Muscle-Sparing Extrapleural Approach for the Repair of Aortic Coarctation

Abstract

This paper describes a muscle-sparing, extrapleural approach to repair aortic coarctation, and evaluates the results with established standards. Forty consecutive patients with aortic coarctation (median age, 8 days; weight, 3.3 kg) were approached with a less invasive technique consisting of a short posterior thoracotomy, with only minimal (24 patients) or no (16 patients) division of thoracic wall muscles and a subperiosteal-extrapleural approach. Extended resection of the coarctation with enlargement of the distal aortic arch was performed in all patients. The median cross-clamp and operative times were 22 and 90 minutes, respectively. The repair was possible in all patients without needing conversion. There was no intraoperative or postoperative related complication. Two patients died early of low cardiac output as a result of ventricular fibroelastosis and respiratory failure. One patient died late of unrelated cause. The perioperative mean gradients across the neoarch were less than 5 mm Hg in all but 3 patients with proximal (2 patients) or mid arch (1) stenosis. The median ventilation time, intensive care unit stay, and hospital stay in isolated coarctation repairs was 2, 4.5, and 11 days, respectively. One patient had a recurrent stenosis at the site of surgical repair. Two patients underwent successful balloon dilatation, and 2 had surgical enlargement plasty of the proximal aortic arch at the time of intracardiac repair. None of the patients required chronic antihypertensive medication. At 29 months, freedom from reintervention on the isthmus and arch plus isthmus was 97.1% and 89.7%, respectively. A muscle-sparing, extrapleural approach for the repair of aortic coarctation is possible and provides results similar to conventional techniques. The approach reduces postoperative morbidity related to division of thoracic wall muscles and handling of the lung, restores a normal intercostal space, and produces superior cosmetic results, while at the same time leading to early and permanent relief of proximal hypertension.