Should elective repair of coarctation of the aorta be done in infancy?

Our experience with the subclavian flap repair for coarctation of the aorta over the past 10 years includes 53 patients under 1 year of age. Of this group, 35 were newborn infants. All but two had an associated patent ductus arteriosus and 23 (66%) had associated intracardiac anomalies. All neonates had severe congestive heart failure and operation was carried out promptly after they were stabilized with diuretics and inotropic agents. Prostaglandin infusions have been essential to the care of many of these patients. Operative mortality was two of 53 patients (4%). No patient more than 4 days old operation has died, and concomitant pulmonary artery banding was performed in five infants with no deaths. Running nonabsorbable suture was used in 21 patients, interrupted nonabsorbable suture in 23, and continuous monofilament absorbable suture in the last nine. Mean follow-up time has been 46 months. Invasive follow-up studies, performed in 11 patients, have revealed residual systolic gradients of 5, 15, and 20 mm Hg in three and 0 mm Hg in one in whom continuous suture technique was used. The other seven had interrupted suture technique, and no gradient was present. Initial follow-up information for the group with absorbable suture repair suggests no residual gradients. No patient had significant upper extremity or hand morbidity. Eight patients had normal blood pressure and normal arm-to-leg gradients after exercise. When absorbable vascular suture is unavailable, an interrupted suture technique is superior to a continuous running repair. In view of the low operative mortality, the excellent growth of the repaired area, yet the likelihood of late development of cardiovascular disease (especially hypertension) if the repair is effected in childhood or adolescence, we favor prompt subclavian flap repair of coarctation of the aorta in all infants with or without symptoms. Concomitant pulmonary artery banding is seldom indicated.