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Published on: December 11, 2017
Risk factors for recoarctation and results of reoperation: a 40-year review
A Dodge-Khatami1, C L Backer, C Mavroudis
1Division of Cardiovascular-Thoracic Surgery, The Children's Memorial Hospital, Chicago, Illinois 60614, USA.
Insights
Simple end-to-end anastomosis and subclavian flap repair for coarctation of the aorta in children are linked to higher recoarctation rates, particularly with aortic arch hypoplasia. Reoperation for recoarctation is safe and effective.
Area of Science:
- Pediatric Cardiac Surgery
- Congenital Heart Disease
- Aortic Reconstruction
Background:
- Coarctation of the aorta is a congenital heart defect requiring surgical intervention.
- Long-term outcomes and risk factors for recoarctation after primary repair are critical for pediatric cardiac surgery.
- Understanding reoperation results is essential for managing recurrent coarctation.
Purpose of the Study:
- To identify risk factors for recoarctation after primary coarctation repair in children.
- To evaluate the outcomes of reoperation for recurrent coarctation.
- To provide evidence-based recommendations for surgical techniques in pediatric coarctation repair.
Main Methods:
- Analysis of a 40-year single-institution experience (1957-1998) with 271 pediatric patients undergoing primary coarctation repair.
- Comparison of various primary repair techniques: Gore-tex patch aortoplasty (PATCH), resection with extended end-to-end anastomosis (RXEEA), subclavian flap aortoplasty (SFA), and resection with simple end-to-end anastomosis (ETE).
- Logistic regression analysis to determine risk factors for recoarctation, including surgical technique and aortic arch hypoplasia.
Main Results:
- Recoarctation occurred in 11% of patients, with higher rates for ETE (33%) and SFA (20%) repairs.
- ETE repair (OR 17.2), SFA repair (OR 3.5), and aortic arch hypoplasia (OR 15.2) were significant risk factors for recoarctation.
- Reoperation for recoarctation (n=23) had no mortality or paraplegia, with a low incidence of persistent coarctation.
Conclusions:
- Simple end-to-end anastomosis and subclavian flap repair are associated with the highest incidence of recoarctation, especially in conjunction with aortic arch hypoplasia.
- Resection with extended end-to-end anastomosis is recommended for neonates/infants, while Gore-tex patch aortoplasty is suggested for children over 1 year.
- Surgical repair of recurrent coarctation is a safe and effective treatment option with favorable outcomes.
Background:
We analyzed a single institution 40-year experience with children that had coarctation repair to define risk factors for recoarctation and to evaluate the results of reoperation for recoarctation.
Material And Methods:
Between 1957 and 1998, 271 patients had primary surgical repair of coarctation of the aorta. Techniques for primary repair included Gore-tex patch aortoplasty (PATCH; n = 118), resection with extended end-to-end anastomosis (RXEEA; n = 69), subclavian flap aortoplasty (SFA; n = 61), resection with simple end-to-end anastomosis (ETE; n = 18), resection and interposition graft (n = 4), and extra-anatomic graft (n = 1). Techniques for recoarctation repair included PATCH, interposition graft, and extra-anatomic graft.
Results:
Median age at initial repair was 156 days. Major associated cardiac anomalies were present in 96 patients (35%). A hypoplastic aortic arch was present in 37 patients (14%). There were three early deaths (1%) and six late deaths (2%). One patient had paraplegia (0.4%). Recoarctation occurred in 29 patients (11%) and was most frequent with ETE and SFA repairs (33% and 20%, respectively). Multiple logistic regression analysis revealed ETE repair (p = 0.0002), SFA repair (p = 0.049), and aortic arch hypoplasia (p = 0.0001) to be risk factors for recoarctation. Using PATCH as the covariate, the odds ratio to develop recoarctation was 3.5 for SFA, 17.2 for ETE, and 15.2 for hypoplastic aortic arch. There was no mortality or paraplegia after recoarctation repair (n = 23). Six patients had seven balloon angioplasties; two of these patients later required reoperation. Three patients required a second reoperation for persistent coarctation.
Conclusions:
In our 40-year review, simple end-to-end anastomosis and subclavian flap repair had the highest incidence of recoarctation, especially when associated with aortic arch hypoplasia. We recommend resection with extended end-to-end anastomosis for repair of neonates and infants and Gore-tex patch aortoplasty for children over the age of 1 year. Surgical repair of recurrent coarctation is safe, effective, and has a low incidence of persistent coarctation.
