Tailored surgical technique for neonatal coarctation repair through thoracotomy

Abstract

Aortic coarctation in neonate continues to pose a clinical challenge. Low weight, arch hypoplasia and ductal dependence have been identified as risk factors for recurrent coarctation. We hypothesized that a tailored surgical technique may prevent this complication. Retrospective evaluation of neonates who presented for coarctation repaired through thoracotomy was conducted. No primary percutaneous procedure was performed and sternotomy repairs were excluded. Hypoplasia was defined as a ratio of echocardiographic and perioperative distal arch diameter (mm)/weight (kg) < 1. Traditional extended end-to-end anastomosis (EEE), subclavian flap (Waldhausen) and double flap distal arch enlargement by Amato aortoplasty were employed. Mortality and recoarctation requiring reintervention in follow-up were assessed. Records of 340 patients (2003–2019) were analyzed. Median age and weight at repair were 10 [2–30] days and 3080 [1100–5200] g, respectively. Arch hypoplasia was documented in 31 patients (9.1%). Prostaglandin was infused in 220 (65.3%), preoperative mechanical ventilation and inotropic support was documented in 35 (10.8%). EEE repair was performed in 273 (80.3%). Waldhausen in 42 (12.4%) and Amato in 25 (7.4%) were more likely to be performed in presence of arch hypoplasia ( P < 0.0001). Concomitant PAB for associated VSD was necessary in 72 (21.2%). Hospital mortality occurred in 2 (0.58%). Thirty-six procedures (31 percutaneous, 5 surgical) for recoarctation were performed in 33 patients in a median delay of 111 [26–3050] days. One late death occurred. Both low weight ( P = 0.14), hypoplastic arch ( P = 0.65) and ductal dependency ( P = 0.34) did not influence outcome. At 3.6 ± 3.4 years postoperatively, all survivors presented with no residual coarctation. Primary surgical repair for neonatal coarctation still appears to be the gold standard. Even in presence of associated risk factors, a tailored approach using alternative techniques seems to offer comparable results in neonatal coarctation repair.