Arch Obstruction Research Articles

Cerebral perfusion protection in newborns after surgical correction of aortic coarctation with aortic arch hypoplasia

Aim: To compare the rate of neurologic complications in infants with aortic coarctation and aortic arch hypoplasia undergoing aortic arch repair under deep hypothermic circulatory arrest or full-flow perfusion with double arterial cannulation. Material and Methods: This pilot single-center simple blinded prospective study assessed the early postoperative outcomes in infants with aortic arch obstruction. Patients underwent on-pump repair under deep hypothermic circulatory arrest (I group, 20 patients) or full-flow perfusion with double arterial cannulation (II group, 20 patients). Results: In-hospital mortality was 5% (1 patient) in each group (p>0.05). Neurologic complications occurred in 14 (70%) patients of the 1st group and 6 patients (30%) of the 2nd group (p=0.025). The only significant risk factor was head tissue saturation according to near-infrared spectroscopy. Each percent decreased the risk of neurologic event by 6%. Conclusion: Aortic arch repair under full-flow perfusion reduces the rate of neurologic events in infants compared to deep hypo- thermic circulatory arrest. Head tissue saturation was the risk factor of neurologic complications. Each percent decreased the risk of neurologic event by 6%.

Abstract 8911: Incidence and Risk Factors of Aortic Arch Obstruction After the Comprehensive Stage II Procedure

Introduction: Minimal data exist about the incidence and risk factors for arch intervention after Comprehensive Stage II (CSII). Goal of this study was to document incidence of arch interventions after CSII and determine if any differences existed between those that underwent an arch intervention (aiCSII) versus those did not have an intervention. Methods: Retrospective chart review of all hypoplastic left heart syndrome patients that underwent a CSII between 6/1/2005 through 2/1/2020 was performed. Univariate analysis was conducted in addition to principal components analysis (PCA). Results: One hundred patients were evaluated. Sixteen patients underwent 24 arch interventions. Age at initial arch reintervention was 1.3 + 1.2 years (median 1.0 years, range 0.5 - 2.2 years). Univariate analysis showed that the aiCSII group were more likely to be female, to have had a retrograde arch intervention post-hybrid procedure, and to be younger at time of CSII. On echocardiograms, aiCSII group had significantly higher pre-CSII patent ductus arteriosus velocities, arch velocities on their 1 st post-operative and discharge study post-CSII, and arch velocities pre-Fontan. Gradients were higher in the aiCSII via pre-Fontan catheterization. With PCA, echocardiographic and catheterization data remained significantly associated with aiCSII versus those that did not undergo an arch intervention (OR = 4.5 (1.9, 19.8), p < 0.01). Mortality was not associated with arch intervention. Conclusions: Incidence of arch intervention post-CSII was 16%. Echocardiographic arch gradients during the CSII hospitalization were the strongest predictors for subsequent aortic arch interventions. Further studies are needed to determine any modifiable variables that may reduce the incidence of arch interventions.

Abstract 9310: Aortic Arch Shape After Coarctation Repair Predicts Exercise Capacity: A Multicenter Analysis

Introduction: Patients with coarctation of the aorta (CoA) have decreased exercise capacity despite successful repair with no anatomic obstruction. Altered aortic arch shape after surgical repair may increase resistance to flow and affect flow distribution. This study correlates parameters of aorta size and flow with exercise capacity after successful CoA repair. Methods: We retrospectively reviewed patients with repaired CoA at 4 centers who had cardiac magnetic resonance imaging (CMR) and an exercise stress test with respiratory exchange ratio ≥ 1.09 within 1 year. Patients with significant valve disease, outflow tract obstruction, or need for cardiac bypass outside of their arch repair were excluded. Aorta size mismatch (D AAo /D DAo ), defined by the ratio of ascending (AAo) to proximal descending aorta (DAo) diameter, and DAo flow as a percentage of AAo flow, were measured from CMR. Each parameter was correlated with percent predicted peak oxygen consumption (VO2 max). Results: Forty-six patients (age 26 ± 8.4 years) with left ventricular ejection fraction (LVEF) > 52%, met inclusion criteria. Larger D AAo /D DAo and lower %DAo flow correlated significantly with lower VO2 max (Fig). Compared to those with normal VO2 max (n=25), patients with VO2 max <90% predicted (n=21) had a primary repair at an older age (p=0.03) and smaller DAo diameter/m 2 (p=0.04). There were no significant differences in prevalence of arch obstruction by echocardiogram, LVEF, hypertension, blood pressure gradient at rest or exercise, or AAo diameter/m 2 between groups. Conclusions: Aorta size mismatch, due to AAo dilation or small DAo, and associated decreased %DAo flow, correlate significantly with decreased exercise capacity after CoA repair in patients with normal left ventricular systolic function. CMR measurements of aorta geometry and flow can inform the definition of a successful repair and suggest that indications for re-intervention may not be limited to discrete re-coarctation.

Digoxin Associated With Greater Transplant-Free Survival in High- vs Low-Risk Interstage Patients

BackgroundDigoxin has been associated with reduced interstage mortality for patients with functional single ventricles with aortic hypoplasia or ductal-dependent systemic circulation. The NEONATE (type of stage 1 palliation operation, postoperative extracorporeal membrane oxygenation, discharge with opiates, no digoxin at discharge, postoperative arch obstruction, moderate to severe tricuspid regurgitation without an oxygen requirement, and extra oxygen required at discharge in patients with moderate to severe tricuspid regurgitation) score can stratify patients by risk of death or transplantation (DTx) on the basis of clinical factors. The study investigators suspected a variable transplant-free survival benefit of digoxin in high-risk vs low-risk patients. MethodsNational Pediatric Cardiology Quality Improvement Collaborative patients discharged after stage 1 palliation with complete data were categorized as high- or low-risk on the basis of a modified NEONATE score. The primary outcome of DTx was evaluated. A mixed-effect regression evaluated associations between digoxin prescription and risk factors. ResultsA total of 1199 patients were included; 399 (33%) were high risk. Baseline demographics were similar between the cohorts. Blalock-Taussig shunt or a hybrid operation, postoperative extracorporeal membrane oxygenation, opiate prescription, and significant tricuspid regurgitation or arch obstruction were more common in high-risk patients. The odds of DTx were 65% lower in high-risk patients prescribed digoxin compared with patients who were not (P = .001). Digoxin prescription was associated with 60.8% lower DTx in the high-risk cohort (7.8% vs 19.9%; P = .001). There was no significant difference in the DTx rate according to digoxin prescription in the low-risk cohort (4.7% vs 5.7%; P = .46). Blalock-Taussig shunt, aortic arch obstruction, and significant tricuspid regurgitation were most strongly associated with deriving a benefit from digoxin. ConclusionsDigoxin use is associated with significant improvement in transplant-free survival in high-risk but not in low-risk interstage patients. A tailored approach to the use of digoxin in interstage patients may be warranted.

A Simplified Approach to Predicting Reintervention in the Arterial Switch Operation

We investigated patients with transposition anatomy suitable for the arterial switch operation (ASO) to evaluate a simplified approach to prediction of reintervention. A retrospective review was performed of 180 consecutive patients who underwent ASO from 2009 to 2018. Patients were classified as Category I (n = 122) d-transposition of great arteries (dTGA) + intact ventricular septum, Category II (n = 28) dTGA + ventricular septal defect (VSD) and Category III (n = 30) dTGA + Aortic arch obstruction (AAO) +/- VSD or Taussig-Bing Anomaly (TBA) +/- AAO. Outcomes included reintervention-free survival (using Kaplan-Meier estimates) and predictors of reintervention. Median follow up was 3.3 (interquartile range 1.7-5.8) years with no difference between categories(P = 0.082). There were 3 mortalities- 2 early (one each in Category I and II) and one late (in Category I). Reintervention-free survival for the whole group at 1, 3, 5 and 8 years was 94%, 91%, 90% and 86% respectively. Conventional criteria predicting reintervention included the presence of TBA(P = 0.0054) and AAO(P = 0.027). Low birth weight did not predict reintervention(P = 0.2). When analyzed by category, multivariable analysis showed that patients in Category III carried a high risk of reintervention [Hazard risk (HR) = 7.43, 95% confidence interval (CI)=(2.39, 23.11), P < 0.001], but so did those in Category II [HR=6.90, 95% CI = (2.19, 21.75, P < 0.001] when compared to Category I. Conventional risk factors for technical difficulty may not be the best predictors of reintervention. A simplified approach highlights Category II patients (dTGA + VSD) as being at substantial risk of re-intervention, and not part of a low risk cohort.

Long-term evolution of aortic arch interruption repair with pulmonary artery autograft

Surgical correction of the aortic arch interruption (IAA) is regularly complicated by anastomosis stenosis or the long-term occurrence of arterial hypertension. In order to prevent these complications, a new surgical technique has been developed in our center consisting of the interposition of a segment of the main pulmonary artery to enlarge the aortic anastomosis. The purpose of this study was to assess the 10 years outcome of this intervention. Four children undergoing this surgery with a follow-up over 10 years were retrospectively included. Data collected focused on the last measure of blood pressure (BP), the last echocardiographic evaluation, and the aortic arch dimension on the last CT. The whole patients had IAA type B and 22q11 microdeletion. The median follow-up duration was 13.9 years (range: 9.3 to 15.3). None of them had a new surgery of the aortic arch, but one need enlargement of ascending aorta. Only one patient developed a mild restenosis at the isthmic insertion of the pulmonary autograft [Z score −2.7 at CT ( Fig. 1 C)], responsible of mild arterial hypertension (systolic BP 75th percentile, diastolic BP 98th percentile), and a left ventricle hypertrophy (Z score IVSd 2.5, Z Score LVPWd 2.1). The three others patients displayed normal BP, no left ventricular hypertrophy, no significant aortic arch obstruction on Doppler evaluation and minimum Z score of aortic arch at CT from −1.8 to −0.4 ( Fig. 1 A, B, D). None of them did experience a main pulmonary artery stenosis. Reconstruction of the aortic arch with a pulmonary artery autograft for the correction of IAA provides a good long-term result.

Early and Late Outcomes after Arterial Switch Operation: A 40-Year Journey in a Single Low Case Volume Center.

Background and Objectives: The results of the arterial switch operation in large congenital heart centers are excellent, and the results in small and medium centers are improving. The objective of this article is to share our experience utilizing the international knowledge transfer program to improve early and late arterial switch operation outcomes in our center. Materials and Methods: A retrospective analysis of patients who underwent the arterial switch operation in Vilnius University Santaros Clinics Cardiothoracic Surgery Center between 1977–2020 was performed. Results: A total of 127 consecutive arterial switch operations were performed in our center. Surgical mortality during the entire study period was 24.6%. Surgical mortality prior to the program, during the program, and after the program was 88.24%, 41.7%, and 5.81%, respectively (p < 0.0001). The surgical mortality of patients operated on during the last 10 years was 4%. The overall survival estimate for the 97 surviving patients was 96.9%, 94.9%, 93.8%, 93.8%, 93.8%, 93.8% at 1, 3, 5, 10, 15, and 20 years, respectively. Risk factors for early mortality included longer aortic cross-clamp time and operation prior to the knowledge transfer program. The only significant risk factor for late reintervention was concomitant aortic arch obstruction treated at the time of the arterial switch. Conclusions: The surgical treatment of transposition of the great arteries by means of an arterial switch with good results can be possible in low-to-medium volume congenital heart surgery centers. International knowledge transfer programs between high-expertise high-volume congenital heart centers and low-to-medium volume congenital heart centers may help to shorten the learning curve and improve early and late outcomes after an arterial switch. The risk factors for surgical mortality and intervention-free survival in low-volume surgical centers are similar to those in high-volume centers. Late arterial switch-related complications are similar to those among different-sized congenital heart centers.

Arterial Switch Operation in Patients With Taussig-Bing Anomaly and Aortic Arch Obstruction

BackgroundArterial switch operation (ASO) in children with Taussig-Bing anomaly and associated aortic arch obstruction (AAO) is technically demanding. This study sought to determine outcomes of patients with Taussig-Bing anomaly and AAO who underwent ASO at a single institution. MethodsFrom 1983 to 2015, 844 patients underwent an ASO for biventricular repair at The Royal Children’s Hospital. Twenty-eight patients (3.3%) had Taussig-Bing anomaly and AAO. ResultsOf 28 patients, 21 (75%) underwent ASO and AAO repair as a single-stage procedure and 7 (25%) had arch repair before ASO. There were no early or late deaths. Follow-up after hospital discharge was available for all patients. Median follow-up was 17.5 years (interquartile range, 9.2-22.3; range, 4.0-31.5). All patients were in New York Heart Association class I at last follow-up. Freedom from reintervention was 61% (95% confidence interval, 40-76) and 56% (95% confidence interval, 36-73) at 5 and 15 years, respectively, after ASO. The most common reinterventions were repair of recurrent AAO, branch pulmonary artery stenosis, and neoaortic valve repair. Four of 28 patients (14%) required 5 reinterventions (3 reoperations and 2 catheter reintervention) for recurrent AAO at a median of 2.2 years after ASO (interquartile range, 2.1-2.3). ConclusionsPatients with Taussig-Bing anomaly and AAO can undergo ASO with excellent survival. Reintervention is equally common for both left- and right-sided obstruction.

Long-term outcome after the arterial switch operation: 43 years of experience.

OBJECTIVESThe objective of this study was to assess our 43-year experience with arterial switch operation (ASO) for transposition of the great arteries (TGA) by analysing cardiac outcome measures (hospital and late mortality, reoperations and catheter interventions, significant coronary artery obstruction) and to identify risk factors for reoperation and catheter interventions. METHODSA total of 490 patients who underwent ASO for TGA from 1977 to 2020 were included in this retrospective, single-centre study. Data on reoperation and catheter intervention of hospital survivors were estimated by the Kaplan–Meier method and compared using a long-rank test. Risk factors for reoperation and/or catheter intervention were assessed by multivariate Cox regression analysis.RESULTSHospital mortality occurred in 43 patients (8.8%), late death in 12 patients (2.9%) and 43 patients were lost to follow-up. Median follow-up time of 413 hospital survivors was 15.6 (interquartile range 7.0–22.4) years. Reoperations were performed in 83 patients (117 reoperations). Neoaortic valve regurgitation with root dilatation was the second most common indication for reoperation (15/83 patients, 18.1%) after right ventricular outflow tract obstruction (50/83 patients, 60.2%). Risk factors for any reoperation on multivariable analysis were: TGA morphological subtype [TGA with ventricular septal defect: hazard ratio (HR) = 1.99, 95% confidence interval (CI) 1.18–3.36; P = 0.010 and Taussig-Bing: HR = 2.17, 95% CI 1.02–4.64; P = 0.045], aortic arch repair associated with ASO (HR = 3.03, 95% CI 1.62–5.69; P = 0.001) and a non-usual coronary artery anatomy (HR = 2.41, 95% CI 1.45–4.00; P = 0.001). One hundred and one catheter interventions were performed in 54 patients, usually for relief of supravalvular pulmonary stenosis (44/54 patients, 81.5%) or arch obstruction (10/54 patients, 18.5%). Main risk factor for catheter intervention on multivariable analysis was aortic arch repair associated with ASO (HR = 2.95, 95% CI 1.37–6.36; P = 0.006). Significant coronary artery stenosis was relatively uncommon (9/413 patients, 2.2%) but may be underrepresented.CONCLUSIONSPatients after ASO typically have good long-term clinical outcomes but reoperations and interventions remain necessary in some patients. Neoaortic valve regurgitation with root dilatation is the second most common indication for reoperation after right ventricular outflow tract obstruction and an increasing need for neoaortic valve and root redo surgery in future is to be expected.

Interventions after Arterial Switch: A Single Low Case-Volume Center Experience.

Background and Objectives: With the growing population of arterial switch operation survivors, the rate of late complications associated with the operation is growing as well. The aim of this publication is to share our experience and encourage collaboration between congenital cardiac surgeons and interventional cardiologists in treating late complications after arterial switch operation. Materials and Methods: A retrospective analysis of Vilnius University Santaros Clinics Cardiothoracic Surgery Centre arterial switch operation survivors who underwent additional treatment for late neo-pulmonary artery stenosis and aortic arch obstruction between 1989 and 2019 was conducted. Results: Out of 95 arterial switch operation survivors 14 (15%) underwent 36 reinterventions. The majority were treated for neo-pulmonary stenosis. The median time from arterial switch operation to the first reintervention was 1.4 years (interquartile range, 2 months to 2.4 years). 1, 3, 5, and 10 years intervention-free survival in patients treated for neo-pulmonary stenosis and aortic arch obstruction was 98, 94, 94, and 93% vs. 95, 94, 94, and 93%, respectively. There were no complications associated with redo surgical procedures, while eight patients who underwent catheter-based interventional treatment had treatment-related complications, including one death. Conclusions: Both neo-pulmonary stenosis and aortic arch obstruction (new aortic coarctations or aortic recoarctations) tend to develop in the first decade after an arterial switch operation. Surgical and catheter-based interventional treatment with good results is possible even in a small volume center. Close collaboration of the congenital heart team (congenital cardiac surgeons and interventional cardiologists) in choosing the best treatment option for an individual patient helps to minimize the risk of potential complications.

Surgery for Taussig-Bing Anomaly With Aortic Arch Obstruction

Taussig-Bing anomaly with aortic arch obstruction is uncommon and presents a significant technical challenge to the pediatric cardiac surgeon. Herein we describe the arterial switch operation with technical modifications appropriate to the Taussig-Bing anomaly as well as the preferred end to side arch repair. Taussig-Bing anomaly with aortic arch obstruction is uncommon and presents a significant technical challenge to the pediatric cardiac surgeon. Herein we describe the arterial switch operation with technical modifications appropriate to the Taussig-Bing anomaly as well as the preferred end to side arch repair. Commentary: Get in the Groove When Stuck Doing the SwitchOperative Techniques in Thoracic and Cardiovascular SurgeryVol. 26Issue 4PreviewRight ventricular outflow tract obstruction (RVOTO) following the arterial switch operation (ASO) is common, with reported incidence rates of up to 50%.1 For complex transposition of the great arteries (eg transposition of the great arteries with conotruncal criss-cross) or Taussig-Bing anomaly the risk is even higher, secondary to the embryological basis for the underlying anomaly.2-5 Given the complexity of the initial operation, some surgeons may delay management of borderline or inevitable RVOTO, due to complex coronary anatomy or a “less is more” philosophy. Full-Text PDF

Yasui Conversion After Biventricular Repair in Patients With Left Ventricular Outflow Tract Obstruction

Surgical re-intervention for progressive left ventricular outflow tract obstruction after a standard biventricular repair of aortic arch obstruction and ventricular septal defect is rare but can occur. In this situation, left ventricular outflow bypass surgery can be performed to relieve left ventricular outflow tract obstruction by creating an intraventricular baffle to channel the re-opened ventricular septal defect to the pulmonary valve, Damus-Kaye-Stansel anastomosis, and right ventricle-to-pulmonary artery connection with a valved conduit. This strategy, termed as “Yasui conversion,” is a safe and useful alternative procedure for selected patients. Surgical re-intervention for progressive left ventricular outflow tract obstruction after a standard biventricular repair of aortic arch obstruction and ventricular septal defect is rare but can occur. In this situation, left ventricular outflow bypass surgery can be performed to relieve left ventricular outflow tract obstruction by creating an intraventricular baffle to channel the re-opened ventricular septal defect to the pulmonary valve, Damus-Kaye-Stansel anastomosis, and right ventricle-to-pulmonary artery connection with a valved conduit. This strategy, termed as “Yasui conversion,” is a safe and useful alternative procedure for selected patients.

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

Management of aortic arch hypoplasia in neonates and infants.

Surgical management of aortic arch hypoplasia (AAH) with associated intracardiac anomalies is a challenge in newborns. We reviewed the characteristics and outcomes of neonates and infants who underwent pulmonary artery banding concomitant to arch repair and single-stage total repair at our institution. Medical records of 60 patients undergoing aortic arch reconstruction for AAH from 2014 to 2019 were retrospectively reviewed. Twenty-five patients were female (41.6%), and the age of the patients ranged from 4 to 120 days (median, 19.5 days). The patients were divided into two groups: Group 1 (23 patients) underwent pulmonary artery banding concomitant to arch repair, and Group 2 (37 patients) underwent single-stage total repair in addition to arch repair. All arch repair procedures consisted of an extended (to the midportion of the ascending aorta) patch aortoplasty. Postoperative early mortality occurred in 12 patients, eight in Group 1 (34.8%) and four in Group 2 (10.8%). There was an early survival advantage in Group 2 (p = .019). Recoarctation occurred in 13 cases (21.6%), and 11 (18.3%) of them required reintervention (balloon angioplasty: 7, reoperation: 4). On univariate analysis, risk factors associated with death were pulmonary artery banding (hazard ratio [HR], 0.44; confidence interval [CI], 0.09-2; p = .019), prematurity (HR, 4.67; CI, 1.34-16.18; p = <.001), preoperative mechanical ventilation support requirement (HR, 0.048; CI, 0.52-6.39; p = .048), and functional single ventricle (HR, 0.43; CI, 0.1-1.86; p = .006). The mean duration of follow-up was 21.9 ± 15.1 months, and there was no late death in either group. Single-stage repair of AAH with intracardiac pathologies has better results than palliation, according to survival rates and postoperative results. The use of the patch augmentation technique in AAH is valid and associated with an acceptable incidence of recurrent arch obstruction.

Selective Lesser Curvature Augmentation With Geometric Study for Repair of Aortic Arch Obstruction

We repaired aortic coarctation and interrupted aortic arch with extended end-to-end anastomosis (EAA) through median sternotomy and performed lesser curvature augmentation with a pulmonary autograft patch (PAP) in selected patients with a long gap between anastomotic sites. We reviewed these outcomes and geometric implications. All neonates and infants with biventricular morphology who underwent aortic arch reconstruction through median sternotomy between 2005 and 2019 were evaluated. Aortic arch geometry was analyzed with computed tomography routinely performed before and after surgery from 2009 on. There were 91 consecutive patients (median age, 1.2 months). Ten patients received PAP. One early death and no late deaths were noted. Overall survival was 98.9% at 10 years. Two left bronchomalacia and 1 recoarctation occurred in patients with EAA. Freedom from recoarctation was 97.4% at 10 years. We examined 68 patients with computed tomography. We used PAP in patients with a significantly longer gap between anastomotic sites indexed by the square root of the body surface area; its cutoff value was 29.0 mm/m (area under the curve, 0.86 mm/m). The PAP created a significantly greater arch angle (median, 91° versus 83°) and arch/descending diameter ratio (median, 1.2 versus 1.0) and preserved the arch width indexed by the square root of the body surface area (median, before surgery: 35.7 versus 34.4 mm/m; after surgery: 36.5 versus 29.9mm/m), compared withEAA. Aortic arch reconstruction with the current combined strategy provides satisfactory outcomes. Guided by geometric analysis, lesser curvature augmentation can be applied to patients who might experience recoarctation or airway compression with a directly anastomosed aortic arch.

Arterial switch operation for Taussig-Bing anomaly with aortic arch obstruction.

The short-term survival rate after single-stage correction of Taussig-Bing anomaly with aortic arch obstruction remains favorable. However, some cases are encountered occasionally in which single-stage correction was not performed during the neonatal period. Accordingly, we evaluated the midterm outcomes of different surgical strategies. Seven patients who underwent an arterial switch operation and intraventricular rerouting as definitive surgery between 2007 and 2017 were investigated. Of these 7 patients, 3 had undergone previous pulmonary artery banding and aortic arch reconstruction. The median body weight at definitive surgery was 3.3 kg (range 2.9-8.3 kg). At definitive surgery, the arrest time for single-stage correction (162.3 ± 21.7 min) was significantly shorter than that of staged repair (206.3 ± 5.1 min, p = 0.020). There was no hospital or late death. One patient in both strategy groups underwent aortic reintervention 54 months and 7.1 months after the definitive operation. Neoaortic valve (perinatal pulmonary valve) diameter decreased significantly from the perinatal valve diameter following definitive surgery (median +4.94z and +2.12z, respectively, p = 0.016) but there was no significant difference in the neopulmonary valve (perinatal aortic valve) diameter. Both single-stage correction and staged repair patients showed a similar trend. At the last follow-up, no patient had greater than mild neoaortic or neopulmonary valve regurgitation. The surgical outcomes of both single-stage correction and staged correction for Taussig-Bing anomaly with aortic arch obstruction are excellent. Both strategies produce similar changes in the diameter and regurgitation grade of the neoaortic and neopulmonary valves.

Single-stage repair for coarctation with ventricular septal defect: results of 100 cases at a single centre.

The outcomes of the single-stage surgical repair of aortic arch hypoplasia (AAH) and/or coarctation of the aorta (CoA) associated with ventricular septal defect (VSD) remain controversial, especially in a lower middle-income country. This study reports the results of a single-stage repair protocol at our institution for AAH/CoA with VSD using selective cerebral perfusion. This retrospective study included 100 consecutive patients who underwent single-stage repair via median sternotomy using selective cerebral perfusion for AAH/CoA with VSD from July 2010 to March 2017. The patients consisted of 65 males and 35 females. The median age of the patients was 67 days (range 4-2266 days); the median weight was 3.8 kg (range 2.1-15 kg). The average cardiopulmonary bypass time was 132 ± 28 min, the aortic cross-clamp time was 92 ± 23 min and the selective cerebral perfusion time was 33 ± 10 min. The survival rate of all patients was 94.7 ± 2.3%, with an in-hospital mortality of 5% and no late mortality at a median follow-up of 37 months (range 4-96 months). Four patients required reoperation due to recoarctation. The overall event-free survival rate following surgery was 87.1%. The median pressure gradient across the anastomosis at the last follow-up was 8.3 ± 2.8 mmHg. Multivariate logistic regression analysis revealed proximal aortic arch obstruction as a predictor of mortality (odds ratio = 3.8). The aortic isthmus diameter was identified as a predictor for reintervention by Cox regression (hazard ratio = 6.7). Single-stage repair for AAH/CoA with VSD is safe and feasible in a developing country.

Cerebral regional oxygen saturation variability in neonates following cardiac surgery.

BackgroundReduced cerebral regional oxygen saturation (crSO2) variability in neonates, as measured by near-infrared spectroscopy, following cardiac surgery with deep hypothermic circulatory arrest (DHCA) is associated with poor neurodevelopmental outcomes. We sought to evaluate the variability of crSO2 in a cohort of neonates following cardiac surgery with brief or no exposure to DHCA.MethodsVariability of averaged 1-min crSO2 values was calculated for the first 48 h following cardiac surgery in consecutive neonates over a 30-month period. Neonates requiring aortic arch repair underwent antegrade cerebral perfusion with either brief or no exposure to DHCA.ResultsThere were 115 neonates included in the study. Reduced crSO2 variability was observed in neonates with aortic arch obstruction (p = 0.02) and non-survivors (p = 0.02). Post hoc analysis demonstrated that the reduction in crSO2 variability was not as marked as in previously studied neonates with aortic arch obstruction who received DHCA alone (p < 0.001).ConclusionsNeonates with aortic arch obstruction have reduced crSO2 variability following cardiac surgery. The reduction in crSO2 variability observed in aortic arch obstruction is likely influenced by a number of factors, including perioperative perfusion technique. The impact of interventions on crSO2 variability and resultant influence on neurodevelopmental outcomes requires further study.Impact Neonates with aortic arch obstruction have reduced crSO2 variability following cardiac surgery, which has been associated with poor neurodevelopmental outcomes, and is likely influenced by a number of factors, including perioperative perfusion technique.The contribution of perioperative perfusion technique to crSO2 variability following neonatal cardiac surgery is significant.Monitoring of crSO2 variability may provide insights into the adequacy of cerebral perfusion in neonates following cardiac surgery.

Anatomic Risk Factors for Reintervention After Arterial Switch Operation for Taussig-Bing Anomaly

This study aimed to determine the factors related to reintervention, especially for pulmonary stenosis (PS), in patients with Taussig-Bing anomaly (TBA) after the arterial switch operation. This retrospective study included 34 patients with TBA who underwent the arterial switch operation between 1993 and 2018. Preoperative anatomic and physiologic differences and long-term outcomes were determined using a case-matched control with transposition of the great arteries with ventricular septal defect and TBA with an anterior and rightward aorta. At arterial switch operation, median age was 43 days (range, 16 to 102) and median body weight was 3.6 kg (range, 2.8 to 3.8 kg). Aortic arch obstruction and coronary anomalies were present in 64% and 41% of patients, respectively. The hospital mortality rate was 11%, including one cardiac death, and the late mortality rate was 2.9%. Furthermore, 41% patients underwent 26 reinterventions for PS. Patients undergoing PS-related reintervention had a significantly larger native pulmonary artery to aortic annulus size ratio than patients not receiving reintervention (1.69 vs 1.41, P= .02). This ratio was the only predictor of PS-related reintervention; it was significantly higher in the TBA group than in the transposition of great arteries/ventricular septal defect group. The PS-related reintervention was required more in the TBA group than in the transposition of great arteries/ventricular septal defect group. Regardless of complex coronary anatomy and associated anomalies, early and late survival were acceptable. Postoperative PS was strongly associated with having a larger native pulmonary valve, suggesting that an optimal surgical reconstruction was required for achieving an appropriate aortopulmonary anatomic relationship during the arterial switch operation.

Delayed maturation of the structural brain connectome in neonates with congenital heart disease.

There is emerging evidence for delayed brain development in neonates with congenital heart disease. We hypothesize that the perioperative development of the structural brain connectome is a proxy to such delays. Therefore, we set out to quantify the alterations and longitudinal pre- to post-operative changes in the connectome in congenital heart disease neonates relative to healthy term newborns and assess factors contributing to disturbed perioperative network development. In this prospective cohort study, 114 term neonates with congenital heart disease underwent cardiac surgery at the University Children’s Hospital Zurich. Forty-six healthy term newborns were included as controls. Pre- and post-operative structural connectomes were derived from mean fractional anisotropy values of fibre pathways traced using diffusion MR tractography. Graph theory parameters calculated across a proportional cost threshold range were compared between groups by multi-threshold permutation correction adjusting for confounders. Network-based statistic was calculated for edgewise network comparison. White-matter injury volume was quantified on 3D T1-weighted images. Random coefficient mixed models with interaction terms of (i) cardiac subtype and (ii) injury volume with post-menstrual age at MRI, respectively, were built to assess modifying effects on network development. Pre- and post-operatively, at the global level, efficiency, indicative of network integration, was lower in heart disease neonates than controls. In contrast, local efficiency and transitivity, indicative of network segregation, were higher compared to controls (all P < 0.025 for one-sided t-tests). Pre-operatively, these group differences were also found across multiple widespread nodes (all P < 0.025, accounting for multiple comparison), whereas post-operatively nodal differences were not evident. At the edge-level, the majority of weaker connections in heart disease neonates compared to controls involved inter-hemispheric connections (66.7% pre-operatively; 54.5% post-operatively). A trend showing a more rapid pre- to post-operative decrease in local efficiency was found in class I cardiac sub-type (biventricular defect without aortic arch obstruction) compared to controls. In congenital heart disease neonates, larger white-matter injury volume was associated with lower strength (P = 0.0026) and global efficiency (P = 0.0097). The maturation of the structural connectome is delayed in congenital heart disease neonates, with a pattern of lower structural integration and higher segregation compared to controls. Trend-level evidence indicated that normalized post-operative cardiac physiology in class I sub-types might improve structural network topology. In contrast, the burden of white-matter injury negatively impacts network strength and integration. Further research is needed to elucidate how aberrant structural network development in congenital heart disease represents neural correlates of later neurodevelopmental impairments.