Neonatal Arch Research Articles

Changes in Neonatal Intraoperative Electroencephalogram Alpha: Delta Ratios Precede Neurologic Injury.

Background: Unrecognized intraoperative cerebral ischemia during neonatal aortic arch reconstruction may precede neurologic injury. Electroencephalogram (EEG) alpha:delta ratio (A:D) changes predict cerebral ischemia; however, if A:D differences can identify ischemia during neonatal antegrade cerebral perfusion (ACP) and aortic arch reconstruction is unknown. We hypothesized that A:D changes would precede neurologic injury. Methods: Simultaneous EEG derived left versus right: hemispheric and anterior cerebral A:Ds were retrospectively measured at baseline and every 5 min during arterial cannulation, cooling, ACP, and the rewarming phases of the operation. A paired left versus right A:D difference >25% was considered significant for ischemia, and the duration of a significant and continuous A:D difference was quantified in minutes. Neonates were divided into two groups: (1) new neurologic injury (stroke or seizure) and (2) no known neurologic injury. Results: From 72 neonates, there were no significant differences in the baseline A:Ds. Seven neonates (9.7%) developed a new neurologic injury (seizure = 3, stroke = 2, seizure and stroke = 2). Male gender and longer ACP times were significantly associated with neurologic injury. In neonates with a neurologic injury, the duration of a significant and continuous A:D difference was longer within the hemispheric and anterior regions. Multivariable analysis demonstrated that a significant and continuous anterior A:D difference (odds ratio: 1.345, 95% CI 1.058-1.712; P = .01) was independently associated with neurologic injury. Conclusions: A longer continuous anterior A:D difference > 25% was independently associated with neurologic injury. Intraoperative EEG monitoring could be considered during neonatal arch reconstruction.

Timing of surgical repair of the stented aortic arch and coarctation in neonates.

We report a neonate with aortic arch hypoplasia and coarctation, in whom patency of the arterial duct could not be re-established and who was too ill to undergo primary surgical correction safely. This patient was treated in two stages: 1) angioplasty and stenting, 2) surgical correction. The safe period for surgical correction may be 2-3 weeks after angioplasty and stenting.

The Usefulness of Computed Tomography in Predicting Left Ventricular Outflow Tract Obstruction After Neonatal Arch Repair

This study investigated the outcome after neonatal arch repair, and the usefulness of computed tomography (CT) in predicting the development of left ventricular outflow tract (LVOT) obstruction (LVOTO). A total of 150 neonates who underwent arch repair between 2008 and 2019 were included. The diameters of the aortic valve annulus (AVA) and LVOT in millimeters were measured with transthoracic echocardiography (TTE) or CT and indexed by subtracting body weight in kilograms. The outcomes of interest were the development of LVOTO (peak flow velocity > 3 m/s on TTE) and reintervention or reoperation for LVOTO. The median follow-up duration was 3.6 years. The rates of overall survival, freedom from reintervention for LVOTO, and freedom from the LVOTO development at 7 years were 93.7%, 88.2%, and 81.0%, respectively. In univariable Cox regression analysis, weight-indexed CT-measured LVOT diameter (concordance index [C-index] = 0.73, P = 0.002) and weight-indexed TTE-measured AVA diameter (C-index = 0.69, P = 0.001) were significant predictors of LVOTO. The maximal chi-square test identified the following cutoff values for predicting LVOTO: 1.4 for weight-indexed CT-measured LVOT diameter and 1.6 for weight-indexed TTE-measured AVA diameter. The high-risk group (both measures lower than the cutoff values) had a significantly lower rate of freedom from LVOTO development than the low-risk group (both measures higher than the cutoff values) (P < 0.001). The weight-indexed CT-measured LVOT diameter could be used to predict LVOTO development after neonatal arch repair, as an independent measure or complementary to traditional measures.

Reconstruction of the Aortic Arch in Neonates and Infants: The Importance of Patch Material.

Objectives:Restenosis after aortic arch reconstruction is a known complication in neonates and infants. Homograft is the most commonly used patch material for aortic arch reconstructions in our center. Since 2014, tissue-engineered bovine pericardium (CardioCel) has been used as an alternative. The aim of our study was to determine whether the choice of material affected the development of restenosis in these patients.Methods:Data of all neonates and infants who underwent aortic arch reconstruction with the use of any patch material between 2005 and 2016 were analyzed. Restenosis was defined by the need for reintervention, either percutaneous or surgical.Results:Forty-one patients underwent aortic arch repair. Excluding the 30-day mortality, 36 patients represented the study population. At primary repair, the aortic arch was reconstructed with homograft (n = 26) or CardioCel (n = 10). Restenosis was documented during the first year of life in 13 patients: Six (23%) patients in the homograft group and seven (70%) patients in the CardioCel group (P = .01). In the homograft group, the median time from operation to first intervention for restenosis was 22.0 (range: 14-32) weeks, as compared to 14.0 (range: 7-21) weeks in the CardioCel group (P = .04).Conclusion:We conclude that choice of patch material is likely to be an important determinant for the risk of restenosis needing reintervention following reconstruction of the aortic arch in neonates and infants.

Use of aortic arch measurements in evaluating significant arch hypoplasia in neonates with coarctation

BackgroundSurgical repair for neonatal arch hypoplasia with coarctation can be performed by a sternotomy or thoracotomy. ObjectivesThis study retrospectively investigates the use of pre-surgical absolute aortic arch measurements in guiding the optimal approach for neonates with coarctation and aortic arch hypoplasia. MethodsPatients ≤ 30 days old who underwent coarctation repair via a median sternotomy or lateral thoracotomy between January 2000 and July 2018 were retrospectively reviewed. Neonates requiring intracardiac surgery were excluded. Specific aortic arch measurements were obtained and 3 ratios calculated: distal transverse arch diameter/carotid artery diameter (DT/CA), distal transverse arch diameter/distance from the carotid to subclavian artery (CSA) and isthmus diameter/descending aorta diameter (I/D). ResultsOf 118 patients, 65 had a lateral thoracotomy and 53 had a median sternotomy. Distal transverse arch, the carotid artery and isthmus diameters correlated with surgical approach. The DT/CA ratio was statistically significant with an ROC curve (p < 0.0001; AUC 0.761) identifying a ratio of 0.9 (sensitivity 91%, specificity 32%) or less as indicative of aortic arch hypoplasia which is likely best suited for a median sternotomy repair. Reintervention rates were similar for both approaches overall and within the first 6 months of operation. ConclusionIn neonates with coarctation, pre-surgical aortic arch measurements and ratios can be utilized to identify aortic arch hypoplasia and guide surgical approach. In our institution, neonates with a DT/CA ratio of 0.9 or less routinely underwent arch reconstruction by a median sternotomy. Re-intervention rates in the median sternotomy and lateral thoracotomy groups were comparable.

Near-Infrared Spectroscopy Assessment of Tissue Oxygenation During Selective Cerebral Perfusion for Neonatal Aortic Arch Reconstruction.

Objective: Optimal selective cerebral perfusion (SCP) management for neonatal aortic arch surgery has not been extensively studied. We induced mild hypothermia during SCP and used the tissue oxygenation monitor to ensure adequate perfusion during the cardiopulmonary bypass (CPB).Methods: Eight cases were recruited from September 2018 to April 2020. SCP was maintained at 30°C, and CPB was adjusted to achieve a mean right radial artery pressure of 30 mmHg. The near-infrared tissue saturation (NIRS) monitor was applied to assess the right and left brain, flank, and lower extremity during the surgery.Results: During surgery, the mean age was 4.75 days, the mean body weight was 2.92 kg, the CPB duration was 86.5 ±18.7 min, the aortic cross-clamp time was 46.1 ± 12.7 min, and the SCP duration was 14.6±3.4 min. The brain NIRS before, during, and after SCP was 64.2, 67.2, and 71.5 on the left side and 67.9, 66.2, and 70.1 on the right side (p = NS), respectively. However, renal and lower extremity tissue oxygenation, respectively decreased from 61.6 and 62.4 before SCP to 37.7 and 39.9 after SCP (p < 0.05) and then increased to 70.1 and 90.4 after full body flow resumed. No stroke was reported postoperatively.Conclusion: SCP under mild hypothermia can aid in efficient maintenance of brain perfusion during neonatal arch reconstruction. The clinical outcome of this strategy was favorable for up to 20 min, but the safety duration of lower body ischemia warrants further analysis.

Ascending Aortic Slide for Interrupted Aortic Arch Repair

Interrupted aortic arch (IAA) often presents with a wide gap between the proximal and distal portions of the arch which challenge a tension-free anastomosis, potentially increasing the risk for residual or recurrent arch obstruction, and left main bronchial compression. When possible, to preserve potential for growth of the repair, native tissue-to-tissue reconstruction is always preferred. Accordingly, rather than forcing a direct anastomosis with native tissue under tension or needing an interposition graft, the ascending aortic slide is an alternative useful technique to repair interrupted aortic arch in neonates and infants with difficult anatomy. Using a bridging flap of native tissue from the split ascending aorta and completion with patch material to fill in the lesser arch curvature, it has successfully been used in nine babies for bi-ventricular repair and uni-ventricular palliation with satisfactory results, and potential for growth. Interrupted aortic arch (IAA) often presents with a wide gap between the proximal and distal portions of the arch which challenge a tension-free anastomosis, potentially increasing the risk for residual or recurrent arch obstruction, and left main bronchial compression. When possible, to preserve potential for growth of the repair, native tissue-to-tissue reconstruction is always preferred. Accordingly, rather than forcing a direct anastomosis with native tissue under tension or needing an interposition graft, the ascending aortic slide is an alternative useful technique to repair interrupted aortic arch in neonates and infants with difficult anatomy. Using a bridging flap of native tissue from the split ascending aorta and completion with patch material to fill in the lesser arch curvature, it has successfully been used in nine babies for bi-ventricular repair and uni-ventricular palliation with satisfactory results, and potential for growth. Commentary: Sometimes, the Bench Players Are Your Most Valuable PlayersOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 26Issue 3PreviewIn the current issue of the Operative Techniques Journal, Dodge-Khatami and Meyer describe their strategy for repair of interrupted aortic arch using the ascending aortic slide technique to bridge the gap between the interrupted arch segments. In their technique, the medial ascending aorta is split longitudinally in half starting from the sinotubular junction up to the arch origin. This ascending aorta flap is then rotated leftward and posteriorly and used as a posterior bridge of native tissue to connect the proximal and distal parts of the interruption. Full-Text PDF

Cirugía de arco aórtico con circulación extracorpórea en período neonatal

IntroductionAortic arch repair has shifted from deep hypothermia plus circulatory arrest to cerebral perfusion at tepid temperatures. A step forward is simultaneous brain-coronary perfusion, allowing beating-heart arch surgery. MethodsA “Y” cannula from the arterial line delivers oxigenated blood to brain and heart. The arch is repaired on a beating heart at 25°C. Intracardiac repair is performed after running cardioplegia through the root line. 68 patients are classified into three groups. A: Norwood (9 neonates); B: aortic arch (20 children); C: aortic arch plus intracardiac repair (39 patients). Associated anomalies in group C: ventricular septal defect (15), arterial switch (9), atrial septal defect (6), cor triatriatum (3), aortic commissurotomy (2), comprehensive repair (2), ostium primum (1), Yasui (1). Fourteen lately patients had their descending aorta additionally cannulated to achieve a total body perfusion strategy. ResultsMean by-pass time was 155minutes (range 63-353). Mean brain-coronary perfusion was 36minutes (18-60). Mean coronary ischemia was 34minutes (0-160). The heart was not arrested in group B patients. Follow-up was complete for a mean of 52 months (2-78). Five patients died in the postop. Three requiered angioplasty for recoarctation. ConclusionsSelective brain-coronary perfusion is feasible and easy to switch to conventional cardioplegia delivery. Coronary ischemia can be notably reduced, being even zero minutes in isolated arch surgery. Total body perfusion may reduce morbidity in neonatal arch surgery.

Факторы риска острого почечного повреждения после операций по поводу патологии дуги аорты у новорожденных

Цель. Выявить частоту и факторы риска возможного острого почечного повреждения (ОПП) при проведении операций на дуге аорты у новорожденных.

Invited Commentary

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

End-to-side anastomosis for interrupted aortic arch in neonates and infants

Objective: To review the early and mid-term results of end-to-side anastomosis technique for interrupted aortic arch in neonates and infants. Methods: Clinic data of 46 patients were diagnosed as interrupted aortic arch in Department of Cardiac Surgery, Guangzhou Women and Children's Medical Center between January 2010 and December 2016 were analyzed retrospectively. Twenty-six cases were neonates. The median age underwent surgery was 23 days (range: 2 days to 8 years). Anatomical subtypes included 36 cases of type A and 10 cases of type B. There was no type C case. The reconstruction of the aortic arch was completed by an extended end-to-side anastomosis technique between the descending aorta and the undersurface of the proximal aortic arch. In 42 patients, all with intracardiac anomalies, had concomitant complete repair of intracardiac anomalies through a median sternotomy. The remaining 4 patients, all without intracardiac anomalies, an end-to-side anastomosis was constructed through a left thoracotomy. During follow-up, aortic arch recurrent obstruction, left ventricular outflow tract obstruction (LVOTO) and tracheal stenosis were focused. Results: There were 3 surgical deaths, with amortality rate of 6.5%. The remaining 43 patients survived after surgery. In 39 of these patients, deep hypothermic cardiac arrest (DHCA) strategy was used for brain protection, and the mean time of DHCA was (16±3) minutes. Eight patients underwent delayed sternal closure. The mean mechanical ventilation time and ICU stay time were (3.4±1.6) days (range: 2 to 12 days) and (6.4±2.7) days (range: 3 to 16 days) respectively. In 16 patients, all with tracheal or bronchial stenosis before surgery, mechanical ventilation was successfully evacuated, and no new airway stenosis occurred. There was no residual pressure difference between upper and lower extremity arterial blood pressure at discharge. Echocardiography showed normal arterial blood flow velocity in aortic arch. At a mean follow-up of (36.2±18.9) months (range: 6 months to 7 years), there were two patients lost and one late date. Four patients developed a recurrent stenosis at the aortic arch, of which two were severe, and the other two were mild. In 2 patients, both with mild LVOTO before surgery, no significant increase in the degree of obstruction was found during the follow-up. Two patients developed new mild to moderate LVOTO without clinical symptoms, and continued to follow up. In all patients, the tracheal or bronchial stenosis were extenuated, and there was no new progressive airway stenosis by regular bronchoscopy. Conclusions: The end-to-side anastomosis technique for the reconstruction of the aortic arch achieved excellent early and mid-term results in neonates and infants suffered from interrupted aortic arch. Reducing the anastomotic tension by extensive mobilization is the key to prevent postoperative early complications and late recurrent arch obstruction.

Invited Commentary

Invited Commentary

Neonatal Aortic Arch Reconstruction With Direct Splanchnic Perfusion Avoids Deep Hypothermia

Neonatal aortic arch reconstruction, typically performed with deep hypothermia and selective cerebral perfusion, leaves splanchnic organ protection dependent on hypothermia alone. A simplified method of direct in-field descending aortic perfusion during neonatal arch reconstruction permits the avoidance of deep hypothermia. We hypothesize that direct splanchnic perfusion at mild hypothermia provides improved or equivalent safety compared with deep hypothermia and may contribute to postoperative extracardiac organ recovery. Included were 138 biventricular patients aged younger than 90 days undergoing aortic arch reconstruction with cardiopulmonary bypass. Patients were grouped according to perfusion method A (selective cerebral perfusion with deep hyperthermia at 18° to 20°C) or method B (selective cerebral perfusion and splanchnic perfusion at 30° to 32°C). Patient characteristics and perioperative clinical and serologic data were analyzed. Significance was assigned for p of less than0.05. Of the 138 survivors, 63 underwent method A and 75 underwent method B. The median age at operation was 8.5 days (range, 6 to 15 days), and median weight was 3.2 kg (range, 2.8 to 3.73 kg), with no significant differences between groups. Cardiopulmonary bypass times were comparable between the two perfusion methods (p= 0.255) as were the ascending aortic cross-clamp times (p= 0.737). The postoperative glomerular filtration rate was significantly different between our groups (p= 0.028 to 0.044), with method B achieving a higher glomerular filtration rate. No significant differences were seen in ventilator time, postoperative length of stay, fractional increase of postoperative serum creatinine over preoperative serum creatinine, and postoperative lactate. A simplified method of direct splanchnic perfusion during neonatal aortic arch reconstruction avoids the use of deep hypothermia and provides renal protection at least as effective as deep hypothermia.

Modeling Outcomes: Modified Aortic Arch Advancement for Neonatal Hypoplastic Arch.

Numerous surgical approaches regarding aortic arch advancement for neonatal arch hypoplasia have been described. These repairs can be classified into two categories: those that incorporate a patch and those that do not. The decision between repairs remains largely experiential, rather than empirical, because of the limited number of reported outcomes. We report early outcomes from neonates undergoing modified aortic arch advancement with an anterior patch and our experience using computational fluid dynamic modeling to better understand the hemodynamic consequences associated with this repair. A retrospective review of neonates undergoing aortic arch advancement with anterior patch in 2014 at a single institution was performed. Anatomical, perioperative, and follow-up data were collected. Three-dimensional cardiac magnetic resonance images were used to generate computational fluid dynamic models of the modified anterior patch and direct end-to-side repairs. Cardiac waveform inputs were simulated and hemodynamic analyzed. Ten neonates underwent modified aortic arch advancement. No hemodynamically significant gradients were observed at a median follow-up of 0.77 (0.30-1.2) years. Asymmetrical flow was observed in the end-to-side repair, whereas more concentric laminar flow was observed throughout the modified model. Spatial variations in velocities immediately distal to the anastomosis were greater in the end-to-side model (0.35 vs 0.17 m/s, P < 0.001). Time-averaged variations in wall shear stress during systole were greater in the end-to-side model at the same location (3.44 vs 1.98 dynes/cm, P < 0.001). Early outcomes after the use of an anterior patch for neonatal hypoplastic aortic arch repair show favorable hemodynamic outcomes.

Aortic coarctation repair in neonates with intracardiac defects: the importance of preservation of the lesser curvature of the aortic arch.

The aim of this study was to evaluate the mid-term outcomes of a strategy for repair of coarctation of the aorta (CoA) and hypoplastic aortic arch (HAA) with a modified, extended end-to-end repair that preserves the lesser curvature of the aortic arch in neonates with intracardiac defects. We studied 21 neonates who underwent CoA repair and remote intracardiac repair (2000-2013). Fifteen patients had HAA, and six patients had no HAA. Follow-up ranged from 0.4 to 12.8 years (median, 7.5 years), and all patients underwent cardiac catheterization and blood pressure measurement in both the arms and legs. The overall median age at the time of CoA repair was seven days and the median age at the time of intracardiac defect repair was 18.6 months. There were no hospital deaths and one case had recoarctation (4.8%). The overall mean pressure gradient at the latest follow-up was 3.4 ± 5.7 mmHg. Critical deformation of arch geometry was not found. No patient had hypertension or an abnormal arm-leg gradient. There was no difference in the cardiac catheterization data or blood pressure between patients with and without HAA. A modified, extended end-to-end repair for CoA and HAA resulted in a low rate of recoarctation, no operative mortality, maintenance of a smooth rounded arch, and normal blood pressures in the arms and legs during mid-term follow-up. These results suggest that this technique may be acceptable for repair of CoA and HAA in neonates with intracardiac defects.

Aortic Arch Advancement for Aortic Coarctation and Hypoplastic Aortic Arch in Neonates and Infants

The optimal treatment for infants with aortic coarctation and hypoplastic aortic arch is controversial. The goal of this study was to report the short-term and mid-term outcomes of aortic arch advancement (AAA) in infants with hypoplastic aortic arch. All infants who underwent AAA at our institution from 1995 to 2012 were included. AAA consisted of coarctectomy and end-to-side anastomosis of the descending aorta to the distal ascending aorta/proximal arch through a median sternotomy. The cohort was divided into four groups: (1) isolated AAA (n=29, 11%), (2) AAA with closure of ventricular septal defect (n=56, 20%), (3) AAA with other biventricular repairs (n=115, 42%), and (4) AAA as part of single-ventricle palliation (n=75, 27%). The cohort included 275 patients: 125 (45%) were female, and the median age was 14 days (interquartile range, 7-34 days). Genetic abnormalities were present in 48 patients (17%). Neurologic adverse events occurred in 3 patients (1%), all in group 4. Left bronchial compression was seen in 2 patients (0.7%); only one required intervention. Vocal cord dysfunction was noted in 36 of 95 patients (38%) on routine laryngoscopy. Only 1 patient had clinical residual dysfunction at the last follow-up visit. Perioperative mortality was 3% (n=8). At a median follow-up time of 6 years, 8 patients (3%) had reinterventions at a median time of 5 months (3-17 months) after repair. AAA is a safe, effective, and durable operation with low rates of adverse events and mid-term reintervention. The advantages include native tissue-to-tissue reconstruction and preserved potential for growth. As such, it is the ideal technique for the management of hypoplastic aortic arch in neonates and infants.

Preoperative Assessment of the Aortic Arch by High-Pitch Dual-Source Computed Tomography in Neonates and Babies with Congenital Heart Disease: A Single-Center, Retrospective Analysis of 37 Cases

Objectives: Evaluation of feasibility, impact and image quality of high pitch DSCT, and 3D reconstructions to assess the arbitrary anatomical malformations of the aortic arch in neonates and babies.

Favourable Anatomy After End-to-Side Repair of Interrupted Aortic Arch

To evaluate cardiovascular outcomes in patients with aortic arch repair and their possible correlation with arch geometry. Ten patients who underwent end-to-side repair for aortic arch interruption (IAA), older than 10 years were compared to a cohort of 10 post coarctation (CoA) repair patients matched for age, sex and age at repair. Mean age at operation was 9.7±6.5 days. Patients underwent a resting and 24 h blood pressure measurements, exercise study, MRI, transthoracic echocardiography and vascular studies. Seven patients developed hypertension, two from IAA group and five from CoA group. Nine patients (45%) had gothic arch geometry, three from IAA group and six from CoA group. Despite differences in arch geometry, both groups had normal LV mass, LV function and vascular function. No differences in functional or morphologic outcomes could be demonstrated between the end-to-side repair of the arch by sternotomy and the conventional coarctation repair by thoracotomy. A favourable arch geometry can be achieved after the end-to-side repair of the aortic arch. In the present study, we could not correlate adverse arch geometry with any adverse cardio-vascular outcomes. After neonatal arch repair, the contributive role of aortic arch geometry to late hypertension remains uncertain.

Newborn Aortic Arch Reconstruction With Descending Aortic Cannulation Improves Postoperative Renal Function

A clinically driven transition in perfusion technique occurred at Children's Hospital and Medical Center, Omaha, Nebraska, from primarily selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest to a technique of dual arterial perfusion including innominate artery and descending aortic cannulation (DAC), with continuous mildly hypothermic (>30 °C) full-flow cardiopulmonary bypass to the entire body. This study retrospectively compared outcomes in a recent cohort of neonates undergoing aortic arch reconstruction with the two techniques. The clinical records of 142 consecutive neonates undergoing operations involving aortic arch reconstruction at a single institution between April 2004 and September 2012 were reviewed. Renal function changes were graded according to the pediatric RIFLE score (based on risk, injury, failure, loss, and end-stage kidney disease). Sixteen patients, 8 supported with selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest and 8 with DAC, required immediate postoperative extracorporeal membrane oxygenation and were excluded from renal function analysis. Multivariable regression models evaluated predictors of pediatric RIFLE score. Patients with DAC had shorter median bypass support (113 versus 172 minutes; p < 0.001) and myocardial ischemic time (43 versus 81 minutes; p < 0.001). Patients with DAC had less median fluid gain at 24 hours (37 versus 69 mL/kg; p < 0.001), and lower incidence of acute kidney injury (5% versus 31%; p < 0.001). Fewer patients with DAC (31% versus 58%; p = 0.001) required open chest. Use of selective cerebral perfusion bracketed by brief periods of deep hypothermic circulatory arrest, single-ventricular physiology, and aortic cross-clamp time were found to be multivariable predictors of serious kidney dysfunction. Multisite arterial perfusion, including DAC, and maintenance of continuous mildly hypothermic full-flow cardiopulmonary bypass may offer advantages as a perfusion strategy for neonatal arch reconstruction. Prospective investigation of this technique is warranted.

Surgical Management of Neonatal Atrioventricular Septal Defect With Aortic Arch Obstruction

For neonates with atrioventricular septal defect and aortic arch obstruction including coarctation of the aorta, we sought to determine whether a difference in outcomes exists after a primary neonatal versus staged surgical repair (neonatal arch repair with delayed intracardiac repair). This retrospective cohort study included consecutive neonates with atrioventricular septal defect and aortic arch obstruction who underwent cardiac surgery before 28 days of age at six centers from 1990 to 2009. Characteristics and outcomes between patients undergoing neonatal versus staged repair were compared. Of 66 study patients, 31 (47%) underwent primary neonatal repair and 35 (53%) underwent staged repair. At baseline echocardiogram, a greater percentage of neonatal repair patients had relative unbalanced ventricular size (56% versus 35%, p = 0.02). There were no other differences in demographic characteristics, cardiac anatomical or functional details, or surgical technique. Those undergoing neonatal repair tended to be more likely to have at least moderate left atrioventricular valve regurgitation early after repair (42% versus 19%, p = 0.05) and to have at least one major in-hospital complication (42% versus 20%, p = 0.06). After the initial cardiac operation, compared with the neonatal repair group, patients undergoing staged repair had greater survival (87% versus 57% at 6 years, log-rank p = 0.02) and freedom from the first unplanned cardiac reoperation (69% versus 45% at 6 years, log-rank p = 0.005). For neonates with atrioventricular septal defect and aortic arch obstruction, when compared with neonatal repair, a staged approach was associated with improved survival and lower morbidity.