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Kumar A, Bhat IH, Kumar B, T Shyam KS. Role of perioperative echocardiography in repair of incomplete shone complex: A case series. Ann Card Anaesth 2020; 22:444-448. [PMID: 31621686 PMCID: PMC6813699 DOI: 10.4103/aca.aca_80_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Multilevel obstruction of left-sided heart structures was originally characterized by Shone et al. The formulation of an appropriate operative strategy remains challenging and needs to be individualized for this complex subset of patients. Intraoperative transesophageal echocardiography (TEE) not only helps in delineating spatial anatomy but also reveals associated anomalies that help in decision-making regarding operative strategies for these patients. Here, we discuss five such cases of Shone's anomaly presenting at varied age group with different associated anomaly in which intraoperative TEE played a pivotal role in the management.
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Affiliation(s)
- Alok Kumar
- Department of Anaesthesia and Critical Care, Army Hospital (Research and Referral), New Delhi, India
| | - Imran Hussain Bhat
- Departments of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhupesh Kumar
- Departments of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K S T Shyam
- Department of Cardiothoracic and Vascular Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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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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Takhar AS, Thaper A, Byrne A, Lobo DN. Laparoscopic Cholecystectomy in a Patient with Myotonic Dystrophy. J R Soc Med 2017; 97:284-5. [PMID: 15173332 PMCID: PMC1079494 DOI: 10.1177/014107680409700609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Arjun S Takhar
- Section of Surgery, Department of Anaesthetics, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH, UK
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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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5
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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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Dave H, Rosser B, Reineke K, Nguyen-Minh S, Knirsch W, Prêtre R. Aortic arch enlargement and coarctation repair through a left thoracotomy: significance of ductal perfusion. Eur J Cardiothorac Surg 2012; 41:906-12. [PMID: 22219416 DOI: 10.1093/ejcts/ezr110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To analyse the technique of neonatal aortic arch enlargement without cardiopulmonary bypass through a left posterior thoracotomy, as an adjunct to extended resection for Coarctation and severe arch hypoplasia. METHODS Ten neonates with coarctation, severe arch hypoplasia and a persistent ductus arteriosus (PDA) were subjected to arch repair through a left posterior thoracotomy. Nine of these patients had associated significant intracardiac anomalies; three of them received pulmonary artery (PA) banding. After exclusion from circulation, the roof of the intervening arch between left carotid and left subclavian was enlarged using a patch. After adequate reperfusion, a classic resection and extended end-to-end anastomosis was performed. Median age and weight were 5.5 (1-10) days and 3.3 (2.2-4.1) kg respectively. The median preoperative arch diameter was 1.07 (0.75-1.32) mm/kg body weight. RESULTS All patients could be successfully operated with this approach. The non-ischaemic and ischaemic aortic clamp times were 40 (15-68) and 23 (18-32) min, respectively. The median postoperative arch diameter achieved was 1.43 (1.06-1.46) mm/kg body weight. None of the patients had significant gradient early postoperatively. Two patients with recurrent stenosis were successfully treated with balloon dilatation (1) or surgery with cardiopulmonary bypass (CPB) (1). One patient has a corrected gradient of 16 mmHg in the proximal arch which is being observed. The remaining patients are free from stenosis at a median follow-up of 30.1 (13.2-57.8) months. CONCLUSIONS Use of PDA for lower body perfusion allows complex reconstruction of the arch without incurring lower body ischaemia. The extended resection could then be performed without excessive stretch. This modification saves these patients from undergoing a complex arch reconstruction with CPB in the early neonatal period.
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Affiliation(s)
- Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital Zurich, Zurich, Switzerland.
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7
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Cho SH, Cho YH, Jun TG, Yang JH, Park PW, Huh J, Kang IS, Lee HJ. Outcome of Single-Stage Repair of Coarctation with Ventricular Septal Defect. J Card Surg 2011; 26:420-4. [DOI: 10.1111/j.1540-8191.2011.01255.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Walters HL, Ionan CE, Thomas RL, Delius RE. Single-stage versus 2-stage repair of coarctation of the aorta with ventricular septal defect. J Thorac Cardiovasc Surg 2008; 135:754-61. [PMID: 18374752 DOI: 10.1016/j.jtcvs.2007.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2007] [Accepted: 12/18/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The results of single-stage and 2-stage repair of coarctation of the aorta with ventricular septal defect have improved, but the optimal treatment strategy remains controversial. This study compares our results with these 2 approaches. METHODS We performed a retrospective analysis of 46 patients, 23 with single-stage repair and 23 with 2-stage repair, who underwent completed surgical treatment of coarctation of the aorta with a ventricular septal defect at the Children's Hospital of Michigan between March 1994 and June 2006. RESULTS The average number of operations in the single-stage group was 1.5 +/- 0.6, and in the 2-stage group it was 2.2 +/- 0.4 (P < or = .0001). Postoperative complications were similar, except for the number of planned reoperations to perform delayed sternal closure in the single-stage operation (n = 7) compared with the 2-stage operation (n = 1, P = .023). The patient age in the single-stage group at the time of discharge (completed repair time) was a median of 39.0 days (range, 19-250 days) compared with a median of 113.0 days (range, 26-1614 days) in the 2-stage group after stage 2 (P < or = .0001). Freedom from cardiac reintervention was 89.8% in the single-stage group versus 84.9% in the 2-stage group (P = .33). The hospital mortality was 4.4% (1 patient) in each group. The actuarial survival rate was 95.7% in the single-stage group versus 90.6% in the 2-stage group (P = .38). CONCLUSIONS The advantages of single-stage over 2-stage repair of a ventricular septal defect with coarctation of the aorta include an earlier age at completion of repair, fewer operations, and fewer incisions. Postoperative complications and hospital mortality are similar. The one disadvantage of a single-stage repair was the increased need for delayed sternal closure compared with the 2-stage approach.
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Affiliation(s)
- Henry L Walters
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit, Mich 48201, USA.
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Walters HL, Ionan CE, Thomas RL, Delius RE. Technique of single-stage repair of coarctation of the aorta with ventricular septal defect. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2008:22-30. [PMID: 18396221 DOI: 10.1053/j.pcsu.2007.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The results of single-stage and two-stage repair of coarctation of the aorta (CoA) with ventricular septal defect (VSD) have improved, but the optimal treatment strategy remains controversial. This article emphasizes the technical details for performing the single-stage repair of CoA with VSD and compares the results of this technique with the two-stage approach. A retrospective analysis of 46 patients who underwent completed surgical repair of CoA with VSD at Children's Hospital of Michigan, either using the single-stage (N=23) or the two-stage (N=23) techniques, was performed. The postoperative complications, hospital mortality, freedom from cardiac re-interventions, and actuarial survival were the same in both groups. The advantages of single-stage over two-stage repair include an earlier age at completion of repair, fewer operations, and fewer incisions. The one disadvantage of a single-stage repair was the increased need for delayed sternal closure compared with the two-stage approach, but this disadvantage has been neutralized in the recent era.
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Affiliation(s)
- Henry L Walters
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, MI 48201, USA.
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10
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Kanter KR. Management of infants with coarctation and ventricular septal defect. Semin Thorac Cardiovasc Surg 2008; 19:264-8. [PMID: 17983955 DOI: 10.1053/j.semtcvs.2007.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2007] [Indexed: 11/11/2022]
Abstract
The management of patients with aortic coarctation and ventricular septal defect (VSD) remains controversial. A 2-stage repair uses staged coarctation repair +/- pulmonary artery banding followed by VSD closure with 2 separate operations. This has the advantage of a straightforward coarctation repair (except in the case of proximal arch hypoplasia) and a simpler VSD closure at a later date. A subset of patients will have spontaneous VSD closure that obviates the need for subsequent operation. Disadvantages include a period of palliation between operations and the complications of a pulmonary band. A single-stage approach involves simultaneous coarctation repair and VSD closure on cardiopulmonary bypass with circulatory arrest or regional perfusion during coarctation repair. This has the advantages of complete repair in infancy without palliation and the ability to deal with proximal arch hypoplasia. Disadvantages include a technically more challenging operation and the need for circulatory arrest or regional cerebral perfusion. Some series have suggested a higher risk for recoarctation. An alternative method involves coarctation repair without cardiopulmonary bypass through a thoracotomy followed by VSD closure during the same operation (1 stage, 2 incisions). This affords excellent clinical results with complete repair in infancy. One can avoid prolonged periods of aortic cross clamping, cardiopulmonary bypass, and circulatory arrest/regional perfusion. Compared with the other strategies, there are decreased total intensive care unit and hospital stays.
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Affiliation(s)
- Kirk R Kanter
- Division of Cardio-Thoracic Surgery, Department of Surgery, Emory University School of Medicine, and Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia 30322, USA.
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Alsoufi B, Cai S, Coles JG, Williams WG, Van Arsdell GS, Caldarone CA. Outcomes of Different Surgical Strategies in the Treatment of Neonates with Aortic Coarctation and Associated Ventricular Septal Defects. Ann Thorac Surg 2007; 84:1331-6; discussion 1336-7. [PMID: 17888993 DOI: 10.1016/j.athoracsur.2007.05.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2007] [Revised: 04/29/2007] [Accepted: 05/01/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND We reviewed surgical results after treatment of aortic coarctation (CoA) associated with ventricular septal defect (VSD) in neonates. We examined morbidity associated with the two different therapeutic strategies of combined repair versus initial coarctation repair alone and attempted to identify preoperative predictors to guide optimal surgical management. METHODS Between 1990 and 2006, 141 neonates with CoA and VSDs underwent operation using two management strategies. In group A (n = 89), initial simple CoA repair was done through posterolateral thoracotomy, plus concomitant pulmonary artery banding (n = 54), followed by VSD closure. In group B (n = 52), both defects were repaired simultaneously through a sternotomy. RESULTS Overall 10-year survival was 90.8%, with no difference between groups. The 5-year freedom from arch reoperation was 93.5%, with no difference between groups. The 10-year freedom from reoperation for subaortic obstruction was 95% for group A and 75% for group B (p = 0.016). In group A, 41 patients required secondary VSD closure at a median interval of 48 days after CoA repair. Freedom from reoperation at 1 month and 5 years was 78.5% and 45.8% in group A versus 97.8% for both in group B. Preoperative predictors for requirement for later VSD closure in group A were VSD type other than muscular (p = 0.0009) and larger VSD identified by higher VSD diameter/aortic valve annulus ratio (p < 0.0001). CONCLUSIONS Results of both treatment strategies are good. Neonates with larger VSDs, especially outlet, malalignment, and perimembranous types, are likely to require VSD closure. Although midline sternotomy and combined treatment strategy may be necessary in neonates with proximal arch hypoplasia, initial coarctation repair alone is valid option at the possible expense of additional operation.
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Affiliation(s)
- Bahaaldin Alsoufi
- The Cardiac Centre, Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada.
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12
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Kanter KR, Mahle WT, Kogon BE, Kirshbom PM. What is the Optimal Management of Infants With Coarctation and Ventricular Septal Defect? Ann Thorac Surg 2007; 84:612-8; discussion 618. [PMID: 17643644 DOI: 10.1016/j.athoracsur.2007.03.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Revised: 03/06/2007] [Accepted: 03/07/2007] [Indexed: 11/27/2022]
Abstract
BACKGROUND The management of patients with aortic coarctation and ventricular septal defect (VSD) remains controversial. We reviewed our experience with coarctation and VSD from 2002 to 2006. METHODS Three approaches were used to manage 36 consecutive infants with coarctation and VSD. Group I had staged coarctation repair with or without pulmonary artery banding, followed by VSD closure with two separate operations (two-stage, n = 11); Group II had coarctation repair and VSD closure on cardiopulmonary bypass (CPB) with circulatory arrest or regional perfusion during coarctation repair (one-stage, one-incision, n = 10); Group III had coarctation repair without CPB through a thoracotomy, followed by VSD closure during the same operation (one-stage, two-incisions, n = 15). RESULTS No patients died. One recoarctation occurred in group II. Group II had significantly longer times for CPB (135.6 +/- 31.8 versus 94.3 +/- 29.8 minutes for group I; 67.6 +/- 16.7 minutes for group III; p < 0.001) and combined regional perfusion/circulatory arrest (30.0 +/- 17.0 versus 5.3 +/- 11.9 minutes for group I, 1.1 +/- 4.4 minutes for group III, p < 0.0001). Group III compared with group II had significantly shorter lengths of stay in the intensive care unit (119.5 +/- 64.8 versus 220.8 +/- 198.8 hours, p = 0.04) and hospital (8.4 +/- 3.8 versus 24.4 +/- 24.4 days, p = 0.01). Combining values for the two hospitalizations in the group I infants, lengths of stay in the intensive care unit (178.8 +/- 70.8 hours) and hospital (20.5 +/- 11.6 days) were intermediate between groups II and III. CONCLUSIONS Primary repair of infants with coarctation and VSD using a one-stage approach through separate incisions affords excellent clinical results. One can avoid prolonged aortic cross-clamping, CPB, and circulatory arrest/regional perfusion. Compared with the group undergoing combined coarctation and VSD repair simultaneously by sternotomy, total lengths of stay in the intensive care unit and hospital were significantly decreased.
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Affiliation(s)
- Kirk R Kanter
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA.
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13
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Lai YQ, Zhou QW, Wei H, Zhang C, Zhang ZG. Intrapulmonary channel for one-stage correction of aortic arch obstruction. Asian Cardiovasc Thorac Ann 2006; 14:402-6. [PMID: 17005888 DOI: 10.1177/021849230601400511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are several methods of surgical repair of aortic coarctation or interruption; the optimal technique is still controversial. The purpose of this study was to assess a new surgical method: intrapulmonary channel for one-stage repair of aortic coarctation or interruption associated with intracardiac anomalies. Between 1993 and 1995, 4 patients with aortic coarctation or interruption and intracardiac anomalies received one-stage surgical correction. Their ages ranged from 5 to 26 years (mean, 16 years). The aortic arch lesions were preductal coarctation in 2, and type B interruption in 2. Coexisting anomalies consisted of patent ductus arteriosus in 4, ventricular septal defect in 3, and aortopulmonary window in 1. An intrapulmonary channel was constructed in all patients, and co-existing anomalies were corrected simultaneously. There was no hospital death or late mortality. A cerebral complication occurred in one patient because of air embolism. Mean follow-up was 9.5 years (range, 8.5-11.5 years). There was no evidence of recoarctation or late aneurysm formation. For selected patients with aortic coarctation or interruption and intracardiac anomalies, an intrapulmonary channel might be an option for one-stage correction.
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Affiliation(s)
- Yong-Qiang Lai
- Division of Cardiac Surgery, Beijing Anzhen Hospital, Capital University of Medical Sciences, 36 Wuluju, Chaoyang District, Beijing 100 029, China.
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14
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Kaltman JR, Jarvik GP, Bernbaum J, Wernovsky G, Gerdes M, Zackai E, Clancy RR, Nicolson SC, Spray TL, Gaynor JW. Neurodevelopmental outcome after early repair of a ventricular septal defect with or without aortic arch obstruction. J Thorac Cardiovasc Surg 2006; 131:792-8. [PMID: 16580436 DOI: 10.1016/j.jtcvs.2005.12.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2005] [Revised: 12/06/2005] [Accepted: 12/12/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Cross-sectional studies of intermediate-term survivors of infant cardiac surgery have revealed a high frequency of neurodevelopmental disabilities. Few data exist regarding neurodevelopmental outcome of infants undergoing surgical intervention for a ventricular septal defect. The purpose of this study was to evaluate the neurodevelopmental outcome at 1 year of age of children who had surgical repair in infancy of a ventricular septal defect or a ventricular septal defect with aortic arch obstruction. METHODS Children who underwent repair of a ventricular septal defect or single-stage repair of a ventricular septal defect with aortic arch obstruction at less than 6 months of age were assessed at 1 year of age by using the Bayley Scales of Infant Development II, which yields the Mental Development Index and the Psychomotor Development Index, both with an expected mean of 100 +/- 15. RESULTS At 1 year, 55 patients (ventricular septal defect alone = 36; ventricular septal defect with aortic arch obstruction = 19) returned for evaluation. The mean Mental Development Index was 92.6 +/- 11.7, with 3 (5%) patients scoring 70 or less. The mean Psychomotor Development Index was 86.1 +/- 16.4, with 10 (18%) patients scoring 70 or less. Patients with a suspected or confirmed genetic syndrome had both a lower Mental Development Index score (P = .011) and a lower Psychomotor Development Index score (P = .001). Mental Development Index and Psychomotor Development Index were independent of anatomic (specifically aortic arch obstruction) and intraoperative factors (specifically deep hypothermic circulatory arrest). CONCLUSIONS Neurodevelopmental outcome at 1 year of age was within the normal limits for most patients who underwent repair of a ventricular septal defect or a ventricular septal defect with aortic arch obstruction during infancy.
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Affiliation(s)
- Jonathan R Kaltman
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa 19104, USA.
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Fesseha AK, Eidem BW, Dibardino DJ, Cron SG, McKenzie ED, Fraser CD, Price JF, Chang AC, Mott AR. Neonates With Aortic Coarctation and Cardiogenic Shock: Presentation and Outcomes. Ann Thorac Surg 2005; 79:1650-5. [PMID: 15854946 DOI: 10.1016/j.athoracsur.2004.11.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2004] [Indexed: 12/01/2022]
Abstract
BACKGROUND Some neonates with coarctation of the aorta (COA) present with cardiogenic shock and secondary end-organ injury. The management of this subgroup imposes unique challenges. We review our perioperative strategy and outcomes for neonates with COA who presented with cardiogenic shock. METHODS Neonates (younger than 30 days) with isolated COA or COA with aortic arch hypoplasia were identified. Retrospective review was performed to identify and characterize patients who presented with cardiogenic shock, defined as impaired left ventricular (LV) or right ventricular (RV) systolic function, or both, respiratory failure requiring tracheal intubation, and metabolic acidosis. RESULTS Thirteen neonates presented in cardiogenic shock and underwent surgical repair. No patients required catheter or surgical reintervention for recoarctation. There were no deaths at a mean follow-up of 54 months. Group I neonates (isolated COA, n = 7) underwent end-to-end anastomosis through left thoracotomy. The mean age and pH at presentation were 9 (+/-1.1) days and 7.07 (+/-0.21), respectively. The mean preoperative and postoperative LV myocardial performance indices (MPI) were 0.81 (+/-0.22) and 0.37 (+/-0.16), respectively (p = 0.002). Group II neonates (COA with arch hypoplasia +/- ventricular septal defect, n = 6) underwent aortic arch advancement and ventricular septal defect closure through median sternotomy. The mean time from diagnosis to surgery in group II was 5.5 (+/-1.9) days versus 2.4 (+/-1.5) days in group 1 (p = 0.01). The mean age and pH at presentation were 11.8 (+/-9.3) days and 7.02 (+/-0.21), respectively. The mean preoperative and postoperative LV MPI were 0.46 (+/-0.13) and 0.35 (+/-0.11), respectively (p = 0.02). The total hospital length of stay in group II patients was 18 (+/-6.23) days versus 11.3 (+/-5. 7) days in group I (p = 0.04). CONCLUSIONS Timely intervention with a strategy individualized to the patient anatomy can be performed with excellent outcomes in neonates with COA and cardiogenic shock. Neonates with isolated COA had worse preoperative LV MPI, which reflects more significant global left ventricular systolic dysfunction in this subgroup. The elapsed time from diagnosis to surgery was decreased in neonates with isolated COA.
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Affiliation(s)
- Assaf K Fesseha
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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Bhutta A, Nasim A. Left arm pain 22 years after repair of aortic coarctation. J R Soc Med 2004. [PMID: 15173331 DOI: 10.1258/jrsm.97.6.283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Aqeel Bhutta
- Department of Vascular Surgery, South Manchester University Hospitals Trust, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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Pearl JM, Manning PB, Franklin C, Beekman R, Cripe L. Risk of recoarctation should not be a deciding factor in the timing of coarctation repair. Am J Cardiol 2004; 93:803-5. [PMID: 15019901 DOI: 10.1016/j.amjcard.2003.11.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2003] [Revised: 11/26/2003] [Accepted: 11/26/2003] [Indexed: 10/26/2022]
Abstract
To determine whether early coarctation repair is a significant risk for recoarctation in the modern era, 120 patients, including 87 infants, who underwent isolated coarctation repair at a single institution, were reviewed. At a mean follow-up of 44.4 months, there have were no late reoperations, and 2 patients required balloon aortoplasty. The overall incidence of late reintervention was 1.7%, with only 2.4% (2 of 83) in those <1 year old.
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Affiliation(s)
- Jeffrey M Pearl
- Division of Pediatric Cardiothoracic Surgery, Children's Hospital Medical Center, and the Department of Surgery, University of Cincinnati, Cincinnati, Ohio 45229, USA.
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Tomita H, Yazaki S, Kimura K, Hayashi G, Fujita H, Okada Y, Watanabe K, Kurosaki KI, Ono Y, Yagihara T, Echigo S. Balloon angioplasty of postoperative coarctation in the transverse arch in infants: protecting the common carotid artery. Catheter Cardiovasc Interv 2003; 60:529-33. [PMID: 14624435 DOI: 10.1002/ccd.10667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We performed balloon angioplasty in three patients with postoperative coarctation in the transverse arch adjacent to the left common carotid artery. The age at arch reconstruction was 5, 6, and 2 days, while the interval between operation and balloon dilatation was 59 days, 87 days, and 12 months, respectively. Two balloons, one in the stenosis and the other in the left common carotid artery, were introduced over a wire sequentially and inflated simultaneously until the waist of the balloon in the arch disappeared. After balloon dilatation, a significant reduction in the peak-to-peak pressure gradient and an increase in vessel diameters were observed in all patients. Further growth of the transverse arch was documented at follow-up in two patients. No aneurysm has been detected in any patients. We believe that placing a protective balloon in the neck vessel increases safety during balloon dilatation of coarctation in the transverse arch.
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Affiliation(s)
- Hideshi Tomita
- Department of Pediatrics, National Cardiovascular Center, Osaka, Japan.
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Aeba R, Katogi T, Hashizume K, Iino Y, Koizumi K, Hotoda K, Inoue S, Matayoshi H, Yoshitake A, Yozu R. The limitation of staged repair in the surgical management of congenital complex heart anomalies with aortic arch obstruction. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2003; 51:302-7. [PMID: 12892461 DOI: 10.1007/bf02719382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
OBJECTIVE Severe aortic arch obstruction including an interrupted aortic arch in congenital complex heart anomalies remains a challenge in surgical management. METHODS Treatment and outcomes in 75 consecutive patients who underwent an aortic arch repair as the first step of the staged repair protocol between 1975 and 2000 were reviewed. Their ages at repair ranged from 1 day to 8.5 months. RESULTS Cross-sectional postoperative follow-up data were available in all the patients. The follow-up period ranged from 0 to 27.6 years (mean: 7.3 +/- 7.3 years). There were 20 postoperative hospital deaths (27%) and 7 late deaths. The Kaplan-Meier estimate of survival was 81.3% +/- 4.5% at 1 month, 68.0% +/- 5.4% at 1 year, 65.0% +/- 5.5% at 5 years, 63.1% +/- 5.7% at 10 years, 63.1% +/- 5.7% at 20 years. By Cox regression analysis, body weight of 2.5 kg or less is the only independent determinant of postoperative mortality (p = 0.04, multivariable odds ratio: 2.50, [95% confidence interval: 1.02-6.1]). The aortic arch morphology, the primary cardiac lesion, or date of operation did not reach a statistically significant level to show correlation with mortality. Reintervention to reconstruct the aortic arch was performed at 9 occasions in 8 of the 55 patients who survived the primary operation (14.5%). The Kaplan-Meier estimate of the reintervention-free rate was 91.3% +/- 4.2% at 5 years, 85.5% +/- 5.6% at 10 years, 75.6% +/- 8.2% at 20 years. Using multivariable Cox regression analysis, interrupted aortic arch (versus aortic coarctation) was the only independent predictor of a shorter time to reintervention (p = 0.001, multivariable odds ratio: 16.1, [95% confidence interval: 3.2-80.2]). CONCLUSIONS The staged repair protocol was associated with significant limitations in patient survival and with the development of recurrent aortic arch obstruction. Thus, a primary repair protocol may serve as an alternate approach, especially in patients with low weight or with an interrupted aortic arch.
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Affiliation(s)
- Ryo Aeba
- Division of Cardiovascular Surgery, Keio University, Tokyo, Japan
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Gaynor J. Management strategies for infants with coarctation and an associated ventricular septal defect. J Thorac Cardiovasc Surg 2003. [DOI: 10.1067/mtc.2003.238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Abstract
BACKGROUND In general, neonates with severe left ventricular outflow tract obstruction, aortic valvar stenosis or atresia, and arch hypoplasia with either interruption or coarctation, and a small left ventricle undergo Norwood palliation followed classically by a bidirectional cavopulmonary shunt and eventual modified Fontan. However, a subset of patients, usually neonates with a ventricular septal defect, may have adequate left ventricle and mitral valve sizes making them candidates for future biventricular repair (BVR). In view of the long-term advantage of BVR, the feasibility and outcome of this approach was studied. Additionally, echocardiographic data were reviewed in an attempt to develop objective prognostic criteria for selection of patients suitable for BVR. METHODS During a 4-year period, 8 of 58 infants undergoing Norwood palliation were identified as potential two-ventricle candidates. Their mean age was 6 days. Diagnoses included aortic atresia (n = 1), or aortic valve stenosis and subaortic stenosis (n = 7), with an interrupted aortic arch in 3 and coarctation in 4. All patients had a ventricular septal defect and a left ventricle that was considered to be apex forming. Mean mitral valve size was 11 mm (z-score = -1.7). Mean aortic valve size was 4.1 mm (mean z-score = -8.4). RESULTS All 8 patients survived Norwood palliation. Six subsequently underwent BVR with ventricular septal defect closure and a right ventricle to pulmonary artery conduit at a mean age of 7 months. One patient is awaiting repair, and 1 underwent a cavopulmonary shunt. At the time of BVR, mean mitral valve z-score was essentially unchanged at -1.4 (14 mm). No early deaths or late deaths occurred during a mean follow-up of 32 months. CONCLUSIONS A small subset of patients requiring Norwood palliation as newborns may be candidates for eventual BVR with low risk. In general, patients suitable for BVR have a mitral valve z-score of more than -3 and a normal-sized left ventricle. Recognition of neonatal BVR candidates enables consideration of complete neonatal repair. However, single-stage repair needs to be compared with the excellent results obtainable with the staged approach.
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Affiliation(s)
- Jeffrey M Pearl
- Department of Pediatric Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, OSB-3, Cincinnati, OH 45229, USA.
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