Arch Reintervention Research Articles

Selective versus standard cerebro-myocardial perfusion in neonates undergoing aortic arch repair: A multi-center study.

The results of neonatal aortic arch surgery using cerebro-myocardial perfusion were analyzed. Selective cerebral and myocardial perfusion, using two separate pump rotors, was compared with standard perfusion, using a single pump rotor with an arterial line Y-connector. Between May 2008 and May 2016, 69 consecutive neonates underwent arch repair using either selective cerebro-myocardial perfusion (Group A, n=34) or standard perfusion (Group B, n=35). The groups were similar for age, weight, BSA, prevalence of one-stage or staged repair, and single ventricle palliation; male gender was more frequent in Group A. The duration of the cerebro-myocardial perfusion was comparable (27±8 vs. 28±7 min, P=0.9), with higher flows in Group A (57±27 vs. 39±19 mL/kg/min, P=0.01). Although cardioplegic arrest was more common in Group B (13/34 vs. 23/35, P=0.03), the duration of myocardial ischemia was longer in Group A (64±41 vs. 44±14 min, P=0.04). There was 1 hospital death in each group, with no permanent neurological injury in either group. Cardiac morbidity (1/34 vs. 7/35, P=0.02) was more common in Group B, while extracardiac morbidity was similar in both the groups. During follow-up (3.2±2.4 years), 5 late deaths occurred with a comparable 5-year survival rate (75±17% vs. 88±6%, P=0.7) and freedom from arch reintervention (86±6% vs. 84±7%, P=0.6). Risk of cardiac morbidity was greater with standard cerebro-myocardial perfusion (OR=5.2, CI 3.3-6.8, P=0.001) and with perfusion flows less than 50 mL/kg/min (OR 3.7, CI 1.87-5.95, P=0.04). Cerebro-myocardial perfusion is a safe and effective strategy to protect the brain and heart in neonates undergoing arch repair. Selective techniques using higher perfusion flows may further attenuate cardiac morbidity.

Risk factors of mortality and recoarctation after coarctation repair in infancy

The main challenge of aortic coarctation repair in infants is to obtain durable results without morbidity. We aimed to describe predictors of mortality and of arch aortic re-intervention after aortic coarctation repair. Between January 2000 and March 2014, we retrospectively included consecutive infants with isolated coarctation or coarctation with ventricular septal defect (CoA + VSD) who had surgical repair of the aortic arch before three months of age. Five hundred and thirty patients were included: 308 (58%) patients had isolated coarctation and 222 (42%) had CoA + VSD. Three hundred and eighty-five (72.6%) only had coarctation repair, 51 patients (9.6%) had coarctation repair with closure of VSD, and 94 patients (17.8%) had coarctation repair and pulmonary artery banding. Mean age at operation was 13 ± 1.6 days. Mean weight at repair was 3.2 ± 0.75 kg. Median follow-up was 7.57 [0.25–15.98] years. Sixty-one patients (11.5%) needed reintervention on the aortic arch (surgery or endovascular interventions). Freedom from aortic arch reintervention was 90% at one year, and 88.5% at five years. Rates of aortic arch reintervention were similar in the different surgical strategy groups ( P = 0.80). However, in patients receiving prostaglandin E1 (PGE1), the end-to-end repair was at higher risk of re-coarctation compared to the extended end-to-side repair ( P = 0.0081). The risk factors of aortic arch reintervention were age at repair < 15 days ( P = 0.032), and the need for PGE1 infusion at surgery ( P = 0.0072). Overall mortality was 3.6% (19 patients) without significant difference between surgical strategies ( P = 0.078). In multivariate analysis, the risk factors of death were the presence of VSD ( P = 0.037), and low weight at surgery ( P = 0.001). The use of PGE1 may modify the aortic arch anatomy and mask the boundaries of the resection to be performed. Strategies to improve the surgical strategy preoperatively should be developed.

Intervention for arch obstruction after the Norwood procedure: Prevalence, associated factors, and practice variability

ObjectiveArch obstruction after the Norwood procedure is common and contributes to mortality. We determined the prevalence, associated factors, and practice variability of arch reintervention and assessed whether arch reintervention is associated with mortality. MethodsFrom 2005 to 2017, 593 neonates in the Congenital Heart Surgeons' Society Critical Left Heart Obstruction cohort underwent a Norwood procedure. Median follow-up was 3.7 years. Multivariable parametric models, including a modulated renewal analysis, were performed. ResultsOf the 593 neonates, 146 (25%) underwent 218 reinterventions for arch obstruction after the Norwood procedure: catheter-based (n = 168) or surgical (n = 50) at a median age of 4.3 months (quartile 1-quartile 3, 2.6-5.7). Interdigitation of the distal aortic anastomosis was protective against arch reintervention. Development of ≥ moderate tricuspid valve regurgitation and right ventricular dysfunction at any point was associated with arch reintervention. Nonsignificant variables for arch reintervention included shunt type and preoperative aortic measurements. Surgical arch reintervention was protective against arch reintervention, but transcatheter reintervention was associated with increased reintervention. Arch reintervention was not associated with increased mortality. There was wide institutional variation in incidence of arch reintervention (range, 0-40 reinterventions per 100 years patient follow-up) and in preintervention gradient (range, 0-64 mm Hg). ConclusionsInterdigitation of the distal aortic anastomosis during the Norwood procedure decreased the risk of arch reintervention. Surgical arch reintervention is more definitive than transcatheter. Arch reintervention after the Norwood procedure is not associated with increased mortality. Serial surveillance for arch obstruction, integrated with changes in right ventricular function and tricuspid valve regurgitation, is recommended after the Norwood procedure to improve outcomes.

Rates of Interventions in Isolated Coarctation Repair in Neonates Versus Infants: Does Age Matter?

In the current era, coarctation repair is usually performed as soon as diagnosis is established. We sought to determine if neonatal isolated coarctation repair had a higher rate of intervention postdischarge when compared with older infants. We conducted a retrospective review of neonates (≤30 days of age) and infants (1 to 6 months of age) undergoing isolated coarctation repair between January 1, 2000, and March 31, 2016. Preoperative and postoperative Z scores of arch, aortic valve, and isthmus; rates of reintervention; and length of stay (LOS) were compared between groups. Linear or Cox regression was used to determine predictors of postoperative intensive care unit and hospital LOS during index surgery and postdischarge interventions for the entire cohort. There were 213 (71.5%) neonates and 85 (28.5%) infants. There was no difference in aortic valve morphology between groups. There was a trend but no statistical difference in postdischarge coarctation reintervention (neonates 10.3% versus infants 4.7%; p= 0.1) orleft ventricular outflow tract, aortic valve, or mitral valve interventions (9.9% versus 9.4%; p= 0.9). Median postoperative intensive care LOS (3.01 versus 2.28 days; p< 0.001) and postoperative hospital LOS (6.23 versus 4.85 days; p < 0.001) were significantly higher in neonates. Median follow-up was 3 (interquartile range,0.2 to 9) years for the entire cohort. On multivariable modeling, preoperative hypoplastic arch was associated with arch reinterventions, particularly in infants (10%; p= 0.003). Preoperative left-sided catheter intervention, left-sided obstructive lesions, and age predicted postdischarge intervention on left-sided structures. Coarctation repair can be safely performed in infants and neonates with acceptable postdischarge intervention. Severity of aortic arch hypoplasia is an important discriminator for reinterventions on the arch, particularly in infants.

Risk factors of mortality and recoarctation after coarctation repair in infancy

The main challenge of aortic coarctation repair in infants is to obtain durable results without morbidity. We aimed to describe predictors of mortality and of arch aortic re-intervention after aortic coarctation repair. Between January 2000 and March 2014, we retrospectively included consecutive infants with isolated coarctation or coarctation with ventricular septal defect (CoA + VSD) who had surgical repair of the aortic arch before three months of age. Five hundred and thirty patients were included: 308 (58%) patients had isolated coarctation and 222 (42%) had CoA + VSD. Three hundred and eighty-five patients (72.6%) only had coarctation repair, 51 patients (9.6%) had coarctation repair with closure of VSD, and 94 patients (17.8%) had coarctation repair and pulmonary artery banding. Mean age at operation was 13 ± 1.6 days, with 294 patients (55.5%) operated before 2 weeks. Mean weight at repair was 3.2 ± 0.75 kg. Median follow-up was 7.57 [0.25–15.98] years. Sixty-one patients (11.5%) needed reintervention on the aortic arch (surgery or endovascular interventions). Freedom from aortic arch reintervention was 90% at one year, and 88.5% at five years. Rates of aortic arch reintervention were similar in the different surgical strategy groups ( P = 0.80). However, in patients receiving prostaglandin E1 (PGE1), the end-to-end repair was at higher risk of re-coarctation compared to the extended end-to-side repair ( P = 0.0081). The risk factors of aortic arch reintervention were age at repair < 15 days ( P = 0.032), and the need for PGE1 infusion at surgery ( P = 0.0072). Overall mortality was 3.6% (19 patients) without significant difference between surgical strategies ( P = 0.078). In multivariate analysis, the risk factors of death were the presence of VSD ( P = 0.037), and low weight at surgery ( P = 0.001). Coarctation repair in young infants has an overall good outcome. The use of PGE1 may modify the aortic arch anatomy and mask the boundaries of the resection to be performed. Strategies to improve the surgical strategy preoperatively should be developed.

Reintervention following stage 1 palliation: A report from the NPC-QIC Registry.

Single ventricle heart disease with aortic arch hypoplasia has high morbidity and mortality, with the greatest risk after stage 1 palliation. Residual lesions often require catheter-based or surgical reintervention to minimize risk. We sought to describe the types, frequency, and risk factors for re-intervention between stage 1 and stage 2 palliation, utilizing the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry. The NPC-QIC registry, consisting of patients discharged after stage 1 palliation, was queried. Hybrid stage 1 palliation patients were excluded from this study. The primary risk factor was shunt type and the primary outcome was re-intervention. Of 1156 patients, (50%) had re-intervention. There was no difference in total rate of re-intervention by shunt type (BT shunt 52% vs. RVPA shunt 48%; P=.17). Patients with a BT shunt had increased re-intervention during stage 1 hospitalization (P=.002). During the interstage period, following discharge from stage 1 palliation, patients with a BT shunt had increased aortic arch re-intervention (P<.005), while patients with an RVPA shunt had increased re-intervention on the shunt and the pulmonary arteries (P=.02). Postoperative mechanical ventilation >14 d (P<.01) was the only risk factor associated with re-intervention by multivariable analysis, regardless of shunt type. Re-intervention between stage I and stage 2 palliation is common. There is no difference in cumulative frequency of re-intervention between shunt types, though types and timing of re-intervention varied between shunt types. Longitudinal assessment of the NPC-QIC database is important to identify long term outcomes of patients requiring re-intervention.

Porcine Small Intestinal Submucosa May Be a Suitable Material for Norwood Arch Reconstruction

Norwood palliation typically requires patch augmentation of the ascending aorta and aortic arch. Patients having undergone Norwood palliation are at risk of recurrent arch obstruction, the risk of which may be affected by the type of patch material used at the time of Norwood palliation. We sought to determine the freedom from neoaortic arch reintervention and overall survival in patients who underwent Norwood palliation utilizing porcine small intestinal submucosa (PSIS) as the patch material. Retrospective chart review was performed to identify patients who underwent a Norwood operation utilizing PSIS material at our institution. Cardiac diagnosis, age at surgery, shunt type, need for reintervention, and outcome (survival, transplant, and death) were evaluated. Forty-four patients had PSIS material utilized for arch reconstruction at the time of Norwood palliation. There were only five neoaortic arch reinterventions in 4 patients (11.4%). An additional 10 reinterventions, unrelated to the PSIS patch, were performed, including five shunt revisions and five branch pulmonary artery interventions. There were 3 deaths, and 5 patients underwent transplantation. Median follow-up was 387.5 days (range, 4 to 1,513). Freedom from neoaortic arch reintervention and survival after Norwood palliation with PSIS patch material is promising. The PSIS appears noninferior and may be an appropriate tissue choice for Norwood palliation. Studies with longer follow-up are needed to determine the rate of neoaortic reintervention over time.

Giessen Procedure as Comprehensive Stage II Palliation With Aortic Arch Reconstruction After Hybrid Bilateral Pulmonary Artery Banding and Ductal Stenting for Hypoplastic Left Heart Syndrome.

This article reviews our experience using hybrid stage I palliation in the neonatal period and subsequently with comprehensive stage II palliation for hypoplastic left heart syndrome. Between June 1998 and April 2017, 154 patients with the diagnosis of hypoplastic left heart syndrome and variants underwent a hybrid stage I palliation (bilateral pulmonary artery banding and ductal stenting). One hundred thirty-nine patients could be further univentricularly palliated. One hundred twenty-one patients underwent a comprehensive stage II operation with an operative mortality of 6.6%. The hybrid procedure provides reproducible results with reduced in-hospital, interstage, and long-term mortality and lower rates of aortic arch reinterventions.

Long-Term Mortality and Cardiovascular Burden for Adult Survivors of Coarctation of the Aorta

Objective To examine the contemporary long-term outcome after coarctation repair. Methods This is a retrospective cohort study of 834 patients aged ≥16 years who underwent coarctation repair under single-centre follow-up. Repair was performed at a median age of 3 years (lower-upper quartile: 1 month to 15 years) by surgery in 83% (690/834) and angioplasty/stenting in 17% (144/834). Survival was compared with an age- and gender matched normal population. Other outcomes included arch reintervention, aortic valve intervention, ascending aortic intervention, and residual/re-coarctation and resting hypertension at latest follow-up. Results After a median follow-up of 27 years (lower-upper quartile: 18–36), there were 38 late deaths (5%, 38/834). Overall survival was 99%, 88% and 65% at 30, 50 and 70 years of age, respectively, significantly reduced compared with a matched normal population (standardised mortality ratio: 3.20, log-rank: p Conclusions Long-term survival in contemporary adult survivors of coarctation repair is significantly lower than a matched normal population with accelerated decline after the third decade. Nearly 60% of patients eventually develop hypertension, whereas approximately 50% require further invasive cardiovascular treatment by 50 years of age. Our risk-stratifying data may enable personalised follow-up strategies for this common congenital heart condition.

Single-Stage Repair of Coarctation of the Aorta and Ventricular Septal Defect: A Comparison of Surgical Strategies and Resource Utilization.

We sought to compare clinical outcomes and resource utilization for two surgical approaches for single-stage repair of coarctation of the aorta and ventricular septal defect (VSD). This was a retrospective chart review of 21 consecutive neonates and infants undergoing single-stage repair of coarctation of the aorta and VSD. Group 1 included 13 patients with both arch repair and VSD repair completed via sternotomy. Group 2 included eight patients with off-pump arch repair via left thoracotomy followed by repositioning and VSD repair via sternotomy. Primary clinical outcome was arch reintervention. Secondary outcomes included various measures of resource utilization. Group 1 patients demonstrated younger age at repair (median of 10 days vs 57 days for group 2; P = .05) and lower proximal arch z scores (-4.2 vs -2.3 for group 2; P = .003). Arch reintervention occurred in 0 of 8 patients in group 2 and 1 (7.7%) of 13 patients in group 1 ( P = nonsignificant). Group 2 was associated with lower total charges (US$68,301 vs US$211,723 for group 1; P = .0007), shorter length of stay (8 days vs 23 days for group 1; P = .004), and shorter duration of postoperative mechanical ventilation (0.5 days vs 4.0 days for group 1; P = .0008). Group 2 was also associated with shorter total cardiopulmonary bypass time (86 minutes vs 201 minutes for group 1; P = .0009). Single-stage two-incision repair of coarctation and VSD in appropriately selected patients may be associated with higher value of care. Confirmation of this finding will require further study based on larger numbers of patients.

Predicting the Need for Neoaortic Arch Intervention in Infants with Hypoplastic Left Heart Syndrome Through the Glenn Procedure.

Neoaortic recoarctation is present in up to over one-third of patients having undergone the Norwood procedure for hypoplastic left heart syndrome. Some of these patients will require reintervention by catheterization or surgery through the time of the Glenn procedure. Echocardiography and catheterization are often utilized in this period to assess hemodynamics although no specific criteria have been identified to predict whether and when neoaortic arch reintervention will be needed. We sought to identify predictors, including but not limited to echocardiographic and catheterization gradients, to predict such intervention. A retrospective analysis was conducted including patients with hypoplastic left heart syndrome. Patients with significantly comorbid lesions such as isomerism, anomalous pulmonary venous connections, and significant atrioventricular valve insufficiency were excluded as were patients without interstage echocardiographic and catheterization data. Receiver operator curve analysis was performed to establish peak-value gradients by echocardiography and catheterization that were predictive of neoaortic reintervention from the time of the Norwood through the time of the Glenn. These values were then entered into a multivariate regression with several other factors to determine what factors were predictive of need for such intervention. Bland-Altman analysis was conducted to compare echocardiographic and catheterization gradients. A peak echocardiographic gradient of 26mmHg (100% sensitivity, 85% specificity) and a peak-to-peak catheterization gradient of 8.5mm Hg (83% sensitivity, 86% specificity) were found to be predictive of need for neoaortic arch reintervention after multivariate analysis. Echocardiographic and catheterization gradients were found to have poor correlation with one another. A peak gradient of 26mmHg or greater by echocardiography and a peak-to-peak gradient of 8.5mmHg or greater by catheterization after the Norwood but prior to the Glenn are predictive of need for neoaortic reintervention through the time of the Glenn hospitalization.

Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?

ObjectiveThis retrospective study presents our operative results, mortality, and morbidity with regard to pulmonary artery growth and reinterventions on the pulmonary artery and aortic arch, including key features of our institutional standards for the 3-stage hybrid palliation of patients with hypoplastic left heart syndrome. MethodsBetween June 1998 and February 2015, 182 patients with hypoplastic left heart structures underwent the Giessen hybrid stage I procedure. Among these, 126 patients with hypoplastic left heart syndrome who received a univentricular palliation or heart transplantation were included in the main analysis. Median age and body weight of patients at hybrid stage I were 6 days (0-237) and 3.2 kg (1.2-7), respectively. Comprehensive stage II operation was performed at 4.5 months (2.9-39.5), and Fontan completion was established at 33.7 months (21.1-108.2). Operative and interstage mortality, morbidity, growth and reinterventions on the pulmonary arteries, and long-term operative results of the aortic arch reconstruction were assessed. ResultsMedian follow-up time after Giessen hybrid stage I palliation was 4.6 years (0-16.8). Operative mortality at hybrid stage I, comprehensive stage II, and Fontan completion was 2.5%, 4.9%, and 0%, respectively. Cumulative interstage mortality was 14.2%. At 10 years, the probability of survival is 77.8%. Body weight (<2.5 kg) and aortic atresia had no significant impact on survival. McGoon ratio did not differ at comprehensive stage II and Fontan completion (P = .991). Freedom from pulmonary artery intervention was estimated to be 32.2% at 10 years. Aortic arch reinterventions were needed in 16.7% of patients; 2 reoperations on the aortic arch were necessary. ConclusionsIn view of the early results and long-term outcome, the hybrid approach has become an alternative to the conventional strategy to treat neonates with hypoplastic left heart syndrome and variants. Further refinements are warranted to decrease patient morbidity.

Invited Commentary

The group from the Royal Children’s Hospital, Melbourne has reported an extensive series of end-to-side repair for aortic arch lesions, coarctation, and aortic arch interruption [1Lee M.G.Y. Brink J. Galati J.C. et al.End-to-side repair for aortic arch lesions offers excellent chances to reach adulthood without reoperation.Ann Thorac Surg. 2014; 98: 1405-1411Abstract Full Text Full Text PDF PubMed Google Scholar]. Two aspects of this report are notable: (1) the long follow-up of these patients and (2) the uniform technique applied to the arch repair. The 18-year survival was 93%, with a freedom from arch reoperation of 87%. These results are exemplary and provide a benchmark for future reports using differing methods of arch repair. The aortic arch was repaired by direct anastomosis in all cases without need for patch supplementation, which I think is remarkable when one considers how small the ascending aorta can be in cases of interruption. There must presumably be great potential for growth of the ascending aorta in this group of patients. However, it is also commented on in Lee and colleagues' article that extensive repair of the aortic arch is advocated because there is evidence that the aortic arch hypoplasia existing in the infant may well persist into adult life, predisposing to aortic arch problems, the need for reintervention, and systemic hypertension. Regarding the arch repair technique itself, the authors emphasize the need for extensive mobilization of the descending thoracic aorta and interruption of the first 3 intercostal arteries. The authors note the limitations for use of the end-to-side repair in the case of complex root reconstructions, for instance in the Damus-Kaye-Stansel type of repair, which may risk bronchial obstruction. As far as I am aware, this is one of the longest follow-ups reported in a group of patients with aortic arch pathologic processes. It is evident from the technical aspects described in the article that meticulous technique with excision of all duct tissue will allow excellent early outcomes and long-term survival in the majority of cases, even when intracardiac repairs are required. End-to-Side Repair for Aortic Arch Lesions Offers Excellent Chances to Reach Adulthood Without ReoperationThe Annals of Thoracic SurgeryVol. 98Issue 4PreviewThe purpose of this study was to determine the rate of reinterventions from birth to adulthood after end-to-side anastomosis technique for interrupted and hypoplastic aortic arches. Multicenter data have shown that more than half of patients require arch reintervention in the 2 decades after repair. Full-Text PDF

End-to-Side Repair for Aortic Arch Lesions Offers Excellent Chances to Reach Adulthood Without Reoperation

The purpose of this study was to determine the rate of reinterventions from birth to adulthood after end-to-side anastomosis technique for interrupted and hypoplastic aortic arches. Multicenter data have shown that more than half of patients require arch reintervention in the 2 decades after repair. The follow-up of 170 consecutive patients undergoing end-to-side repair through sternotomy for interrupted aortic arch (95) or coarctation (75) in one institution between 1985 and 2012 was reviewed. Associated lesions included ventricular septal defect (143) and bicuspid aortic valve (50). One-stage repair was performed in 158 patients (93%). There were 12 hospital deaths (7%), and 4 early arch reinterventions (2 for bronchial compression). Eleven hospital survivors (7%) were lost to follow-up. After a mean of 10 ± 6 years, there were 9 late deaths. Eighteen-year survival was 93% (95% confidence interval: 87 to 96). Eight patients had bronchial compression, 5 during initial stay and 3 after hospital discharge; 2 of them required surgery. Eighteen-year freedom from arch reoperation was 87% (95% confidence interval: 76 to 93). An additional 10 patients underwent balloon dilation, for an 18-year freedom from reintervention (balloon dilation or surgery) of 77% (95% confidence interval: 65 to 85). At last follow-up, 24 patients (16%) had an echocardiographic gradient greater than 25 mm Hg. Blood pressure was recorded in 105 patients, and only 11 (10%) were hypertensive. The end-to-side anastomosis technique for repair of aortic arch lesions results in a low rate of mortality, arch reoperation, and late hypertension. The development of arch obstruction requiring balloon dilation warrants continuous follow-up of these patients.

Outcomes of the Modified Norwood Procedure: Hypoplastic Left Heart Syndrome Versus Other Single-Ventricle Malformations

Recent studies have suggested that survival after the modified Norwood procedure is influenced by anatomy and is worse for patients with hypoplastic left heart syndrome (HLHS) than for patients with other forms of functional single ventricle. This study aimed to compare the outcomes of the modified Norwood procedure for these two groups at a single center. A retrospective chart review compared modified Norwood procedure outcomes between children with HLHS (n=40) and children with other single-ventricle malformations (n=19) from January 2002 to August 2012. The HLHS patients had a lower mean age (10.0±13.2days) at the time of operation than the non-HLHS patients (16.5±18.5days). The difference was not significant. The number of patients with a Sano modification was significantly higher in the HLHS group (HLHS 85% vs non-HLHS 32%; p<0.001). The follow-up data did not differ between the groups (HLHS 3.6±3.2years vs non-HLHS 4.8±3.3years, nonsignificant difference). The overall operative survival was 85%: 83% for the patients with HLHS and 89% for the patients with non-HLHS (nonsignificant difference). The Kaplan-Meier transplant-free survival estimate at 10years was 73% and did not differ between the HLHS patients (67%) and the non-HLHS patients (84%, nonsignificant difference). The timing of stages 2 and 3 palliation (bidirectional Glenn and external conduit Fontan) did not differ significantly (HLHS, 7.0±2.8months and 3.0±0.5years vs non-HLHS 6.1±1.7months and 2.8±0.8years). The two groups were similar with respect to the need for post-Norwood extracorporeal membrane oxygenation support, aortic arch reinterventions, atrioventricular valve repair, pulmonary artery reconstruction, pacemaker implantation, and progression to bidirectional Glenn and Fontan completion. The modified Norwood reconstruction provides good palliation for HLHS as well as other forms of functional single-ventricle anatomy. Survival, postoperative morbidity, and progression to Glenn and Fontan are not significantly different.

Aortic arch reconstruction in newborns with an autologous pericardial patch: contemporary results

The incidence of recurrent aortic arch obstruction after Norwood procedure and other types of aortic arch reconstruction in newborns remains high. Biological and synthetic materials are used to enlarge the aorta. We report our experience using autologous pericardium to reconstruct the aortic arch in patients with hypoplastic left heart syndrome, aortic arch interruption and hypoplastic aortic arch. A retrospective analysis of 39 consecutively operated patients evaluated after an initial Norwood and other types aortic arch repair was performed. The presence of recurrent arch obstruction (mean gradient ≥ 20 mmHg) and its management were noted. The mean weight of our patients was 3.2 ± 0.7 kg. The mean age at primary surgical correction was 7.4 ± 6.8 (range 1-35 days). All patients were discharged without a significant residual gradient at the aortic arch except 4 who had a peak gradient of ≥ 30 mmHg. The overall incidence of recurrent arch obstruction was 28.2% (11 patients). Four (12.1%) patients had a distal obstruction, 1 (3%) had proximal obstruction and 1 had a mid-transverse arch obstruction. All patients underwent aortic arch reintervention consisting of balloon dilatation, and only after unsuccessful dilatation, 3 underwent surgical patch aortoplasties. The use of autologous pericardium in aortic arch reconstruction procedure is effective and associated with an acceptable incidence of recurrent arch obstruction. Its availability and characteristics make it an attractive alternative to other materials.

Single-Center Experience of Arch Reconstruction in the Setting of Norwood Operation

Arch reconstruction is a key part of the Norwood operation for hypoplastic left heart syndrome and is related to late morbidity. Since 2003, our surgical technique has been standardized to a right ventricle to pulmonary artery conduit, arch reconstruction with homograft patch, and Damus-Kaye-Stansel anastomosis onto homograft patch, with partial or complete resection of any coarctation ridge. We studied the impact of the surgical approach on arch reinterventions and outcome. A retrospective review of echocardiogram, catheterizations, and hospital records of patients who underwent stage1 reconstruction from January 2003 to December 2010 was performed. A total of 289 patients underwent stage 1 reconstruction during this period. Age and body weight at operation were 9.3 ± 25 days and 3.1 ± 0.6 kg. Early survival was 86%. Seventy-three patients (25%) underwent intervention for recoarctation: balloon angioplasty (n = 68) or surgical intervention (n = 11). Eighteen patients underwent multiple interventions for recoarctation. Size of ascending aorta and incomplete resection of ductal tissue were risk factors for reintervention (p = 0.01 and p = 0.02). Patients with an ascending aorta diameter less than 2 mm had significantly higher reintervention rates (p = 0.01). Our standard technique for the Norwood operation has good results but further intervention for recoarctation is common. Size of ascending aorta and incomplete resection of coarctation tissue were risk factors for recoarctation. Complete resection of coarctation tissue may reduce the incidence of recoarctation. A small ascending aorta may predict late arch problems.

Aortic arch reconstruction in neonates: factors influencing survival and arch re-intervention

Aortic arch reconstruction in neonates: factors influencing survival and arch re-intervention

Factors Associated With Subsequent Arch Reintervention After Initial Balloon Aortoplasty in Patients With Norwood Procedure and Arch Obstruction

The aim of this study was to determine whether there are identifiable factors associated with increased risk for aortic arch reintervention in patients who have undergone balloon aortoplasty (BD) for aortic arch obstruction (COA) after the Norwood procedure (NP). BD has been shown to be an effective acute therapy for COA after the NP. However, recurrent obstruction requiring repeat intervention is not uncommon. All patients who underwent BD as the initial intervention for COA after the NP from to January 1993 to May 2009 were retrospectively analyzed (n = 116). The median age at initial BD was 4.5 months. The median follow-up period was 3.4 years. Procedures were considered acutely successful in 92% of patients, with a median gradient reduction overall from 24 to 3 mm Hg (p < 0.0001) and a COA diameter increase of 52% (p < 0.0001). By Kaplan-Meier analysis, freedom from reintervention was 69% at 1 year and 58% at 5 years, and freedom from reoperation was 82% at 1 year and 79% at 5 years. By Cox regression analysis, proximal arch obstruction, age <3 months at BD, moderate or greater ventricular dysfunction, moderate or greater atrioventricular valve regurgitation on pre-catheterization echocardiography, and higher post-BD coarctation gradient were associated with shorter freedom from reoperation. Despite a high acute success rate, a significant proportion of patients treated with BD for post-NP COA underwent reintervention during follow-up. The risk for arch reintervention is highest in patients with proximal arch obstruction, those age <3 months at the time of BD, and those with less successful acute results.

Aortopulmonary Index as a Novel Morphologic Correlate of Early Recurrence of Coarctation of Aorta after Surgical Repair in Infancy

The aim of this study was to determine morphologic correlates of early reintervention for recurrent coarctation in infants undergoing surgical repair in the current era. Medical records of infants who underwent repair of coarctation were retrospectively reviewed. Zscores for aortic segments, relative aortic arch segmental dimensions (indexed to ascending or descending aortic dimension), and aortopulmonary index (the ratio of aortic to pulmonary annular diameter) were derived from preoperative echocardiograms. Eighty-seven patients underwent repair (median age, 13 days). Early arch reintervention (<1 year after surgery) was performed in 11. Lower aortopulmonary index and Z scores of the aortic annulus and sinotubular junction were associated with early reintervention. Aortopulmonary index < 0.6 was the best correlate (sensitivity, 72.7%; specificity, 73.7%; area under the curve, 0.732). Aortic arch dimensions were not correlated with early reintervention. In the current era, aortopulmonary index rather than aortic arch hypoplasia is correlated with the need for reintervention for recurrent coarctation within 1 year of surgery.