Invited Commentary

Abstract

The surgical repair of arch obstruction dates back to the first report of successful repair of aortic coarctation by Clarence Crafoord in 1944 [1Crafoord C. Nylin G. Congenital coarctation of the aorta and its surgical treatment.J Thorac Surg. 1945; 14: 347-361Abstract Full Text PDF Google Scholar]. The spectrum of aortic arch obstruction extends from the simplest form with isolated coarctation to the most complex form of obstruction, which involves complete interruption of the aorta. Although little controversy exists about the technique to repair either isolated coarctation or aortic interruption, there is a tremendous amount of controversy about the surgical management of transverse aortic arch hypoplasia. Perhaps the most controversial area is surgical management of proximal transverse arch hypoplasia, which Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] have described in their article. In dealing with arch hypoplasia, there is no commonly accepted way to describe the problem. Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] use a proximal transverse arch diameter that is less than 50% of the diameter of the ascending aorta. Surgical lore suggests that an arch size that is the patient’s weight in kilograms plus one is an acceptable standard. Z scores are probably the most common means of determining deviation from normal, but even so, there are multiple different z score programs that exist that are not identical in their measurements. A similar degree of controversy exists regarding the surgical approach to transverse arch hypoplasia. Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] champion a median sternotomy approach for their patients, but there are plenty of data to suggest that the relief of distal obstruction through a thoracotomy approach will allow for improved flow through the area of proximal hypoplasia and, ultimately, growth in this area [3Kotani Y. Anggriawan S. Chetan D. et al.Fate of the hypoplastic proximal aortic arch in infants undergoing repair for coarctation of the aorta through a left thoracotomy.Ann Thorac Surg. 2014; 98: 1386-1393Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 4Siewers R. Ettedgui J. Pawl E. TallmanT del Nido P. Coarctation and hypoplasia of the aortic arch: will the arch grow?.Ann Thorac Surg. 1991; 52: 608-613Abstract Full Text PDF PubMed Scopus (68) Google Scholar]. This controversy may be completely addressed only by a randomized controlled multiinstitutional trial. Ultimately, the ideal approach to the management of arch hypoplasia will be identified only after much longer-term follow-up. The goal of congenital heart surgery is not survival measured in months or years but in decades. The quality of that survival will also be critical in determining the best operative management, by taking into account such factors as the need for both operative and percutaneous reintervention, the need for further medical management, and detailed long-term neurodevelopmental outcomes in these patients. In particular, longitudinal neurodevelopmental outcomes are paramount to determining the success of this surgical procedure related to the consequences of the bypass technique [5Ohye R. Goldberg C. Donohue J. et al.The quest to optimized neurodevelopmental outcomes in neonatal arch reconstruction: the perfusion techniques we use and why we believe in them.J Thorac Cardiovasc Surg. 2009; 137: 803-806Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. In this paper, Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] definitely present a safe and effective management strategy, but the quest to determine the ideal strategy remains elusive. Arch Augmentation via Median Sternotomy for Coarctation of Aorta With Proximal Arch HypoplasiaThe Annals of Thoracic SurgeryVol. 106Issue 4PreviewCoarctation of the aorta can be associated with hypoplasia of the proximal transverse aortic arch. One approach to manage this condition is via left thoracotomy and extended end-to-end anastomosis with the expectation that the proximal arch will grow over time. Our preferred approach is to augment the aorta via midline sternotomy. We hypothesized that this approach is safe, durable, and allows reliable growth of the aorta. Full-Text PDF