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Reinterventions after repair of common arterial trunk in neonates and young infants
D B McElhinney1, H A Rajasinghe, B N Mora
1Division of Cardiothoracic Surgery, University of California, San Francisco, USA. mcelhinney@email.chop.edu
Insights
Reintervention after common arterial trunk repair in infants is frequent, with many patients needing multiple procedures. Minimizing factors like pulmonary artery stenosis during initial repair can reduce future interventions.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Cardiovascular Surgery
Background:
- Improving outcomes in early common arterial trunk (CAT) repair necessitates understanding long-term reintervention needs.
- As early survival rates rise, reintervention in older pediatric and adult CAT patients becomes a growing clinical concern.
Purpose of the Study:
- To determine the rates of reintervention following common arterial trunk repair in neonates and early infants.
- To analyze factors influencing the need for reinterventional procedures.
Main Methods:
- Retrospective review of 159 infants (<4 months) undergoing primary common arterial trunk repair (1975-1998).
- Focus on postoperative reinterventions, including conduit, valve, and pulmonary artery procedures.
- Actuarial analysis of freedom from reintervention and specific procedure types.
Main Results:
- 40 of 128 early survivors required early reintervention.
- 121 reinterventions were performed in 81 patients during a median follow-up of 98 months.
- Freedom from first conduit reintervention was 45% at 5 years; allograft conduits predicted longer time to replacement.
- Pulmonary artery stenosis and residual VSD closure were significant reintervention indications.
Conclusions:
- The need for reintervention after common arterial trunk repair in infancy is substantial.
- Conduit reintervention is common; optimizing initial repair to prevent pulmonary artery stenosis and VSD is crucial.
- Long-term surveillance is essential for managing reinterventional needs in this population.
Objectives:
To determine rates of reintervention after repair of common arterial trunk in the neonatal and early infant periods.
Background:
With improving success in the early treatment of common arterial trunk, the need for reinterventional procedures in older children, adolescents and adults will become an increasingly widespread concern in the treatment of these patients.
Methods:
We reviewed our experience with 159 infants younger than four months of age who underwent complete primary repair of common arterial trunk at our institution from 1975 to 1998, with a focus on postoperative reinterventions.
Results:
Of 128 early survivors, 40 underwent early reinterventions for persistent mediastinal bleeding or other reasons. During a median follow-up of 98 months (range, 2 to 235 months), 121 reinterventions were performed in 81 patients. Actuarial freedom from reintervention was 50% at four years, and freedom from a second reintervention was 75% at 11 years. A total of 92 conduit reinterventions were performed in 75 patients, with a single reintervention in 61 patients, 2 reinterventions in 11 patients and 3 reinterventions in 3 patients. Freedom from a first conduit reintervention was 45% at five years. The only independent variable predictive of a longer time to first conduit replacement was use of an allograft conduit at the original repair (p = 0.05), despite the significantly younger age of patients receiving an allograft conduit (p < 0.001). Reintervention on the truncal valve was performed on 22 occasions in 19 patients, including 21 valve replacements in 18 patients and repair in 1, with a freedom from truncal valve reintervention of 83% at 10 years. Surgical (n = 29) or balloon (n = 12) reintervention for pulmonary artery stenosis was performed 41 times in 32 patients. Closure of a residual ventricular septal defect was required in 13 patients, all of whom underwent closure originally with a continuous suture technique. Eight of 16 late deaths were related to reintervention.
Conclusions:
The burden of reintervention after repair of common arterial trunk in early infancy is high. Although conduit reintervention is inevitable, efforts should be made at the time of the initial repair to minimize factors leading to reintervention, including prevention of branch pulmonary artery stenosis and residual interventricular communications.