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Decision making for the surgical management of aortic coarctation associated with ventricular septal defect
R M Brouwer1, A H Cromme-Dijkhuis, M E Erasmus
1Division of Cardiothoracic Surgery, University Hospital Groningen, The Netherlands.
Insights
Optimal surgical management for infants with coarctation of the aorta and ventricular septal defect depends on preoperative criteria. A multistage repair reduces recoarctation risk, while single-stage repair minimizes the need for secondary ventricular septal defect treatment.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Thoracic Surgery
Background:
- Coarctation of the aorta (CoA) and ventricular septal defect (VSD) are common congenital heart defects.
- Surgical repair can be performed in a single stage or multiple stages.
Purpose of the Study:
- To determine if preoperative criteria can guide the choice between single-stage and multistage surgical repair for infants with CoA and VSD.
- To evaluate the long-term outcomes of different surgical strategies.
Main Methods:
- Retrospective analysis of 80 infants younger than 3 months with CoA and VSD treated surgically between 1980 and 1993.
- Comparison of a multistage repair group (initial CoA repair, delayed VSD closure) with a single-stage repair group (simultaneous repair).
- Identification of preoperative risk factors for VSD reoperation.
Main Results:
- In-hospital mortality was 7.5%.
- Multistage repair showed significantly better freedom from recoarctation (91.3% vs. 60.0%) at 5 years.
- Single-stage repair demonstrated superior freedom from secondary VSD treatment (100% vs. 40.7%) at 5 years.
- Spontaneous VSD closure occurred in 47.8% of infants.
- Preoperative left-to-right shunt and VSD extension were risk factors for needing VSD closure.
Conclusions:
- Preoperative criteria, specifically left-to-right shunt and VSD extension, can help predict the need for secondary VSD surgery.
- A tailored approach balancing the risks of recoarctation and secondary VSD treatment optimizes surgical management.
- Minimizing the number of procedures per infant is a key consideration.
Abstract:
Coarctation of the aorta and associated ventricular septal defect may be repaired simultaneously or by initial coarctation repair with or without banding of the pulmonary artery. The question is whether specific preoperative criteria can enable the surgeon to choose the optimal surgical management. Between 1980 and 1993, 80 infants younger than 3 months with coarctation and ventricular septal defect were treated surgically. In 64 infants (multistage group), simple coarctation repair was performed through a posterolateral approach, with concomitant banding of the pulmonary artery in 10 infants. Twenty ventricular septal defects were closed as a secondary procedure and four were closed as a tertiary procedure. Sixteen infants (single-stage group) underwent one-stage repair through an anterior midline approach. The total in-hospital mortality rate was 7.5%. Freedom from recoarctation after 5 years was 91.3% in the multistage group versus 60.0% in the single-stage group (p = 0.018). Freedom from secondary ventricular septal defect treatment in the multistage group after 5 years was 40.7%, versus 100% in the single-stage group (p = 0.016). Thirty-seven ventricular septal defects (47.8%) closed spontaneously. In particular, the preoperative left-to-right shunt and extension of the perimembranous VSD into the inlet or outlet were risk factors for the need for eventual surgical ventricular septal defect closure after initial coarctation repair. On the basis of these two risk factors, the probability of the need for eventual surgical treatment of ventricular septal defect after initial coarctation repair can be calculated. This policy offers a well-considered choice between single-stage and multistage repair, weighing the risk of secondary ventricular septal defect treatment versus the risk of recoarctation. Finally, the number of surgical procedures per infant will be as low as possible.