Distal Transverse Arch Dimensions Dictate Long-Term Aortic Arch Gradients Following Coarctation of the Aorta Repair...

Regardless of the surgical approach to repair coarctation of the aorta (CoA), a portion of the distal transverse arch (DTA) remains incorporated within the anastomosis. We hypothesized that retention of a small DTA segment results in an elevated gradient. Infants were divided into two groups based on the surgical approach: (1) Sternotomy and aortic arch repair where the DTA was nearly excised and (2) Thoracotomy and extended end-to-end anastomosis (EEEA), which incorporates most of the DTA within the anastomosis. Follow-up echocardiograms quantified the aortic arch gradient, and children with a gradient in the upper quartile for each surgical approach were analyzed. From 230 infants, 51.3% (118) underwent sternotomy and aortic arch repair, and 48.7% (112) underwent thoracotomy and EEEA. Post-operatively, the sternotomy group had a significantly greater duration of ventilation and hospital length of stay but without a difference in mortality. Follow-up aortic arch gradients were significantly lower within the sternotomy group (11.9 ± 7.0 mmHg vs. 14.5 ± 7.5 mmHg; p = 0.002). Children with an aortic arch gradient in the upper quartile from the thoracotomy group had significantly smaller preoperative DTA dimensions. Multivariate regression demonstrated that sternotomy and aortic arch repair independently reduced the follow-up aortic arch gradient (Odds Ratio: 0.075 95% CI 0.006, 0.877; p value = 0.039). Incorporating smaller DTA segments within the anastomosis results in higher gradients that may have implications in the development of hypertension during adulthood and suggests the consideration of the DTA dimension during CoA repair.