Reverse subclavian flap repair of hypoplastic transverse aorta in infancy
K R Kanter1, R N Vincent, D A Fyfe
1Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA. kkanter@emory.org
Insights
Reverse subclavian flap aortoplasty effectively treats hypoplastic aortic arch and coarctation in infants. This technique offers good survival rates with low recurrence of obstruction.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Defects
- Vascular Reconstruction
Background:
- Hypoplastic aortic arch with coarctation presents a surgical challenge in infants.
- Reverse subclavian flap aortoplasty provides a bypass-free, foreign material-free approach.
Purpose of the Study:
- To evaluate the efficacy of reverse subclavian flap aortoplasty for hypoplastic aortic arch and coarctation in infants.
- To assess operative outcomes, recurrence rates, and long-term survival.
Main Methods:
- Retrospective review of 46 infants (<3 months) undergoing reverse subclavian flap aortoplasty for hypoplastic arch and coarctation.
- Analysis of patient demographics, associated cardiac defects, surgical procedures, and follow-up data.
Main Results:
- Two hospital deaths (4.3%); two late deaths, yielding 91% overall survival.
- Five recurrent obstructions (10.9%) managed with balloon dilatation or reintervention.
- Successful correction of associated defects in 26 children, with 29 subsequent operations.
Conclusions:
- Reverse subclavian flap aortoplasty is an effective treatment for infantile hypoplastic aortic arch and coarctation.
- The procedure demonstrates acceptable operative and intermediate survival with low recurrence rates.
Background:
Management of hypoplastic aortic arch associated with coarctation in infancy can be challenging. Reverse subclavian flap aortoplasty plus coarctation resection offers simplicity without needing foreign material or cardiopulmonary bypass.
Methods:
Since 1988, 46 of 162 infants less than 3 months undergoing coarctation repair had hypoplastic arch enlargement with reverse subclavian flap aortoplasty. Median age was 11 days; mean weight was 3.2 kg. Thirty-seven patients (80%) had associated cardiac defects including single or multiple ventricular septal defects (14 infants), transposition of the great arteries (7), aortic or mitral stenosis (5), and complete atrioventricular septal defect (5 infants). Twenty-eight patients had pulmonary artery banding; 2 had an arterial switch operation through a separate median sternotomy.
Results:
There were two hospital deaths: one 4 months postoperatively in a patient requiring a Norwood procedure the next day for underestimated left ventricular hypoplasia; the other of sepsis more than 1 month postoperatively. On follow-up from 1 to 129 months (mean, 38 months), there were five recurrent obstructions: three at the coarctation site treated with balloon dilatation and two at the arch site. Twenty-six children had their heart defects corrected with 29 subsequent operations including an arterial switch operation for transposition of the great arteries/ ventricular septal defect (3 infants), relief of aortic or mitral stenosis +/- ventricular septal defect closure (5), multiple ventricular septal defect closure (3), a bidirectional Glenn (2), complete atrioventricular septal defect (2), and anomalous left coronary with ventricular septal defect repair (1 infant). Four children await debanding and ventricular septal defect closure or Glenn anastomosis. There have been two late deaths (overall survival, 91%).
Conclusions:
Reverse subclavian flap aortoplasty is excellent for relief of arch hypoplasia and coarctation in infants with low recurrence rates and acceptable operative and intermediate survival.
