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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:S0003-4975(24)00337-0. [PMID: 38904587 DOI: 10.1016/j.athoracsur.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Berset SG, Dave H, Balmer C, Nowacka A, Pfister R, Myers PO, Prêtre R. Muscle-sparing aortic coarctation repair. JTCVS Tech 2020; 3:249-256. [PMID: 34317891 PMCID: PMC8302918 DOI: 10.1016/j.xjtc.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 11/10/2022] Open
Abstract
Objective Surgery for aortic coarctation repair provides excellent hemodynamic results but may be complicated by musculoskeletal issues. The purpose of the study was to determine the midterm results of a muscle-sparing surgical approach to aortic coarctation repair, with special emphasis on the repair and on the musculoskeletal changes associated with a posterior thoracotomy. Methods We included all children with aortic coarctation operated on with our minimally invasive approach between June 2002 and October 2004, with a follow-up of ≥4.5 years. Patients were assessed clinically and echocardiographically. The spine, left chest, and shoulder were assessed clinically and radiographically. Results Thirty-one children were included. The age at operation ranged from 1 day to 15 months and weight ranged from 980 g to 10 kg. All patients underwent an extended end-to-end anastomosis coarctation repair through a minimal (n = 19) or total-muscle sparing (n = 12) or extrapleural (n = 18) approach. Five patients had an additional enlargement procedure on the aortic arch. 27 patients had no residual or recurrent gradient. Four patients exhibited restenosis, for which 1 underwent a percutaneous angioplasty and 2 underwent surgical reintervention. All patients were free of hypertension. One patient had borderline values. The musculoskeletal assessment was normal in all but 3 patients. Two patients who underwent other subsequent thoracic surgeries developed thoracogenic scoliosis of moderate severity. A third patient had a left winged scapula. No rib fusion or intercostal space enlargement was found. Conclusions Compared with a conventional approach, our minimally invasive surgical approach led to excellent musculoskeletal outcomes without compromising the hemodynamic results.
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Affiliation(s)
- Stephanie G Berset
- Department of Internal Medicine, Vaud University Hospital, Lausanne, Switzerland
| | - Hitendu Dave
- Department of Cardiology, Zurich University Children's Hospital, Zurich, Switzerland
| | - Christian Balmer
- Department of Cardiology, Zurich University Children's Hospital, Zurich, Switzerland
| | - Anna Nowacka
- Department of Cardiovascular Surgery, Valais Hospital, Sion, Switzerland
| | - Raymond Pfister
- Department of Cardiovascular Surgery, Vaud University Hospital, Lausanne, Switzerland
| | - Patrick O Myers
- Department of Cardiovascular Surgery, Vaud University Hospital, Lausanne, Switzerland
| | - René Prêtre
- Department of Cardiovascular Surgery, Vaud University Hospital, Lausanne, Switzerland
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Murtuza B, Alsoufi B. Current Readings on Surgery for the Neonate With Hypoplastic Aortic Arch. Semin Thorac Cardiovasc Surg 2017; 29:S1043-0679(17)30294-0. [PMID: 29180283 DOI: 10.1053/j.semtcvs.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2017] [Indexed: 11/11/2022]
Abstract
Aortic arch hypoplasia is commonly present in neonates born with ductal-dependent coarctation of the aorta. The ideal surgical repair of neonates with proximal arch hypoplasia continues to be debated. Controversy exists about the fate of the hypoplastic proximal aortic arch following surgical repair and whether that will eventually grow to normal size upon relief of the distal obstruction or will persist as a residual lesion that can affect the long-term outlook of those patients. There is new evidence that residual proximal arch hypoplasia and the shape of the reconstructed arch both have an important impact on vascular remodeling and on the subsequent development of hypertension. Those concerns about late outcomes despite what was originally deemed a successful repair in infancy, coupled with improved cardiopulmonary bypass and cerebral perfusion techniques that allow surgeons to address proximal arch hypoplasia with low morbidity, have rekindled the debate on how to address proximal arch hypoplasia, with the aim to offer a neonatal surgery that would last for a lifetime and provide both optimal early recovery and late freedom from hypertension and related complications.
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Affiliation(s)
- Bari Murtuza
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
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Aguilar Jiménez JM, Garcia Torres E, Arlati F, Vera Puente F, Mendoza Soto A, Granados Ruiz MÁ, Olmedilla Jodar M, Llorente de la Fuente AM, Comas Íllas JV. Manejo del neonato con coartación de aorta e hipoplasia de arco. CIRUGIA CARDIOVASCULAR 2015. [DOI: 10.1016/j.circv.2014.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Mishima A, Nomura N, Ukai T, Asano M. Aortic coarctation repair in neonates with intracardiac defects: the importance of preservation of the lesser curvature of the aortic arch. J Card Surg 2014; 29:692-7. [PMID: 25041795 DOI: 10.1111/jocs.12407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to evaluate the mid-term outcomes of a strategy for repair of coarctation of the aorta (CoA) and hypoplastic aortic arch (HAA) with a modified, extended end-to-end repair that preserves the lesser curvature of the aortic arch in neonates with intracardiac defects. METHODS We studied 21 neonates who underwent CoA repair and remote intracardiac repair (2000-2013). Fifteen patients had HAA, and six patients had no HAA. Follow-up ranged from 0.4 to 12.8 years (median, 7.5 years), and all patients underwent cardiac catheterization and blood pressure measurement in both the arms and legs. RESULTS The overall median age at the time of CoA repair was seven days and the median age at the time of intracardiac defect repair was 18.6 months. There were no hospital deaths and one case had recoarctation (4.8%). The overall mean pressure gradient at the latest follow-up was 3.4 ± 5.7 mmHg. Critical deformation of arch geometry was not found. No patient had hypertension or an abnormal arm-leg gradient. There was no difference in the cardiac catheterization data or blood pressure between patients with and without HAA. CONCLUSIONS A modified, extended end-to-end repair for CoA and HAA resulted in a low rate of recoarctation, no operative mortality, maintenance of a smooth rounded arch, and normal blood pressures in the arms and legs during mid-term follow-up. These results suggest that this technique may be acceptable for repair of CoA and HAA in neonates with intracardiac defects.
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Affiliation(s)
- Akira Mishima
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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Langley SM, Sunstrom RE, Reed RD, Rekito AJ, Gerrah R. The neonatal hypoplastic aortic arch: decisions and more decisions. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:43-51. [PMID: 23561817 DOI: 10.1053/j.pcsu.2013.01.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Neonatal patients with hypoplasia of the aortic arch constitute a heterogeneous group with a wide spectrum of severity. The milder end of the spectrum comprises patients with aortic coarctation and isthmus hypoplasia. At the other end of the spectrum are patients with severe transverse arch hypoplasia or hypoplastic left heart syndrome. The aim of this paper is to discuss the various strategies and surgical approaches available for this group of patients, focusing on the surgical decisions that influence individual patient management. Many of the things discussed are applicable to any neonatal arch problem. We also describe and discuss in detail our surgical technique for patients who undergo neonatal repair of a hypoplastic aortic arch via median sternotomy.
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Affiliation(s)
- Stephen M Langley
- Section of Pediatric and Congenital Cardiac Surgery, Doernbecher Children’s Hospital, Oregon Health & Science University, Portland, OR 97239, USA.
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