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Neonatal coarctation repair. Influence of technique on late results
C J Knott-Craig1, R C Elkins, K E Ward
1Section of Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City 73190.
Insights
Neonatal coarctation repair has high risks. Resection and end-to-end anastomosis (RETE) did not reduce reintervention rates compared to subclavian flap angioplasty (SFA). Vigilant follow-up is crucial in the first year post-surgery.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Neonatal Intensive Care
Background:
- Coarctation repair in neonates (<28 days) has higher mortality and restenosis rates than in older infants.
- Resection of pericoarctation ductal tissue is a potential strategy to mitigate restenosis risk.
Purpose of the Study:
- To evaluate the outcomes of different coarctation repair techniques in neonates.
- To assess the impact of repair methods on mortality and restenosis rates.
Main Methods:
- Retrospective review of 111 neonates undergoing primary coarctation repair between 1973 and 1991.
- Comparison of outcomes for resection and end-to-end anastomosis (RETE), subclavian flap angioplasty (SFA), and patch angioplasty (PA).
- Analysis of hospital mortality, late mortality, reintervention rates for restenosis, and long-term survival.
Main Results:
- Hospital mortality was 14.4% overall, with no significant difference between RETE (10.7%), SFA (16.7%), and PA (16.7%).
- Associated complex cardiac pathology significantly increased operative risk (25% vs. 8.4%, P = .02).
- Twenty percent of patients required reintervention for restenosis, with PA having a significantly higher rate (47%) compared to RETE (16%) and SFA (13%) (P = .02).
- Late mortality was 13.6%, with 92% occurring within the first year.
- Freedom from reintervention at 1 and 8 years was 80% and 77%, respectively.
- Actuarial survival at 8 years was 73% overall, but 90% for simple coarctation.
- Multivariate analysis identified associated cardiac pathology as the only negative predictor of survival and patch angioplasty as the only predictor for reintervention.
Conclusions:
- Resection and end-to-end anastomosis (RETE) for neonatal coarctation does not reduce reintervention risk compared to subclavian flap angioplasty (SFA).
- The highest risks for late death and recurrent coarctation occur within the first year post-repair.
- Vigilant patient follow-up is critical during the initial year after coarctation repair.
Background:
Coarctation repair in the neonate (< or = 28 days) is associated with higher mortality and increased incidence of restenosis compared with older infants. It has been suggested that resection of pericoarctation ductal tissue may reduce this risk of restenosis.
Methods And Results:
To further clarify these issues, we reviewed our experience with 111 consecutive neonates undergoing primary repair between 1973 and 1991. Hospital mortality was 14.4% (16 of 111) and was not significantly different for the type of repair:resection and end-to-end anastomosis (RETE) 10.7% (6 of 56), subclavian flap angioplasty (SFA) 16.7% (6 of 36), and patch angioplasty (PA) 16.7% (3 of 18). Associated complex cardiac pathology was associated with higher operative risk: 25% (10 of 40) versus 8.4% (6 of 71) (P = .02). Median follow-up of 4.2 years (range, 0.1 to 18.5 years) was 99% complete. Late mortality was 13.6% (13 of 95), of which 92% occurred within 1 year of repair. Twenty percent (19 of 95) needed reintervention for restenosis, RETE 16% (8 of 50), SFA 13% (4 of 30), and PA 47% (7 of 15) (P = .02). Of these, 84.2% (16 of 19) required reintervention within 1 year of repair. Freedom from reintervention 1 and 8 years after operation was 80 +/- 4% and 77 +/- 5%, respectively. Actuarial survival 8 years after operation was 73 +/- 4%; for simple coarctation, this was 90 +/- 4%. By multivariate analysis, survival was negatively influenced only by presence of associated cardiac pathology (P = .002) and reintervention only by patch angioplasty technique of repair (P = .007).
Conclusions:
In the neonate, resection of coarctation (RETE) does not diminish the risk for reintervention compared with SFA. The risk for both late death and recurrent coarctation are highest within the first year after repair, and follow-up should be particularly vigilant during this period.