Contemporary Results of Aortic Coarctation Repair Through Left Thoracotomy
Carlos M Mery1, Francisco A Guzmán-Pruneda1, Jeffrey G Trost1
1Division of Congenital Heart Surgery, Texas Children's Hospital; Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Houston, Texas.
Insights
Left thoracotomy repair of coarctation of the aorta (CoA) shows low reintervention rates. Complete relief of aortic arch obstruction is key to preventing long-term recoarctation.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Disease
Background:
- Coarctation of the aorta (CoA) management remains controversial despite improved surgical outcomes.
- Left thoracotomy is a common surgical approach for CoA repair.
Purpose of the Study:
- To analyze long-term outcomes of CoA repair via left thoracotomy.
- To identify risk factors for reintervention after CoA repair.
Main Methods:
- Retrospective analysis of 343 patients (<18 years) undergoing initial CoA repair via left thoracotomy (1995-2013).
- Patients categorized into neonates, infants, and older children.
- Univariate and multivariate analyses performed to determine risk factors.
Main Results:
- Low perioperative mortality (1%).
- Only 4% of patients required reintervention at a median 6-year follow-up.
- Postoperative peak velocity ≥2.5 m/s independently predicted reintervention (OR, 4.0).
- 33% of patients had hypertension or cardiac medication dependency at 12 years post-surgery.
Conclusions:
- Left thoracotomy repair of CoA is associated with low morbidity, mortality, and reintervention rates.
- Complete relief of aortic arch obstruction during surgery is crucial for minimizing long-term recoarctation risk.
Background:
Although surgical results for repair of coarctation of the aorta (CoA) have steadily improved, management of this condition remains controversial. The purposes of this study were to analyze the long-term outcomes of patients undergoing CoA repair through left thoracotomy and to define risk factors for reintervention.
Methods:
All patients who were less than 18 years old and who underwent initial repair of CoA through left thoracotomy from 1995 to 2013 at Texas Children's Hospital (Houston, TX) were included. Patients were classified into 3 groups: 143 (42%) neonates (0 to 30 days old), 122 (36%) infants (31 days to 1 year old), and 78 (23%) older children (1 to 18 years old). Univariate and multivariate analyses were performed.
Results:
A total of 343 patients (129 [38%] girls) with median age of 53 days (interquartile range [IQR],12 days to 9 months) and weight of 4.1 kg (IQR, 3.1 to 8.0) underwent repair with extended end-to-end anastomosis (291 patients [85%]), end-to-end anastomosis (44 patients [13%]), interposition graft (2 patients [0.6%]), or subclavian flap (6 patients [2%]). Concomitant diagnoses included genetic abnormalities (48 patients [14%]), isolated ventricular septal defects (58 patients [17%]), small left-sided structures (53 patients,16%), or other complex congenital heart disease (18 patients [5%]). Perioperative mortality was 1% (n = 4, all neonates). At a median follow-up of 6 years (7 days to 19 years), only 14 (4%) patients required reintervention (10 catheter-based procedures, 6 surgical repairs). A postoperative peak velocity of 2.5 m/s or greater was an independent risk factor for reintervention (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.4 to 11.6). Within the cohort, 95 (33%) patients were hypertensive or remained on cardiac medications a median of 12 years (6 months to 19 years) after the surgical procedure. Development of perioperative hypertension was associated with higher risk of chronic hypertension or cardiac medication dependency (OR, 1.9; 95% CI, 1.1 to 3.3).
Conclusions:
CoA repair through left thoracotomy is associated with low rates of morbidity, mortality, and reintervention. Aortic arch obstruction should be completely relieved at the time of surgical intervention to minimize the risk of long-term recoarctation.
