Continuous cerebral and myocardial selective perfusion in neonatal aortic arch surgery

Myocardial Priority Promotes Cardiovascular Recovery for Acute Type A Aortic Dissection Combined with Coronary Artery Disease Undergoing Aortic Arch Surgery

The optimal surgical strategy for acute type A aortic dissection (ATAAD) with coronary artery disease (CAD) remains unclear. The goal of this study was to investigate the cardiovascular protective effects of the myocardial priority (MP) strategy or traditional selective cerebral perfusion (SCP) in ATAAD with CAD. A total of 214 adults were analyzed retrospectively, of which 80 underwent the MP strategy intraoperatively. Seventy-nine pairs were propensity-score-matched and divided into SCP and MP groups. The follow-up period ranged from 6 to 36 months. The MP group had a significantly shorter myocardial ischemic time, higher perfusion flow, higher radial artery pressure, and lower incidence of NIRS decrease >20% of the base value, but a longer lower limb circulatory arrest and bypass time than the SCP group. Although similar adverse cardiac and cerebrovascular events were observed in both groups, a shorter posthospital stay, less blood loss and transfusion, higher postoperative hemoglobin, lower creatinine, and higher PaO2/FiO2 were observed in the MP group. Subgroup analysis showed that when the TIMI Risk Score was <4, the MP group had a lower incidence of low cardiac output and lower postoperative cTnI level. The follow-up patients had similar morbidities between the two groups. The novel MP strategy is associated with a shortened myocardial ischemic time, better maintained perfusion of vital organs, and postoperative recovery after surgery for ATAAD combined with non-severe CAD.

Growth of unrepaired hypoplastic proximal aortic arch and reintervention rate after aortic coarctation repair

BACKGROUND

Treatment of tubular hypoplasia of the aortic arch (THAA) associated with aortic coarctation (CoA) remains controversial. We aimed to evaluate growth of unrepaired hypoplastic proximal aortic arches (PAAs) after surgical repair for CoA.

METHODS

Preoperative and follow-up echocardiographic images of 139 patients who underwent CoA repairs from 2005 to 2012 were reviewed. THAA was defined as PAA z-score <-3 and non-THAA group z-score ≥-3. Reintervention rates due to aortic obstruction were assessed using competing risk models and diameters of the aorta were compared with Mann-Whitney U tests.

RESULTS

Fifty patients (36%) had THAA and 89 (64%) had non-THAA. The survival rate was 94% at 10 years. The overall reintervention rate at 10 years was 9% in the THAA group and 16% in the non-THAA group (P = .54). The catheter reintervention rate at ten years was 2% in the THAA group and 16% in the non-THAA group (P = .031). The surgical reintervention rate at ten years was 7% in the THAA group and 0% in the non-THAA group (P = .016). All 4 patients who required surgical reintervention were in the THAA group and 3 patients with PAA obstruction had preoperative PAA z-scores -3.6, -4.2, and -4.3. Follow-up echocardiograms showed PAA catch-up growth in the THAA group compared with the non-THAA group (preoperative z-score of -3.6 vs -2.3, and at 7 years of -1.1 vs -1.2; P < .001).

CONCLUSIONS

Unrepaired PAA hypoplasia grows after CoA repair. Reintervention rates were comparable between groups but those with THAA had higher surgical reintervention rates.

Medium-term follow-up of autologous pericardial patches for pediatric aortic arch reconstruction

OBJECTIVES

Direct anastomosis, like end-to-end anastomosis or end-to-side anastomosis, is commonly employed to repair aortic coarctation or interrupted aortic arch. Direct anastomosis of the aorta, however, may result in restenosis or bronchial compression. To circumvent these complications, we have applied a technique consisting of aortic reconstruction using glutaraldehyde-fixed autologous pericardial patches.

METHODS

Our database was queried for infants who underwent aortic arch reconstruction using autologous pericardial patches from 2007 to 2019. Medical records, including echography imaging, were reviewed, and Z-scores of aortic arch diameters were retrospectively assessed at baseline, immediately after surgery, and at follow-up end.

RESULTS

Overall, 58 patients met the inclusion criteria, with a median age of 9.8 days at surgery and median postoperative follow-up of 46 months. Re-coarctation requiring re-intervention by either surgery or percutaneous angioplasty was documented in 14.7% of patients. Overall, 9% of patients died of all-cause mortality. The Z-scores evolved favorably from baseline, which clearly indicated hypoplastic aortic arch, to early postoperative status, which clearly showed values close to those obtained in normal infants, with likewise normal values obtained at median 46-month follow-up.

CONCLUSIONS

Glutaraldehyde-fixed autologous pericardial patches were shown to provide correct medium-term results for aortic arch reconstruction. The incidence of restenosis requiring re-intervention was shown to be low. Autologous pericardial patches can be considered as an acceptable and easily available solution for aortic arch repair surgery.