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Results of primary and two-stage repair of interrupted aortic arch
1Kardiocentrum, University Hospital Motol, Prague, Czech Republic. tomas tlaskal@1f motol.cuni.cz
Insights
Primary repair of interrupted aortic arch in neonates shows lower mortality and fewer complications than palliative surgery. This approach is recommended for better long-term outcomes in infants with this congenital heart defect.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Congenital Heart Defects
Background:
- Interrupted aortic arch (IAA) is a severe congenital heart defect requiring timely surgical intervention.
- Surgical outcomes for IAA have improved, necessitating a comparison of different repair strategies.
Purpose of the Study:
- To analyze and compare the outcomes of primary repair versus two-stage (palliative) repair for interrupted aortic arch in neonates and infants.
Main Methods:
- Retrospective analysis of 40 neonates and infants with IAA undergoing either primary repair (19) or palliative surgery (21).
- Follow-up of 50% of patients for an average of 5.1 years, assessing clinical status, residual lesions, complications, and re-interventions.
- Echocardiographic evaluation of aortic arch and left ventricular outflow tract growth.
Main Results:
- Early mortality was significantly higher in the palliative group (61.9%) compared to the primary repair group (36.8%).
- Primary repair was associated with lower rates of severe complications and re-interventions compared to palliative surgery.
- All early survivors (20) are alive at follow-up; patients after primary repair generally exhibit better functional class (NYHA I-II) than those after palliative surgery (some in NYHA III-IV).
Conclusions:
- Primary repair of interrupted aortic arch in neonates offers superior outcomes with reduced mortality and fewer complications.
- While primary repair is recommended, palliative surgery may be considered in unfavorable conditions.
- Patient selection is crucial, and potential development of subaortic stenosis after primary repair warrants monitoring.
Objective:
Early results of primary and two-stage repair of interrupted aortic arch have improved. Experience with different surgical approaches should be analysed and compared.
Methods:
Forty neonates and infants with interrupted aortic arch underwent primary repair (19 patients) or palliative operation (21 patients). Twenty (50%) patients were followed-up for 5.1+/-4.3 years. All patients were regularly examined with the aim of determining clinical development, presence of residual lesions or complications and need for re-intervention. Aortic arch and the left ventricular outflow tract growth were assessed by echocardiographic examination. Data from hospital and outpatient department records were analysed.
Results:
The early mortality was 61.9% after palliative operations and 36.8% after the primary repair. Presence of complications (P < 0.001), earlier year of surgery (P < 0.01), bad clinical condition and acidosis (P < 0.05) represented statistically significant risk factors for death in the whole series. In seven (87.5%) out of eight early survivors, after the initial palliative operation, closure of ventricular septal defect and debanding were done, and in three (37.5%) patients, re-operation for aortic arch obstruction was also required. Out of 12 patients, after the primary repair, one required early re-operation for persistent left ventricular outflow tract obstruction and two needed late re-intervention for left bronchus obstruction. In three (25%) patients, after the primary repair, left ventricular outflow tract obstruction with a maximal systolic pressure gradient higher than 30 mmHg developed. At present, all 20 early survivors are alive. Five patients, after palliative operation, are in NYHA class 1, but in three patients, who are in class III or IV, the outcome is influenced by severe complications. All patients after the primary repair are in class I or II.
Conclusions:
Our experience confirmed better results after the primary repair of interrupted aortic arch, which was associated with lower mortality, prevalence of severe complications and need for re-intervention. Higher prevalence of subaortic stenosis after primary repair could be explained by patient selection early in our experience. We recommend the primary repair of interrupted aortic arch and associated heart lesions in neonates, however, in unfavourable conditions an individualised surgical approach with initial palliative surgery should be considered.