Echocardiographic predictors of left ventricular outflow tract obstruction after repair of interrupted aortic arch

Abstract

Objectives. This study was designed to identify preoperative echocardiographic predictors of left ventricular outflow tract obstruction after repair of interrupted aortic arch and ventricular septal defect closure.Background. Left ventricular outflow tract obstruction becomes apparent in nearly 50% of patients after repair of interrupted aortic arch and ventricular septal defect closure but is seldom recognized preoperatively.Methods. We analyzed the preoperative echocardiograms of all patients with interrupted aortic arch who had postoperative echocardiographic or catheterization data available. Thirty-seven infants (aged 1 day to 10 months, median 5 days) were included. Off-line measurements were performed on hard copies of selected images. The cross-sectional area (indexed to body surface area) and diameters (indexed to the square root of body surface area) of the left ventricular outflow tract; ascending and descending aorta; ventricular septal defect; and mitral, aortic and pulmonary valves were compared with outcome by using analysis of variance. Outcome was classified according to development of postoperative left ventricular outflow tract Doppler gradient (Group 1 ≤ 20 mm Hg, Group 2 > 20 mm Hg).Results. The cross-sectional area of the left ventricular outflow tract was significantly smaller in patients who did than in those who did not develop subaortic obstruction ([mean ± SD] 0.64 ±0.25 vs. 1.7 ± 1.01 cm2/m2, p < 0.004). Left ventricular outflow tract and aortic valve diameters and aortic valve area were not predictive of postoperative left ventricular outflow tract obstruction. Incidence of postoperative left ventricular outflow tract obstruction was lower (p < 0.03) in interrupted aortic arch type A (0 of 6) than in type B (15 of 31). The incidence of aberrant right subclavian artery was lower (p < 0.02) in Group 1 (6 of 22) than in Group 2 (10 of 15).Conclusions. The preoperatively measured cross-sectional area of the left ventricular outflow tract is significantly smaller in patients with interrupted aortic arch who develop subaortic obstruction postoperatively, with a left ventricular outflow tract area ≤ 0.7 cm2/m2being a sensitive predictor. Aortic arch anatomy (i.e., type of interrupted aortic arch and presence of aberrant right subclavian artery) is also predictive of postoperative left ventricular outflow tract obstruction, possibly by influencing the volume of blood flow across the left ventricular outflow tract. These data should enable preoperative identification of infants who may require surgical relief of subaortic stenosis.