Related Experiment Videos
Early repair of coarctation of the aorta
J A Van Son1, F W Mohr, H Hess
1Herzzentrum, University of Leipzig, Russenstrasse 19, D-04289 Leipzig, Germany.
Insights
Surgical repair of aortic coarctation in neonates and infants yields excellent results, with low rates of restenosis and no hypertension. Early intervention is recommended to prevent long-term complications.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Thoracic Surgery
Background:
- Coarctation of the aorta with aortic arch hypoplasia presents surgical challenges.
- Recurrent stenosis and hypertension are common after repair in older children.
Purpose of the Study:
- To evaluate the outcomes of a specific surgical technique for aortic coarctation repair in neonates and infants.
- To assess the incidence of restenosis and hypertension following early surgical intervention.
Main Methods:
- Retrospective review of 52 patients (neonates and infants) undergoing aortic coarctation repair between 1991 and 1997.
- Surgical techniques included end-to-side anastomosis and, in some cases, carotid-subclavian arterioplasty or aortic arch augmentation.
Main Results:
- One early death (2%) due to Shone's syndrome; no late mortality.
- Low incidence of recurrent stenosis (5.7%) and no cases of systemic hypertension at follow-up.
- Early complications included nerve injury and prolonged chest tube drainage.
Conclusions:
- Resection of ductal tissue with end-to-side anastomosis, with or without carotid-subclavian arterioplasty, provides excellent results.
- The technique is safe and effective via left thoracotomy for aortic arches ≥5 mm.
- Early repair in neonates/infants is advocated to prevent hypertension and other adverse outcomes.
Background:
Repair of coarctation of the aorta with hypoplasia and elongation of the proximal aortic arch is a technically demanding procedure with a substantial rate of recurrent stenosis at the coarctation repair site. In addition, a high incidence of hypertension has been reported in patients who underwent repair beyond infancy.
Patients And Methods:
Between January 1991 and June 1997, 52 patients (34 neonates and 18 infants with a median age of 37 days; range 2 days to 8 months) with a mean peak systolic upper to lower extremity resting gradient of 33.5 +/- 18.9 mmHg underwent repair of aortic coarctation. The echocardiographically measured median diameter of the aortic arch immediately distal to the innominate artery was 5.4 mm (range 4.0 to 8.1 mm). Eight patients (15%) were considered hypertensive. In 41 patients, through a left thoracotomy, an end-to-side anastomosis was constructed between the descending aorta and the undersurface of the proximal aortic arch. In 12 of these patients (who all had a hypoplastic and elongated aortic arch) this procedure was preceded by the construction of an extended side-to-side left carotid-subclavian arterioplasty. The remaining 11 patients, all with hypoplasia of the aortic arch, had concomitant complete repair of intracardiac anomalies through a median sternotomy. In 8 of these patients, in addition to anastomosis of the descending aorta to the undersurface of the proximal aortic arch, the ascending aorta and aortic arch were augmented with a pulmonary homograft patch.
Results:
One neonate with associated Shone's syndrome died (2%) on the first postoperative day. There was no late mortality. Early postoperative complications included recurrent laryngeal nerve injury in 1 patient and prolonged chest tube drainage in 4 patients. At a median follow-up of 55 months (range 15 to 92 months), only 3 patients (5. 7%) developed a recurrent stenosis at the coarctation repair site. The remaining 48 patients are free of recurrent stenosis by echocardiography and clinical examination. None of the patients had systemic hypertension.
Conclusions:
1. Coarctation repair consisting of resection of all ductal tissue with end-to-side anastomosis of the descending aorta to the undersurface of the (proximal) aortic arch, if necessary combined with a side-to side left carotid-subclavian arterioplasty, may lead to excellent results. 2. This technique can be applied with low mortality and morbidity via a left thoracotomy if the proximal aortic arch is at least 5 mm in diameter. 3. In view of the low mortality, the low incidence of restenosis at the coarctation repair site, and the absence of substantial morbidity including the development of hypertension, we advocate repair of aortic coarctation at neonatal age or in early infancy to avoid the detrimental sequelae of delayed repair of coarctation, in particular hypertension.