Arch Reintervention Research Articles

Twenty-three years of single-stage end-to-side anastomosis repair of interrupted aortic arches

This study defined long-term results of a policy of single-stage repair of interrupted aortic arch with end-to-side anastomosis. Records of 112 consecutive patients undergoing interrupted aortic arch repair between 1985 and 2007 were reviewed. Single-stage repair was performed in 95 patients, with 90 having end-to-side repair. There were 11 in-hospital deaths (10%). Twelve patients needed arch reintervention during the same hospital stay: 7 for residual arch obstruction and 5 for left main bronchus obstruction. Nine patients were unavailable for follow-up. After a mean of 10 +/- 7 years, 6 late deaths occurred, for 18-year survival of 92% (95% confidence interval [CI], 84%-97%). Patients with end-to-side anastomoses had better 18-year survival (97%, 95% CI, 87%-99%, vs 74%, 95% CI, 44%-89%, P < .01). After discharge, 19 patients underwent further aortic arch intervention. The only factors predictive of late arch reintervention were technique other than end-to-side (P < .001) and reoperation for left outflow tract obstruction. Freedom from arch reintervention after end-to-side repair was 78% at 18 years (95% CI, 59%-89%). Another 16 patients had significant residual obstruction. The 18-year freedom from hypertension was 88% (95% CI, 72%-95%). Single-stage repair with end-to-side anastomosis seems the best approach for most neonates with interrupted aortic arch, because it provides relief of the arch obstruction with low early mortality. After 2 decades of experience with this approach, incidence of late hypertension seems minimal. The need for further arch reintervention warrants close follow-up of these patients.

Factors associated with arch reintervention and growth of the aortic arch after coarctation repair in neonates weighing less than 2.5 kg

Neonates weighing less than 2.5 kg with aortic coarctation are challenging. We sought to find the prevalence of death or aortic arch reintervention and their determinants after coarctation repair. We also sought to define growth trajectories for postrepair aortic arch dimensions and identify factors associated with accelerated longitudinal growth. We reviewed neonates weighing less than 2.5 kg undergoing coarctation repair between 1993 and 2004. Competing-risks methods determined time-related prevalences of death, arch reintervention, and survival without subsequent reintervention. Mixed regression analysis modeled longitudinal growth trajectories of echocardiographically derived aortic arch dimensions. Thirty-six neonates underwent coarctation repair. Initial repair type was simple end to end (n = 3), extended end to end (n = 16), subclavian flap aortoplasty (n = 15), and patch aortoplasty (n = 2). Median initial repair age was 11 days (range 2-69 days) and mean weight was 2.01 +/- 0.33 kg. Overall 1-year survival was 76%. After 1 year from initial repair, 19% had died without subsequent reintervention, 14% underwent arch reintervention, and 67% remained alive without arch reintervention. Neonates with extended end-to-end repairs had increased transverse aortic arch Z-scores (P = .004). Although patients with larger initial transverse aortic arch Z-scores had higher scores across all time points (P < .001), neonates with the smallest transverse aortic arch Z-scores had accelerated growth trajectories (P < .001). Aortic isthmus growth was likewise accelerated in neonates with the smallest initial aortic isthmus Z-score (P < .001). Mortality and arch reintervention are common after initial repair of coarctation of the aorta in neonates weighing less than 2.5 kg. Catch-up growth of both the transverse arch and isthmus occurs after coarctation repair, especially in those with the smallest arch parameters, and may be increased by using an extended end-to-end technique.

Factors Affecting Long-Term Risk of Aortic Arch Recoarctation After the Norwood Procedure

The purpose of this study was to identify factors predicting risk of aortic arch recoarctation after the Norwood procedure. Patient records were reviewed retrospectively for consecutive patients who underwent the Norwood procedure from 1996 to 2005. Preoperative and intraoperative parameters were identified for analysis. Aortic arch recoarctation was defined by the need for catheter or surgical reintervention. Data were analyzed using survival analysis, with freedom from intervention as the outcome. Factors predicting need for reintervention were analyzed using Cox proportional hazards regression. Thirty-five recoarctations were observed in 117 patients (30%). Freedom from aortic arch reintervention at six months, one, three, and five years were 72%, 63%, 56%, and 52%, respectively. The majority of arch reinterventions occurred in the first six months (63%), involving either surgical (43%) or catheter (57%) techniques. The use of bovine pericardium showed the greatest risk for potential recoarctation (hazard ratio = 1.81 [0.90-3.64], p = 0.09). Age, gender, weight, ascending aortic diameter, ventricular morphology, primary anatomic diagnosis, and coarctation shelf resection were not found to be predictors of recoarctation. Most interventions for aortic arch recoarctation after the Norwood procedure occur within the first six months of life. The type of patch material used for arch reconstruction appears to influence, most strongly, the long-term risk of aortic arch recoarctation.

Experience With Bovine Pericardium for the Reconstruction of the Aortic Arch in Patients Undergoing a Norwood Procedure

The incidence of recurrent aortic arch obstruction after the Norwood procedure is between 0% and 36%. Allograft material is frequently used to enlarge the aorta; its use has been associated with the development of significant allosensitization. We report our experience using bovine pericardium for the reconstruction of the aortic arch in patients undergoing a Norwood procedure. A retrospective analysis of 33 consecutive patients evaluated for a second-stage procedure after an initial Norwood repair was performed. All patients underwent a cardiac catheterization. The presence of recurrent arch obstruction (gradient > 10 mm Hg) and its management were noted. Three consecutive patients were tested for anti-HLA antibodies at the time of their Fontan procedure. The mean age at the time of the cardiac catheterization was 4.12 months (range, 2 to 7 months). The incidence of recurrent arch obstruction was 18.2% (6 patients). Four patients (12.1%) had distal obstruction, 1 patient (3%) had proximal obstruction, and 1 patient (3%) had mid-transverse arch obstruction. Five of the 6 patients underwent aortic arch reintervention consisting of four balloon dilatations and two surgical patch aortoplasties. Thirty-one patients advanced to a second-stage procedure, including 30 bidirectional Glenn anastomoses, and 1 Rastelli repair. No significant allosensitization was present in the patients tested. The use of bovine pericardium in the Norwood procedure is associated with an acceptable incidence of recurrent arch obstruction. Its availability, lower cost, and possible immunologic advantages make it an attractive alternative to allograft material.

Interrupted Aortic Arch Repair: Aortic Arch Advancement Without a Patch Minimizes Arch Reinterventions

Surgical repair of interrupted aortic arch (IAA) remains challenging and is associated with significant mortality and incidence of late arch obstruction, as recently reported by the Congenital Heart Surgeons' Society (CHSS). In particular, the CHSS reported that any technique other than direct anastomosis with patch augmentation is a risk factor for arch reintervention. The experience at Texas Children's Hospital with IAA repair using an aortic arch advancement technique without a patch was examined. Between July 1995 and December 2005, 60 patients underwent IAA repair using aortic arch advancement without a patch. Selective cerebral perfusion was used in 25 patients (42%). Cox proportional hazards models were used to analyze 20 variables to determine risk factors for death, arch reintervention, and left ventricular outflow tract (LVOT) reintervention. Median age was 8 days (range, 2 to 271 days) and weight was 3.0 kg (range, 1.7 to 6.1 kg). IAA types were A in 18 (30%) and B in 42 (70%). Associated anomalies were multiple congenital anomalies in 30 (50%) patients, DiGeorge syndrome in 21 (35%), LVOT obstruction in 26 (43%), a single ventricle in 11 (18%), and truncus arteriosus in 6 (10%). Mean follow-up was 3.0 +/- 2.6 years. Five-year freedom from aortic arch reintervention was 100%. Survival at 30 days, 1 year, and 5 years was 93%, 78%, and 76%, respectively. Since July 2000, two of 32 patients have died for an overall survival of 94%. Risk factors for death are older age, multiple congenital anomalies, DiGeorge syndrome, and bicuspid aortic valve. Selective cerebral perfusion was an independent protective variable for survival. Survival for an IAA patient with a ventricular septal defect and no complicating cardiac anomalies was 100%. Aortic arch advancement without a patch can be applied to IAA patients, with the expectation of a minimal need for arch reintervention. This technique affords an excellent survival, to which selective cerebral perfusion may be a contributing factor.

Surgical management of aortopulmonary window associated with interrupted aortic arch: A Congenital Heart Surgeons Society study

The objective was to determine outcomes and risk factors of surgical management of patients with aortopulmonary window associated with interrupted aortic arch. From 1987 to 1997, 472 neonates with interrupted aortic arch were enrolled prospectively from 33 institutions. Associated aortopulmonary window was present in 20 patients. Competing risk methodology determined the prevalence of reintervention for postrepair pulmonary artery and aortic arch obstruction. Interrupted aortic arch was type A in 17 patients and type B in 3 patients. Aortopulmonary window morphology was type I (n = 10), type II (n = 5), and type III (n = 5). Associated cardiovascular anomalies were common, including atrial septal defect (n = 13) and systemic venous anomalies (n = 3). Overall survival after initial admission was 91%, 86%, and 84% at 1, 5, and 10 years, respectively. Fifteen patients underwent single-stage repair, and 4 patients underwent staged repair. There was an increased prevalence of patch augmentation of the interrupted aortic arch anastomosis in lower-weight infants (2.3 kg vs 3.1 kg, P = .07). Competing risk analysis estimated that 5 years after repair, 51% had initial arch reintervention, 6% had initial pulmonary artery reintervention, and 43% were alive without reintervention. Reintervention for arch obstruction was more likely for those with interrupted aortic arch type B (P = .08) and for those with higher weight at initial repair (P = .003). Complete correction of aortopulmonary window in the setting of interrupted aortic arch can be performed with low mortality in the neonatal period. Reinterventions for aortic arch obstruction are the most frequent complication after repair, but pulmonary artery stenosis also occurs. Use of patch augmentation may reduce the need for subsequent arch reintervention.

Influence of surgical strategies on outcome after the Norwood procedure

The study objective was to identify how the evolution of surgical strategies influenced the outcome after the Norwood procedure. From 1992 to 2004, 367 patients underwent the Norwood procedure (median age, 4 days). Three surgical strategies were identified on the basis of arch reconstruction and source of pulmonary blood flow. The arch was refashioned without extra material in group A (n = 148). The arch was reconstructed with a pulmonary artery homograft patch in groups B (n = 145) and C (n = 74). Pulmonary blood flow was supplied by a modified Blalock-Taussig shunt in groups A and B. Pulmonary blood flow was supplied by a right ventricle to pulmonary artery conduit in group C. Early mortality, actuarial survival, and freedom from arch reintervention or pulmonary artery patch augmentation were analyzed. Early mortality was 28% (n = 102). Actuarial survival was 62% +/- 3% at 6 months. Early mortality was lower in group C (15%) than group A (31%) or group B (31%; P <.05). Actuarial survival at 6 months was better in group C (78% +/- 5%) than group A (59% +/- 5%) or group B (58% +/- 4%; P <.05). Fifty-three patients (14%) had arch reintervention. Freedom from arch reintervention was 76% +/- 3% at 1 year, with univariable analysis showing no difference among groups A, B, and C (P =.71). One hundred patients (27%) required subsequent pulmonary artery patch augmentation. Freedom from patch augmentation was 61% +/- 3% at 1 year, and was lower in group C (3% +/- 3%) than group A (80% +/- 4%) or group B (72% +/- 5%; P <.05). Survival after the Norwood procedure improved after the introduction of a right ventricle to pulmonary artery conduit, but a greater proportion of patients required subsequent pulmonary artery patch augmentation. The type of arch reconstruction did not affect the incidence of arch reintervention.

Risk factors associated with mortality and interventions in 472 neonates with interrupted aortic arch: A Congenital Heart Surgeons Society study

We sought to determine the prevalence of outcomes and associated patient and management factors for neonates with interrupted aortic arch. From 1987 to 1997, a total of 472 neonates were enrolled prospectively from 33 institutions. Competing risks methodology was used to determine simultaneous risk and associated incremental risk factors for death, initial and subsequent left ventricular outflow tract procedures, and arch reinterventions. Overall survival was 59% at 16 years after study entry but improved with successive birth cohort. In general, risk factors for death in each of the competing risks analyses included lower birth weight, younger age at study entry, type B interrupted aortic arch, and major associated cardiac anomalies. Of 453 patients who had interrupted aortic arch repair, after 16 years 33% had died and 28% had undergone an arch reintervention. Reintervention was more likely for those who had truncus arteriosus repair, interrupted aortic arch repair by a method other than direct anastomosis with patch augmentation, and the use of polytetrafluoroethylene as either an interposition graft or a patch. From study entry, competing risks after 16 years showed that 28% had died and 34% had undergone an initial left ventricular outflow tract procedure. Initial left ventricular outflow tract procedure was more likely for those with single ventricle, type B interrupted aortic arch, bicuspid aortic valve, or anomalous right subclavian artery. Among those who had undergone an initial left ventricular outflow tract procedure, after 16 years 37% had died and 28% had undergone a second procedure. Anatomic features affect mortality and initial left ventricular outflow tract procedures, whereas characteristics of the arch repair affect arch reintervention.

Recurrent arch obstruction after repair of isolated coarctation of the aorta in neonates and young infants: Is low weight a risk factor?

Background: Repair of aortic coarctation is often delayed in small infants because of the belief that such patients are at risk of recurrent arch obstruction and that growth will decrease this risk. To determine whether low weight was a risk factor for recurrent arch obstruction, we reviewed our experience with coarctation repair via left thoracotomy in infants less than 3 months of age. Methods: From 1990 to 1999, 103 patients less than 3 months of age underwent repair of aortic coarctation through a left thoracotomy. Median age was 18 days (1-90 days), with 45 patients less than 2 weeks. Median weight was 3.3 kg (1.0-6.4 kg) and 14 patients were less than 2 kg. The method of repair was resection and end-to-end anastomosis in 64 patients, subclavian flap angioplasty in 34, and patch augmentation of the arch in 5. Demographic, echocardiographic, and operative variables were analyzed for correlation with recurrent arch obstruction. Results: One early and 1 late death occurred, both in patients who had complications but no evidence of recoarctation. At median follow-up of 24 months, reinterventions for recurrent arch obstruction were performed in 15 patients. The median time to reintervention was 5 months and was less than 1 year in 12 patients. Kaplan-Meier freedom from arch reintervention was 88% at 1 year (95% confidence intervals: 82%-94%) and 82% at 5 years (95% confidence intervals: 72%-92%). Factors associated with shorter duration to arch reintervention by univariable Cox regression included younger age (continuous, P =.01; ||2 weeks, P =.005), smaller transverse arch (absolute diameter, P ||.001; indexed to weight, P =.03; indexed to ascending aortic diameter, P =.02), and smaller ascending aorta (absolute diameter, P =.02). Smaller absolute transverse arch diameter and younger age were the only independent predictors of shorter time to arch reintervention by multivariable Cox regression analysis. Weight and type of repair did not correlate with risk of recoarctation. Conclusions: Low weight is not a risk factor for recurrent obstruction after repair of coarctation of the aorta in infants less than 3 months of age. Rather, risk of recoarctation is more a function of the anatomy of the arch. Thus, it is not indicated to delay repair in low weight infants with the goal of achieving growth.J Thorac Cardiovasc Surg 2001;122:883-90