Repair Of Coarctation In Infants Research Articles

Risk factors of mortality and recoarctation after coarctation repair in infancy.

The main challenge of aortic coarctation (CoA) repair in infants is to obtain durable results without morbidity. We aimed to describe predictors of aortic arch reintervention after aortic CoA repair. Between January 2000 and March 2014, we retrospectively included consecutive infants with isolated CoA or CoA with ventricular septal defect (CoA + VSD) who had surgical repair of the aortic arch before 3 months of age. Five hundred and thirty patients were included: 308 (58%) patients had isolated CoA and 222 (42%) patients had CoA + VSD. Three hundred and eighty-five patients (72.6%) had CoA repair, 51 patients (9.6%) had CoA repair with closure of VSD and 94 patients (17.8%) had CoA repair with pulmonary artery banding. Mean age at operation was 13 ± 1.6 days, with 294 patients (55.5%) operated on before 2 weeks. Median follow-up was 7.57 years. Sixty-one patients (11.5%) needed reintervention on the aortic arch. Freedom from aortic arch reintervention was 90% at 1 year and 88.5% at 5 years. Proportions 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 recoarctation compared to the extended end-to-side repair (P = 0.033). The risk factors of aortic arch reintervention were age at repair <15 days (P = 0.034) and the need for PGE1 infusion at surgery (P = 0.0043). CoA 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. PGE1 treatment should be studied more specifically in another study to improve preoperative management.

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.

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.

Surgical correction of coarctation of the aorta with distal aortic arch hypoplasia in infants

&lt;p&gt;&lt;strong&gt;Aim:&lt;/strong&gt; The paper focuses on assessment of the late results and causes of complications when repairing coarctation with distal aortic arch hypoplasia.&lt;br /&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective randomized study included 54 patients who underwent repair of coarctation of the aorta. All patients were divided in 2 groups depending on the correction type: reconstruction using the modified reverse left subclavian artery flap plasty (Group I, 27 pts) or extended end-to-end anastomosis (Group II, 27 pts).&lt;br /&gt;&lt;strong&gt;Results:&lt;/strong&gt; A postoperative follow-up period was 26 (21;31) months. Recoarctation of the aorta during long-term follow-up was found in 1 patient (3.84%) in Group I and in 2 patients (7.7%) in Group II (p=0.5). Two patients in the Group I (7.7%) and 8 patients in the Group II (30.8%) had arterial hypertension (p=0.03).&lt;br /&gt;&lt;strong&gt;Conclusion:&lt;/strong&gt; With modern types of surgical correction used, the anastomotic area tended to proportionally grow in different segments of the aortic arch and did not influence the postoperative complications rate. Endocardial fibroelastosis and ascending aortic wall rigidity could be considered as predictors of arterial hypertension in the late period after coarctation repair in infants. Low body weight before surgery is a factor of aortic recoarctation development in the late postoperative period. Arterial hypertension persistence depends on the correction type. One-stage reconstruction of the distal aortic arch allows for reducing the rate of arterial hypertension from 30.8% to 7.7%. Despite a range of complications in the late postoperative period, the infants’ quality of life was not affected and was high in both groups.&lt;/p&gt;

Long-Term Results of the Subclavian Flap Repair for Coarctation of the Aorta in Infants

Coarctation is a congenital narrowing of the aorta that often requires repair during infancy. The subclavian flap aortoplasty was once widely favored for its avoidance of a circumferential suture line and low incidence of recoarctation. The aim of this study is to report the long-term results of the subclavian flap repair for coarctation of the aorta in infants. Our operative database was queried for infants with coarctation who underwent subclavian flap aortoplasty from 1966 to 1991. Medical records were reviewed for patient characteristics and outcomes. Survivors were identified for additional phone interview. Fifty-five patients met the inclusion criteria. There were 7 early deaths (in hospital), 11 late deaths, 5 patients lost to follow-up, and 32 known long-term survivors with a mean follow-up of 22.0 years (range 2.4-34.9). Hospital mortality was not associated with patient characteristics but was associated with earlier year of surgery (P = .015). A trend toward decreased overall survival was seen in patients with coarctation with associated cardiac defects (P = .072). Reintervention for recoarctation was required in 3 (6.6%) patients and was not related to the patient characteristics. There were no apparent complications related to subclavian artery sacrifice. Subclavian flap aortoplasty provides excellent long-term results for the repair of coarctation in infants. The incidence of recoarctation requiring reintervention is low and compares favorably with other techniques. Compromise of growth or function of the left arm was not appreciated. The subclavian flap technique remains a viable surgical option for the repair of coarctation in infants.

Prevalence of Prehypertension After Coarctation Repair in Infancy in Patients with a Hypoplastic Arch

Prevalence of Prehypertension After Coarctation Repair in Infancy in Patients with a Hypoplastic Arch

Surgical Strategy for Aortic Coarctation Repair Resulting in Physiologic Arm and Leg Blood Pressures

The goal of aortic coarctation repair is laminar aortic blood flow resulting in a negative or absent arm:leg blood pressure (BP) gradient. Despite satisfactory relief of coarctation, associated arch hypoplasia can result in residual obstruction and postoperative upper body hypertension. We devised a surgical strategy to create a tension-free anastomosis with a diameter as large as both the adjacent proximal and distal aorta using a radically extended end-to-end anastomosis via sternotomy and/or thoracotomy. Sternotomy is chosen when there is significant transverse arch hypoplasia defined as a distal transverse arch ≤ diameter of the left carotid artery, presence of a common brachiocephalic trunk, or coexisting intracardiac lesion requiring repair. Thoracotomy is used in all other cases. From 2000 to 2008, 95 consecutive patients were repaired using this approach, 35 with sternotomy and 60 with thoracotomy. At a mean follow-up of 50 ± 23 months, mean systolic BP was 94 ± 10 mm Hg, and 84% of patients had no residual arm:leg BP gradient. Mean arm:leg BP gradient was not statistically different between groups (-8.5 ± 15 sternotomy and -7.0 ± 10 mm Hg thoracotomy, P= .7). With Doppler echocardiography, 96% of patients demonstrated normal early diastolic reversal of blood flow in the descending thoracic aorta. For aortic coarctation repair in infancy, a strategy designed to directly address aortic arch hypoplasia results in excellent intermediate-term results with normal BP, physiologic arm:leg BP relationship, and near normal descending aortic blood flow velocities by Doppler.

Do High-Risk Infants Have a Poorer Outcome From Primary Repair of Coarctation? Analysis of 192 Infants Over 20 Years

Balloon angioplasty for infant coarctation is associated with a high recurrence rate, making operative repair the gold standard for low-risk infants. Debate exists as to whether high-risk infants might be better served with primary angioplasty. We compared the outcome in high-risk versus low-risk infants over 20 years, in a center that always used surgical repair as the primary intervention. Of 192 infants from 1986 to 2005, 56 were considered "high-risk," defined as requiring prostaglandin infusion together with either epinephrine infusion for 24 hours preoperatively, or ventilation and milrinone infusion for 24 hours preoperatively. All high-risk patients had a period of ventricular dysfunction prior to surgery, ranging from mild to severe. Outcomes were compared using Bonferroni comparison of means or the Fischer exact test as appropriate. Although the high-risk patients were smaller (3.3 ± 0.1 vs 4.2 ± 0.2 kg, p < 0.01), younger (18 ± 4 vs 57 ± 7 days, p < 0.01), and more often required a concomitant pulmonary artery band (25% vs 15%, p = 0.05), their cross-clamp times were the same as the low-risk patients (18.9 ± 0.9 vs 18.0 ± 0.4 minutes, p = 0.27) and there was no difference in postoperative morbidity (7% vs 3%, p = 0.11). However, there was a trend toward higher perioperative mortality (7% vs 2%, p = 0.07). When compared with the published studies of primary angioplasty in comparable high-risk infants, the mortality rate in our surgically treated high-risk group is much lower. Additionally, only 11% of our high-risk group required reintervention, with two-thirds treated successfully with a single angioplasty at 3.8 ± 2.2 years later, far lower than recurrence rates with primary angioplasty. We propose that primary surgical repair of coarctation in infants who are high risk should be the primary treatment, with angioplasty reserved for recurrent coarctation.

Coarctation repair in neonates and young infants: Is small size or low weight still a risk factor?

Previous reports of neonatal coarctation repair demonstrate a high rate of recurrent arch obstruction in small neonates. This study assesses the effect of patient size on reintervention and survival in neonates and infants undergoing repair of simple aortic coarctation. From 1996 to 2006, 167 neonates and infants younger than 90 days with simple coarctation underwent repair. Median patient age was 16 days (range, 1-85 days). Median patient weight was 3.4 kg (range, 0.8-6.0 kg), with 29 patients weighing less than 2.5 kg. All 167 patients included in the study underwent repair through a left thoracotomy. There was 1 early death (1/167, 0.6%). Median follow-up of 4.8 years (range, 0-11.8 years) demonstrated 2 late deaths unrelated to recurrent coarctation. Eighteen patients underwent intervention for recurrent arch obstruction a median of 0.48 years postoperatively (range, 0.14-9.8 years). All were treated with balloon angioplasty and have required no additional intervention. Actuarial freedom from reintervention was 90% at 1 year and 89% at 5 years for infants weighing more than 2.5 kg and 89% at 1 year and 86% at 5 years (P = .31) for infants weighing less than 2.5 kg. There was no difference between survival or reintervention for neonates 30 days of age or younger compared with infants 31 to 90 days of age. Use of polypropylene sutures and female sex did correlate with increased reintervention. Low weight does not affect survival or reintervention rates after coarctation repair in neonates and infants less than 3 months of age. Balloon angioplasty is an effective treatment for recurrent obstruction after coarctation repair in infancy. In the current era, timing of the operation should be based on clinical status.

Mortality and Restenosis Rate of Surgical Coarctation Repair in Infancy: A Study of 191 Patients

Study Design: This is a retrospective cross-sectional study to analyze mortality and the rate of restenosis in the follow-up of patients after surgical repair of isolated aortic coarctation in infancy. Patients and Methods: From 1974 to 2003, 191 patients underwent surgical repair of aortic coarctation in infancy. Follow-up data of 2,432 patient-years were extracted from the clinical files of our outpatient department or from family practitioners. Results: Five patients died (total mortality 2.6%): 1 patient intraoperatively and 2 within 30 days after surgery (early mortality 1.6%). The other 2 patients died within 3 months. All deaths were contributed to patients that underwent surgery in the years up to 1981 and within the first 43 days of life. Of the surviving 186 patients, 31 had reintervention because of restenosis and another 11 patients had a noninvasive brachial-ankle systolic blood pressure gradient >20 mm Hg, suggesting current restenosis. Risk factors for death or restenosis were a hypoplastic aortic arch and a low body length at surgery. Conclusions: Nowadays, surgical repair of coarctation can be performed in infancy with minimal risk. The restenosis rate is considerably high (23%). It is mainly caused by the size of the whole aortic arch, but can also develop during later follow-up.

Repair of aortic coarctation in infants: Results of a tailored surgical approach in the modern era

Repair of aortic coarctation in infants: Results of a tailored surgical approach in the modern era

Coarctation repair in infancy - adverse effects of patch angioplasty

Coarctation repair in infancy - adverse effects of patch angioplasty

Coarctation Repair in Infancy - Adverse Effects of Patch Angioplasty

Coarctation Repair in Infancy - Adverse Effects of Patch Angioplasty

Coarctation repair in infancy by extended aortic arch anastomosis: Cineangiographic evaluation one year from operation

Coarctation repair in infancy by extended aortic arch anastomosis: Cineangiographic evaluation one year from operation

A comparison of coarctation resection and subclavian flap angioplasty using ultrasonographically monitored postocclusive reactive hyperemia

The reported relatively high incidence of early restenosis at the coarctation repair site with subclavian flap angioplasty, especially in infants less than 3 months of age, prompted a physiologically oriented analysis of relief of obstruction from coarctation after subclavian flap angioplasty versus resection and end-to-end anastomosis in infancy. Twenty-one patients who had undergone repair of coarctation in infancy by either subclavian flap angioplasty (nine patients) (median age 8 years) or resection and end-to-end anastomosis (12 patients) (median age 8 years) were evaluated by Doppler spectrum analysis of the blood flow velocities in the femoral artery at rest and during reactive hyperemia. The median resting right upper to lower limb systolic pressure difference (with interquartile range) was similar in the angioplasty, resection and anastomosis, and control groups: -5 mm Hg (18 mm Hg), 0 mm Hg (12 mm Hg), and -2.5 mm Hg (10 mm Hg), respectively. Also, similar resting values for the maximum frequency of the advancing curve and the pulsatility and resistance indices were measured in the three groups. During reactive hyperemia of the leg, however, a significant hemodynamic obstruction across the repair site became clinically manifest in the angioplasty group only, as documented by a lower pulsatility index in comparison with the control group (p = 0.01, Mann-Whitney U test). Comparison of the hemodynamic results between the angioplasty and resection and anastomosis groups in subdivisions of infants operated on at an age of less or greater than 3 months, both at rest and during reactive hyperemia, showed, already at rest, a significantly lower value for the pulsatility index in the former angioplasty subdivision (p = 0.05, Student's t test), indicating a significant resistance at the coarctation repair site in the angioplasty patients operated on before the third month of life. A disadvantage of angioplasty (compared with resection and anastomosis) was noted when angioplasty was performed before the third month of life, and an unequivocal lack of advantage was noted when performed beyond that period regarding relief of obstruction from coarctation. In addition, a definite potential for adverse long-term effects on the hemodynamics of the left upper limb after subclavian flap angioplasty in infancy has been documented. For these reasons we prefer to perform resection and end-to-end anastomosis for repair of coarctation in infancy.

Long-term outcome after repair of coarctation in infancy: Subclavian angioplasty does not reduce the need for reoperation

To assess the influence of surgical technique on the need for reoperation after coarctation repair in infancy, follow-up data were analyzed for 125 consecutive infants (less than 12 months) who underwent repair of coarctation of the aorta by subclavian angioplasty or resection and end to end anastomosis. Sixty-three infants underwent coarctation repair by resection between 1960 and 1980, and 62 underwent subclavian angioplasty between 1977 and 1985. The mean age (+/- SEM) at operation for infants with subclavian flap angioplasty was 1.54 +/- 0.93 months and for infants with resection was 2.70 +/- 0.93 months (p = 0.02). There was no difference between the groups in patient weight at initial repair or the proportion of patients with complex anatomy or aortic arch hypoplasia. Follow-up duration for the subclavian flap group was 2.55 +/- 0.51 years (range 0.3 to 8.2), and for the resection group was 7.97 +/- 3.61 years (range 0.6 to 21). Indication for reoperation was the presence of a coarctation gradient at rest of 40 mm Hg or greater and arm hypertension. Reoperation was required in 5 patients in the subclavian flap group and 12 patients in the resection group. The mean reoperation rate after subclavian flap repair was 0.0356 reoperations per patient-year, and after resection was 0.0342 reoperations per patient-year (p = 0.94). To determine an individual's risk of requiring reoperation from these group measures, a reoperation risk model was developed. The risk of reoperation by the fifth postoperative year was found to be 16.3% after subclavian flap repair and 15.7% after resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Coarctation of the aorta: current surgical management.

AbstractProgress in the management of coarctation of the aorta over the past 40 years is truly impressive. Nonoperative management of this condition has uniformly met with failure; however, a variety of surgical options is now available for the treatment of children and adults with coarctation. In recent years, significant advances have emerged in the treatment of neonates and infants that have resulted in low operative mortality rates. In addition, our own results with the subclavian flap angioplasty in these young patients indicate that the problem of failure of the repaired area to grow has been all but eliminated. The use of prostaglandin E1 has dramatically improved our ability to stabilize the decompensated neonate. Repair of coarctation in infancy is not only safe but desirable to minimize the late cardiovascular morbidity and premature death associated with hypertension.

Repair of Aortic Coarctation in Infants: Experience with an Intraluminal Shunt

From 1962 to mid-1984, 63 infants underwent coarctation repair. Cardiac defects were present in 46 (73%). Repair was by subclavian aortoplasty in 35 patients, resection and end-to-end anastomosis in 19, and other techniques in 6. Three patients died before the repair was completed. In 15 patients, an intraluminal shunt was used during subclavian aortoplasty. Prostaglandin E 1 (PGE 1) was infused in 9 patients. Early (thirty-day) mortality was 16% (10 patients): 4 patients who underwent end-to-end anastomosis; 3 during attempted end-to-end anastomosis; 2 who received bypass grafts; and 1 who had subclavian aortoplasty without a shunt. None of the 15 patients who had subclavian aortoplasty with a shunt died. There were no early deaths among the last 25 patients seen. One patient who underwent subclavian aortoplasty without a shunt is paraplegic. There were 10 late deaths among the 53 patients followed from 1 month to 12 years (mean, 3 years). Arm-leg pressure gradients of 20 mm Hg or greater were found in 4 of the patients who had end-to-end anastomosis but not in any of the patients who had subclavian aortoplasty. Improved results of coarctation repair in infants in this study were attributed to PGE 1, subclavian aortoplasty, and use of an intraluminal shunt.

Coarctation of the aorta in patients younger than three months: A critique of the subclavian flap operation

Unexpected and disappointing late results with the subclavian flap operation prompted this analysis of repair of coarctation in infants under 3 months of age. A total of 134 such patients underwent surgical repair since 1960 with 55 end-to-end anastomoses performed earlier in our experience (mean follow-up 5.0 years) and 67 subclavian flap angioplasty operations performed more recently (mean follow-up 2.0 years). The operative mortality was not significantly different (p = 0.3) between end-to-end anastomosis (29%) and subclavian flap angioplasty (19%), but it was significantly higher (p less than 0.01) in the first week of life (56%). Recurrent coarctation occurred in 16 cases, necessitating reoperation. The reoperation-free rates (with standard error) at 5 years for end-to-end anastomosis and subclavian flap angioplasty were 92% +/- 5% and 75% +/- 7%, respectively (p = 0.01). Eight of 10 patients who had reoperation after angioplasty had early recurrence with continued involution of the periductal tissues and growth of the posterior aortic ridge. Six patients who had recurrence after anastomosis demonstrated late anastomotic growth failure. The most common reoperation technique was patch aortoplasty (10 patients). The high incidence of early recurrence with subclavian flap angioplasty in infants under 3 months of age suggests end-to-end anastomosis as the procedure of choice when applicable.

Growth of the Aorta after Prosthetic Patch Aortoplasty for Coarctation in Infants

We have shown that patch aortoplasty relieves the aortic pressure gradient substantially better than resection with end-to-end anastomosis in infants with coarctation of the aorta. Growth of the intact posterior wall of the unresected coarctation after aortoplasty, however, has not yet been demonstrated to occur. We studied 21 infants less than 2 years of age who underwent prosthetic patch repair of coarctation after 1975. Associated lesions were present in 16 patients, and 12 had a concomitant procedure. Two patients died in the hospital, and 4 died later, all of causes unrelated to the coarctation repair. Systolic blood pressure in the right arm declined from 140 ± 41 mm Hg (mean ± standard deviation) preoperatively to 101 ± 19 mm Hg postoperatively in the whole group and to 95 ± 12 in 10 patients followed for more than 3 years. The right arm–left leg systolic pressure gradient declined from 66 ± 22 mm Hg to 5 ± 14 in all patients and to 4 ± 13 in the group followed more than 3 years. Hypoplastic transverse arch was seen in all but 2 patients. Its relative diameter increased in 6 of 9 patients who underwent catheterization postoperatively and increased more than 50% in 3 patients. Two patients have evidence of narrowing of the aorta at the patch, but both have normal blood pressure in the right arm. In the patient with longest follow-up, an 8-month-old infant seen 8 years after operation, angiograms show the diameter of the aorta at the coarctation to be greater than that at the transverse arch and at the descending aorta. Hemodynamic and angiographic results up to 8 years after patch repair remain good, and there is evidence that both the hypoplastic and intact posterior wall of the aorta can grow after patch repair of coarctation in infancy.