.001). Otherwise, there were no significant differences in clinical variables between the groups. The mean follow-up duration was 55.3 ± 26.7 months. Significant systemic hypertension was not observed in our study cohort. CONCLUSIONS Our modified technique was proven to be not only highly effective in preventing gothic arch geometry, but also as equally safe in terms of early clinical outcomes as conventional arch reconstruction techniques.
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Affiliation(s)
- Dong-Man Seo
- Department of Cardiothoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jiyoung Park
- Department of Cardiothoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Woo Goo
- Department of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Young Hwue Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan, College of Medicine, Seoul, Korea
| | - Jae-Kon Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan, College of Medicine, Seoul, Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan, College of Medicine, Seoul, Korea
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Plunkett MD, Harvey BA, Kochilas LK, Menk JS, St Louis JD. Management of an associated ventricular septal defect at the time of coarctation repair. Ann Thorac Surg 2014; 98:1412-8. [PMID: 25149056 DOI: 10.1016/j.athoracsur.2014.05.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 05/20/2014] [Accepted: 05/27/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of a ventricular septal defect (VSD) at time of coarctation of the aorta (CoA) repair remains controversial, with recent studies advocating concomitant repair of both defects. We evaluated the surgical management and mortality for patients undergoing CoA repair associated with a VSD. METHODS We retrospectively reviewed data submitted to the Pediatric Cardiac Care Consortium of patients undergoing repair of CoA from 1982 to 2007. The cohort was divided into three groups: CoA repair plus VSD closure (group 1); CoA repair plus pulmonary artery band (group 2); and CoA repair without repair of VSD (group 3). Variables reviewed included era, age, and weight at repair, and in-hospital mortality. RESULTS There were 7,860 patients who underwent repair of CoA, of whom 2,022 had an associated VSD (25.7%). Mortality after CoA repair with and without an associated diagnosis of VSD was 8.3% versus 2.1% (p < 0.001). Mean age at repair for group 1 (n = 286) and group 2 (n = 472) was 87.4 days and 21.6 days, respectively (p = 0.004), and median weight was 3.31 kg and 3.30 kg, respectively (p = 0.130). Discharge mortality for group 1 and group 2 was similar, at 8.7% and 9.1%, respectively (p = 0.852). Patients with CoA/VSD who had neither VSD closure nor pulmonary artery banding (group 3) had a hospital mortality of 7.9%. CONCLUSIONS The association of CoA and VSD is common. A strategy of concomitant VSD closure at CoA repair does not result in worse discharge mortality when compared with pulmonary banding with anticipated staged repair of the VSD. These outcomes support continued evaluation of a one-stage approach.
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Affiliation(s)
- Mark D Plunkett
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Brian A Harvey
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Lazaros K Kochilas
- Division of Pediatric Cardiology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Jeremiah S Menk
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - James D St Louis
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota.
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Centella Hernández T, Stanescu D, Stanescu S. Coartación aórtica. Interrupción del arco aórtico. CIRUGIA CARDIOVASCULAR 2014. [DOI: 10.1016/j.circv.2014.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Whiteside W, Hirsch-Romano J, Yu S, Pasquali SK, Armstrong A. Outcomes associated with balloon angioplasty for recurrent coarctation in neonatal univentricular and biventricular norwood-type aortic arch reconstructions. Catheter Cardiovasc Interv 2014; 83:1124-30. [DOI: 10.1002/ccd.25318] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/15/2013] [Accepted: 11/28/2013] [Indexed: 11/10/2022]
Affiliation(s)
- Wendy Whiteside
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
| | - Jennifer Hirsch-Romano
- Section of Pediatric Cardiac Surgery Department of Cardiac Surgery; University of Michigan; Ann Arbor Michigan
| | - Sunkyung Yu
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
| | - Sara K. Pasquali
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
| | - Aimee Armstrong
- Division of Pediatric Cardiology Department of Pediatrics; University of Michigan C.S. Mott Children's Hospital; Ann Arbor Michigan
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Hraška V, Walters HL. Management of Complete Atrioventricular Canal Defect With Aortic Arch Obstruction. World J Pediatr Congenit Heart Surg 2010; 1:199-205. [DOI: 10.1177/2150135110371136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with complete atrioventricular canal defect and aortic arch obstruction represent a particular challenge for management. The incidence is rare, so surgical experience is limited. A reasonable treatment option for newborns and young infants with competent atrioventricular valves is the staged approach, with the arch obstruction repaired first, followed at an appropriate interval by repair of the complete atrioventricular canal defect. If there is a significant degree of atrioventricular valve regurgitation, the primary single-stage correction of both aortic arch obstruction and the intracardiac malformation should be undertaken, irrespective of age. It remains to be seen whether this surgical strategy can be adopted for the entire spectrum of atrioventricular canal defect associated with arch obstruction.
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Affiliation(s)
- Viktor Hraška
- German Pediatric Heart Centre, Asklepios Clinic Sankt Augustin, Germany
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12
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Twenty-three years of single-stage end-to-side anastomosis repair of interrupted aortic arches. J Thorac Cardiovasc Surg 2010; 139:942-7, 949; discussion 948. [PMID: 20304139 DOI: 10.1016/j.jtcvs.2009.09.069] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 08/16/2009] [Accepted: 09/06/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study defined long-term results of a policy of single-stage repair of interrupted aortic arch with end-to-side anastomosis. METHODS Records of 112 consecutive patients undergoing interrupted aortic arch repair between 1985 and 2007 were reviewed. Single-stage repair was performed in 95 patients, with 90 having end-to-side repair. RESULTS There were 11 in-hospital deaths (10%). Twelve patients needed arch reintervention during the same hospital stay: 7 for residual arch obstruction and 5 for left main bronchus obstruction. Nine patients were unavailable for follow-up. After a mean of 10 +/- 7 years, 6 late deaths occurred, for 18-year survival of 92% (95% confidence interval [CI], 84%-97%). Patients with end-to-side anastomoses had better 18-year survival (97%, 95% CI, 87%-99%, vs 74%, 95% CI, 44%-89%, P < .01). After discharge, 19 patients underwent further aortic arch intervention. The only factors predictive of late arch reintervention were technique other than end-to-side (P < .001) and reoperation for left outflow tract obstruction. Freedom from arch reintervention after end-to-side repair was 78% at 18 years (95% CI, 59%-89%). Another 16 patients had significant residual obstruction. The 18-year freedom from hypertension was 88% (95% CI, 72%-95%). CONCLUSIONS Single-stage repair with end-to-side anastomosis seems the best approach for most neonates with interrupted aortic arch, because it provides relief of the arch obstruction with low early mortality. After 2 decades of experience with this approach, incidence of late hypertension seems minimal. The need for further arch reintervention warrants close follow-up of these patients.
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Abstract
Disease of the aortic arch is a common component of congenital heart disease requiring surgical treatment in the neonate. While sometimes found in isolation, aortic arch disease must be placed into the larger context of frequently associated pathology. This review describes the anatomic variations of neonatal aortic arch pathology, surgical approaches and techniques, and expected outcomes.
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Affiliation(s)
- Frank A Pigula
- Department of Cardiac Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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14
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Pocar M, Villa E, Degandt A, Mauriat P, Pouard P, Vouhé PR. Long-Term Results After Primary One-Stage Repair of Transposition of the Great Arteries and Aortic Arch Obstruction. J Am Coll Cardiol 2005; 46:1331-8. [PMID: 16198852 DOI: 10.1016/j.jacc.2005.06.063] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2004] [Revised: 06/10/2005] [Accepted: 06/21/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The study was designed to evaluate perioperative and late results after primary, single-stage arterial switch operation (ASO) associated with aortic arch obstruction repair. Outcome of patients with more than five years of follow-up were analyzed. BACKGROUND The treatment of patients with transposition of the great arteries, or other forms of ventriculoarterial discordance suitable for an ASO, with coexisting arch obstruction is a difficult task. Single-stage repair has become the treatment of choice at many institutions, but large series with long-term results are seldom reported. METHODS Between 1990 and 1998, a primary operation including aortic arch repair through a midline sternotomy was performed in 38 patients. The relief of arch obstruction was accomplished during a period of hypothermic circulatory arrest, employing a wide pericardial patch to enlarge the inner curvature of the entire arch in most patients. RESULTS There were nine (24%) hospital deaths. None could be directly related to aortic arch repair, but additional risk factors for an ASO were common (right ventricular hypoplasia, complex coronary anatomy, uncommon relationship between the great vessels or severe pulmonary hypertension). There were no late deaths. Four patients required cardiac reoperation, whereas three underwent successful treatment of recurrent coarctation with balloon angioplasty. CONCLUSIONS Infants with ventriculoarterial discordance and aortic arch obstruction represent a high-risk subgroup of candidates for an ASO. Despite a non-negligible operative mortality, single-stage primary repair represents the treatment of choice, and follow-up of operative survivors is favorable. Pericardial patch enlargement is a reliable technique for arch obstruction repair.
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Affiliation(s)
- Marco Pocar
- Service de Chirurgie Cardiaque, Hôpital Necker-Enfants Malades, Paris, France
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Miyamoto T, Sinzobahamvya N, Kumpikaite D, Asfour B, Photiadis J, Brecher AM, Urban AE. Repair of Truncus Arteriosus and Aortic Arch Interruption: Outcome Analysis. Ann Thorac Surg 2005; 79:2077-82. [PMID: 15919313 DOI: 10.1016/j.athoracsur.2004.11.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2004] [Revised: 11/17/2004] [Accepted: 11/17/2004] [Indexed: 11/24/2022]
Abstract
BACKGROUND The excellent results for repair of truncus arteriosus reported in some centers have not applied to patients with associated interrupted aortic arch. This work aims at understanding the discrepancy of results in our own experience. PATIENTS AND METHODS Ten patients among 83 consecutive children with truncus arteriosus repaired from 1987 to September 2004 who had aortic arch interruption were analyzed, with particular emphasis on clinical presentation and outcome. The comprehensive Aristotle complexity score was calculated for each patient. The Kaplan-Meier method was used to estimate survivals. RESULTS Preoperative mechanical ventilation was necessary in 5 of the 10 patients; 2 of them were moribund. Associated major lesions were as follows: severe (n = 2) and moderate (n = 4) truncal valve regurgitation, coronary artery anomalies (n = 3) and Di-George's syndrome (n = 4). The comprehensive Aristotle score was at least 20 in 6 patients. There were 5 operative deaths (5 of 10); early mortality was 50% (95% confidence limits: 19% to 81%). These deaths occurred in patients with Aristotle score of 20 or greater (5 of 6 = 83%). All 4 patients who had no moderate or severe truncal valve regurgitation survived the intervention. Survival was a low 37.5% +/- 16.1% from 1 year on compared with a high 95.5% +/- 2.5% for the 73 patients without aortic arch interruption. CONCLUSIONS This study confirms the predictive value of the Aristotle score, hospital mortality being significantly correlated with the highest Aristotle score (p = 0.024). To improve outcome in these high-risk patients, preoperative management should be optimized, repair should not be delayed, and regurgitant truncal valve should be repaired or replaced.
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Affiliation(s)
- Takashi Miyamoto
- Department of Paediatric Cardiothoracic Surgery, German Paediatric Heart Centre, Deutsches Kinderherzzentrum, Sankt Augustin, Germany
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Cetin G, Tireli E, Ozkara A, Koner O, Erdem CC, Söyler I, Gunay I, Onursal E. Aortic Arch Reconstruction with Pulmonary Autograft Patch in Coarctation and Interruption of the Aorta. J Card Surg 2005; 20:167-70. [PMID: 15725143 DOI: 10.1111/j.0886-0440.2005.200363.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The surgical management of the aortic arch pathologies is still subject to discussion. Primary end-to-end anastomosis has some complications such as bronchial compression, tension in the suture lines, and probability of recurrence. On the other hand, patch aortoplasties combined with end-to-end anastomosis carry the risk of aneurysm formation and recurrence. Considering the growth potential, pulmonary autograft patch use in aortic arch reconstructions has recently been introduced into clinical practice. In this study, we present the early findings of combined end-to-end anastomosis and pulmonary autograft patchplasty procedure in six patients. According to our experience the technique applied in this report seems to be more advantageous than other conventional approaches.
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Affiliation(s)
- Gürkan Cetin
- Department of Cardiovascular Surgery, Istanbul University Institute of Cardiology, Istanbul, Turkey.
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Mohammadi S, Serraf A, Belli E, Aupecle B, Capderou A, Lacour-Gayet F, Martinovic I, Piot D, Touchot A, Losay J, Planché C. Left-sided lesions after anatomic repair of transposition of the great arteries, ventricular septal defect, and coarctation: Surgical factors. J Thorac Cardiovasc Surg 2004; 128:44-52. [PMID: 15224020 DOI: 10.1016/j.jtcvs.2004.01.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study was undertaken to identify potential anatomic and surgical factors creating left-sided lesions, namely recoarctation of the aorta and neoaortic regurgitation, after anatomic repair of transposition of the great arteries with ventricular septal defect and aortic coarctation. METHODS From 1983 to September 2002, 109 survivors out of 120 patients were studied. Two-stage repair was performed in 42 patients (group A), and single-stage repair was performed in 67 (groups B and C). Before repair, the diameters of the ascending aorta and main pulmonary artery were measured. In the patients with single-stage repair, coarctation was repaired by extended end-to-end anastomosis in 35 patients (group B) and by pulmonary homograft patch augmentation in 32 patients (group C). The ventricular septal defect was closed through the pulmonary artery in 70 patients and through the right ventricle or atrium in 39 patients. The neoaorto-aortic discrepancy was treated by V-shaped resection of the posterior sinus of Valsalva in 7 cases, pulmonary homograft patch in 32 cases, and anterior splitting of the ascending aorta in all cases. Before discharge from the hospital, neoaortic root and ascending aorta diameters and aortic regurgitation grade were recorded. Neoaortic regurgitation progression and reintervention were the end points of follow-up (97.2 +/- 61.2 months). RESULTS Early and late survivals were significantly better in group C (P <.001). Risk factors for neoaortic regurgitation at discharge by univariate analysis were single-stage repair (P <.05) and ventricular septal defect closure through the pulmonary artery (P =.0076). On multivariate analysis, the latter was the only risk factor for neoaortic regurgitation at discharge and at last follow-up. Multivariate analysis showed that higher neoaortic root/ascending aorta ratio and ventricular septal defect closure through the pulmonary artery were risk factors for neoaortic regurgitation evolution at last follow-up. There were 29 reinterventions, 19 for recoarctation of the aorta and 10 for neoaortic regurgitation with or without aortic root dilatation. Group B (P <.05), high neoaortic root/ascending aorta ratio (P <.01), and progressive neoaortic regurgitation (P <.05) were risk factors for recoarctation of the aorta. Group A was a risk factor for aortic valve replacement at 10 years (P <.05). CONCLUSION Neonatal single-stage repair with pulmonary homograft aortic augmentation remains the optimal approach to transposition of the great arteries with ventricular septal defect and aortic coarctation. It provides better early and late survivals and freedoms from left-sided lesions. Avoidance of late recoarctation of the aorta and progressive neoaortic regurgitation requires meticulous closure of the ventricular septal defect and evenly sized reconstruction of the aorta from root to distal arch.
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Affiliation(s)
- Siamak Mohammadi
- Department of Pediatric Cardiac Surgery, Marie-Lannelongue Hospital, Le Plessis-Robinson, France
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Roussin R, Belli E, Lacour-Gayet F, Godart F, Rey C, Bruniaux J, Planché C, Serraf A. Aortic arch reconstruction with pulmonary autograft patch aortoplasty. J Thorac Cardiovasc Surg 2002; 123:443-8; discussion 449-50. [PMID: 11882814 DOI: 10.1067/mtc.2002.120733] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The optimal technique for aortic arch reconstruction through median sternotomy is still under debate. We have introduced the technique of pulmonary autograft patch aortoplasty as a reliable alternative. METHODS The outcomes of 51 infants who underwent neonatal repair of interrupted aortic arch (n = 28) or coarctation associated with ventricular septal defect (n = 23) since 1992 were analyzed. The patients were reviewed in three groups according to the aortic arch reconstruction technique: group I underwent direct anastomosis (n = 23), group II underwent homograft or pericardial patch aortoplasty (n = 8), and group III underwent pulmonary autograft patch aortoplasty (n = 20). The pulmonary autograft patch consisted in the anterior wall of the main pulmonary artery, between the supracommissural level and the divided ductus arteriosus. The created defect was replaced with fresh autologous pericardium. RESULTS All patients except 1 were discharged without significant residual gradient at the level of the aortic arch. At a median delay of 7 months (range 2-51 months), 11 patients (22%) had recurrence of arch obstruction and underwent balloon angioplasty (n = 8) or surgical correction (n = 3). One patient who had undergone direct anastomosis required reoperation for bronchial compression. At a median follow-up of 29 months, the actuarial freedoms from recurrent arch obstruction were 81% for direct anastomosis, 28% for homograft or pericardial patch aortoplasty, and 100% for pulmonary autograft aortoplasty (P =.03 for group III vs group I and P <.0001 for group III vs group II). CONCLUSIONS The aortic arch repair associated with pulmonary autograft patch augmentation resulted in superior midterm outcomes and therefore constitutes a reliable alternative to the direct anastomosis technique. It allowed complete relief of anatomic afterload and diminished the anastomotic tension, thus reducing the risk of restenosis and tracheobronchial compression. We observed a significantly higher rate of recurrence after patch aortoplasty with other materials.
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Affiliation(s)
- Régine Roussin
- Department of Pediatric Cardiac Surgery, Marie Lannelongue Hospital, 133 Avenue de la Résistance, 92300 Le Plessis-Robinson, France
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Backer CL, Mavroudis C. Congenital Heart Surgery Nomenclature and Database Project: patent ductus arteriosus, coarctation of the aorta, interrupted aortic arch. Ann Thorac Surg 2000; 69:S298-307. [PMID: 10798436 DOI: 10.1016/s0003-4975(99)01280-1] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The extant nomenclature for patent ductus arteriosus (PDA), coarctation of the aorta (CoAo), and interrupted aortic arch (IAA) is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. PDA is subclassified by origin, insertion, and patient weight. CoAo is subclassified into isolated CoAo, CoAo with ventricular septal defect, and CoAo with complex intracardiac anomalies. IAA is subclassified into anatomic types A, B, and C based on the location of the interruption. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.
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Affiliation(s)
- C L Backer
- Department of Surgery, Northwestern University Medical School, Children's Memorial Hospital, Chicago, Illinois 60614, USA.
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Abstract
Pulmonary homografts are used more frequently in cardiac surgery. They are used primarily for reconstruction of the right ventricular outflow tract, both in children with complex congenital disease and in adults undergoing the Ross procedure for aortic valve replacement. They have been used for left ventricular outflow tract reconstruction, but they are less,durable in this high-pressure position. They have excellent hemodynamic characteristics, require no anticoagulation, and are free from problems of thromboembolism. However, there is concern that over time pulmonary homografts may develop stenosis secondary to low-grade immune reactions. Even as they become more popular, a shortage of available grafts may limit their use.
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Affiliation(s)
- L J Dacey
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756-0001, USA
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