Interrupted Aortic Arch Repair Research Articles

Abstract 11589: Late Complications After Interrupted Aortic Arch Repair

Description of Case: A 38-year-old man with known type B interrupted aortic arch (IAA), bicuspid aortic valve, and a complex surgical history (including IAA repair with an ascending-descending aortic conduit, later conduit graft revision, and left pulmonary artery [LPA] stent) presented after many years of loss to follow-up and was found to have hypertensive urgency. Echocardiogram showed turbulent flow in the proximal descending aorta concerning for arch obstruction. Computed tomography angiography (CTA) (Fig. 1 A–C) showed: narrowed proximal graft anastomosis, dilation of the aortic root and ascending aorta, a large pseudoaneurysm arising from the distal graft anastomosis, and LPA stenosis due to compression from the descending aorta. Following improved hypertension, the patient underwent placement of a left carotid-subclavian bypass graft followed by thoracic endovascular aortic repair (TEVAR) with an endograft positioned across the distal aortic jump graft suture line. CTA one month postoperatively (Fig. 1 D–F) confirmed exclusion of the pseudoaneurysm. Discussion: Type B IAA is considered the most common subtype of IAA among cases diagnosed in infancy, though recent data regarding IAA epidemiology are scarce. IAA is associated with other congenital abnormalities, such as ventricular septal defect (VSD), LV outflow tract abnormalities, and 22q11 deletion syndrome. Additional surgical aortic arch procedures in these patients are not uncommon, perhaps especially among patients who required reintervention for LV outflow tract obstruction. While most studies examining long-term outcomes after IAA repair have not commented specifically on late risk of aneurysm or pseudoaneurysm, such findings have been described in the literature. Additionally, use of polytetrafluoroethylene material in arch repair and arch repair by a method other than direct anastomosis—such as were seen in our patient—have been observed to be risk factors for late reintervention.

Abstract 15015: Long Term Outcomes After Interrupted Aortic Arch Repair: A Study From the Pediatric Cardiac Care Consortium

Introduction: Interrupted aortic arch (IAA) is a congenital heart disease that can be successfully repaired. Children are at risk of multiple procedures and residual abnormalities. We used the Pediatric Cardiac Care Consortium (PCCC) to describe post-repair survival of patients with IAA. Methods: We queried the PCCC for patients receiving IAA repair 1982-2003. Death was ascertained from the PCCC and US National Death Index (NDI) to December 2019. Kaplan Meier (KM) plots and multivariable analysis assessed overall long-term survival and baseline characteristics associated with increased hazard of death post-repair. Results: We identified 380 patients (male 200; female 180) with IAA repair (excluding truncus arteriosus). Most had end-to-end anastomosis (n=234, 83.6%), 87 (31.1%) by interposition graft, and 47 (16.78%) by subclavian or carotid flap. There was no data for 11 patients. A total of 280 survived to discharge. Over a median of 22.9 years (IQR 19.78-27.52 years), 39 died. The 25-year survival post-discharge after repair was 86% (Figure 1). Type B2 IAA (aberrant right subclavian artery) was associated with increased death (aHR=1.814; 95% CI=0.891-3.694) versus non-type B IAA and cases with normal subclavians (A1+B1)) after adjusting for era, sex, presence of chromosomal anomalies, and type of surgery. Interposition graft was associated with increased hazard versus end-to end anastomosis (aHR=1.942; 95% CI=0.946-3.988) or vascular flaps (aHR=1.144; 95% CI=0.456-2.870). Other risk factors were female sex and chromosomal anomalies (DiGeorge syndrome primarily) (aHR = 1.948; 95% CI=0.946-4.011 and aHR=1.090; 95% CI=0.429-2.770). Conclusions: Patients with repaired IAA have decreased long-term survival. Female sex, chromosomal anomalies, type B IAA, aberrant right subclavian artery, and interposition graft were risk factors for poor long-term outcomes. Additional analysis of risk factors for long-term outcomes and causes of death is underway.

Tracheobronchial Release for Left Bronchus Compression After Aortic Arch Repair

Narrowing of the retroaortic space after repair of common arterial trunk (CAT) with interrupted aortic arch (IAA) is a well-known issue. We present a newborn with CAT, IAA, and functionally univentricular heart (tricuspid atresia) who underwent repair of CAT, IAA, and left ventricle-to-pulmonary artery (LV-to-PA) conduit placement with the Lecompte maneuver. The patient suffered from left bronchus compression postoperatively, which was relieved by tracheobronchial release.

Truncus Arteriosus with Interrupted Aortic Arch: Aortic Arch Reconstruction Without Circulatory Arrest

AbstractTruncus arteriosus (TA) with interrupted aortic arch (IAA) is a rare congenital cardiac anomaly. Traditionally, IAA would require period of deep hypothermic circulatory arrest (DHCA) for aortic arch reconstruction. DHCA may cause myocardial depression and neuro-developmental dysfunction. IAA repair is presently being performed with hypothermic low-flow selective cerebral perfusion and distal body circulatory arrest. Even though this prevents cerebral adverse effects of DHCA, there is still risk to the spinal cord and kidneys.Here, we describe the aortic arch reconstruction by maintaining the total body perfusion without any periods of circulatory arrest in a neonate with TA with IAA.

Hospital Outcomes Among Infants With Interrupted Aortic Arch With Simple and Complex Associated Heart Defects

There is a lack of current, multi-institutional data regarding hospital outcomes of infants with interrupted aortic arch (IAA). We analyzed the Pediatric Health Information System database to identify infants with IAA who underwent repair during 2004 to 2019. We classified patients as simple or complex based on associated heart defects. We evaluated factors associated with hospital mortality and complications related to 22q11.2 deletion syndrome (22q11.2del) using mixed logistic regression, accounting for hospital clustering. In 1,283 infants included (904 simple, 379 complex), mortality was higher in the complex group (11.7% vs 4.4%, p <0.001). Factors associated with mortality in the simple group were low birth weight (adjusted risk ratio [aRR] 3.77, 95% confidence interval [95% CI] 1.83 to 7.77), non-22q11.2del genetic conditions (aRR 6.44, 95% CI 1.73 to 23.96), and gastrointestinal anomalies (aRR 8.47, 95% CI 3.12 to 22.95), whereas surgery between 2012 and 2015 (aRR 0.36, 95% CI 0.13 to 0.99) was protective. In the complex group, factors associated with mortality were male (aRR 2.32, 95% CI 1.10 to 4.24) and central nervous system anomalies (aRR 3.73, 95% CI 1.62 to 8.59). Compared with their nonsyndromic counterparts, infants with simple IAA and 22q11.2del were at higher risk of sepsis (aRR 1.63, 95% CI 1.02 to 2.39) and gastrostomy tube placement (aRR 3.18, 95% CI 2.13 to 4.74), and infants with complex IAA and 22q11.2del were at higher risk of gastrostomy tube placement (aRR 2.42, 95% CI 1.20 to 4.88). In conclusion, presence of complex cardiac lesions is associated with increased mortality after IAA repair. The co-occurrence of extracardiac congenital anomalies and non-22q11.2del genetic conditions elevates mortality risk. Presence of 22q11.2del is associated with hospital complications.

Management of Interrupted Aortic Arch With Associated Anomalies: A Single-Center Experience.

Interrupted aortic arch (IAA) includes a broad spectrum of associated anomalies. In this study, we present our surgical management and patient-specific decisions regarding IAA anomalies with early- and mid-term outcomes. The medical records of 25 patients undergoing IAA repair between 2014 and 2019 were retrospectively reviewed. Sixteen patients had type B (64%) interruptions, 7 had type A (28%) interruptions, and 2 had type C (8%) interruptions. Fourteen patients had an isolated ventricular septal defect, and 3 of them had associated left ventricular outflow tract obstruction. Other associated anomalies were functional single ventricle (n = 5), Taussig-Bing anomaly (n = 3), aortopulmonary window (n = 1), multiple ventricular septal defects (n = 1), and truncus arteriosus with dextrocardia (n = 1). The initial operation age was 17.2 ± 14 (range: 1 - 60) days. Single-stage total repair was performed for 15 patients. Six patients underwent aortic arch repair and pulmonary artery banding. Four patients with left ventricular outflow tract obstruction or who were premature underwent the hybrid procedure. The aortic arch repair was performed in 16 cases (64%) by the anterior patch augmentation technique, in 3 cases (12%) by the reverse left subclavian artery flap technique, and in 3 cases (12%) by direct end-to-end anastomosis. Postoperative early mortality occurred in 4 (16%) patients, and sternal closure was delayed in 13 (52%) patients. Three patients who underwent a hybrid procedure due to left ventricular outflow tract obstruction underwent biventricular repair 8 to 13 months later. Eight patients (38%) required reintervention due to arch restenosis during the follow-up period. The mean follow-up was 37.1 ± 21.7 months. Planning surgical treatment according to the characteristics of the patients and accompanying anomalies may improve the results.

Direct Arterial Cannulation Allows Easy and Safe Continuous Selective Cerebral Perfusion During Repair of Interrupted Aortic Arch Even for Low Birth Weight Neonates.

To review the outcomes of direct innominate artery cannulation for continuous cerebral perfusion used for repair of interrupted aortic arch (IAA) in a consecutive cohort of neonates regardless of weight. Between September 1999 and April 2016, forty-four children with IAA (18 type A and 26 type B) underwent repair using continuous, hypothermic (18°C) low-flow cerebral perfusion via direct innominate artery cannulation. Associated cardiac lesions were truncus arteriosus (TA; 5), ventricular septal defect (VSD; 30), transposition of the great arteries (TGA; 1), unbalanced atrioventricular septal defect (1), double-inlet left ventricle (1), double-outlet right ventricle (3), and aortopulmonary window (APW; 5). Truncus arteriosus, single VSD, TGA, and APW were corrected while the other patients were palliated. Age at the time of surgery was 7 days (4-120 days) and weight 3.1 kg (2.1-5.8 kg). Selective cerebral perfusion was maintained in all patients. During the selective cerebral perfusion, perfusion flow rate was maintained at 30 mL/kg/min. Aortic cross-clamp time, low-flow, and total cardiopulmonary bypass time were 63 (40-116), 28 (17-41), and 108 (80-217) minutes, respectively. There were no deaths nor clinical evidence of neurological injury. Postoperative ventilation time, length of intensive care unit, and hospital stay were 3 (2-14), 5 (3-21), and 13 (6-27) days, respectively. Follow-up, complete at 84 months (24-221), revealed no late clinically evident neurologic sequelae nor innominate artery complications. Direct innominate arterial cannulation with continuous selective cerebral perfusion can be safely applied for repair of IAA even in low birth weight neonates. It is technically simple and associated with excellent clinical outcomes.

Short and midterm results of surgical treatment of interrupted aortic arch

Objective: To analyze the early and midterm results of surgical treatment of interrupted aortic arch (IAA) with double-ventricular procedure. Methods: The data of the 68 cases with the main diagnosis of IAA with biventricular structure from June 2009 to June 2017 at Department of Cardiac Surgery, Guangdong General Hospital was collected, including 46 cases of type A, 22 cases of type B. There was no type C case. Except for 5 cases without patent ductus arteriosus or other intracardiac malformations, the remaining 63 cases were combined with intracardiac deformity. The age of operation was 8 days to 18 years, including 28 cases(41.2%) of newborns, 32 cases(47.1%) within 1 year old, 6 cases(8.8%) from 1 to 15 years old, and 2 cases(2.9%) above 15 years old. Of the 5 patients with no intracardiac malformations, 4 patients were treated with a left-posterior thoracic lateral incision for primary surgical correction with end-to-side anastomosis, and 1 adult patient was treated with a median sternotomy incision to complete the anastomosis with the assist of extracorporeal circulation. Of the 63 patients with intracardiac malformation, 2 underwent reconstruction of the aortic arch via posterolateral left thoracic incision merely; 2 patients underwent staged surgery to correction the IAA and intracardiac malformation; the remaining 59 patients underwent the one-stage procedure of IAA and intracardiac malformation correction with deep hypothermic circulatory arrest and 43 cases of selective cerebral perfusion. A total of 55 cases of end-to-end or end-to-side anastomosis were performed in all aortic arch reconstruction. There were 6 cases of connection the arch to descending aorta with autogenous pulmonary artery conduit, and 1 case with homemade bovine pericardial conduit. And there were 5 cases of anastomosis enlargement with autogenous pulmonary artery patch, and 1 case with left subclavian artery flap patch. There were 1 case performed with D. K.S. operation for the severe hypogenetic aortic valve and ascending aorta, and 1 case with left ventricular double outlet channel operation for the severe subvalvular aortic stenosis. Results: Follow-up to 9 years, 4 deaths (5.9%) related to circulatory system diseases: 3 cases died within 30 days after surgery (1 case was neonatal, 2 cases were 1 to 12 months old); one died 8 months after surgery for low cardiac output syndrome. In the early postoperative period, 11 cases (16.2%) of residual aortic arch obstruction (pressure gradient >30 mmHg) were observed, of which 3 cases were moderate (4.4%); follow-up to 5 years after operation was residual obstruction in 3 cases and moderate in 2 cases. There were 3 cases with aortic valve and subvalvular obstruction (differential pressure >30 mmHg), 3 cases were followed up to 5 years after aortic valve and subvalvular obstruction, and 2 cases were moderate or above. To date, 5 patients have undergone 6 reoperations of the cardiovascular system: 3 cases because of pulmonary artery stenosis, 2 cases because of severe aortic arch stenosis, and 1 case because of aortic subvalvular obstruction. Conclusions: One-stage surgical repair of IAA is safe and clinically effective in the neonatal and infant. But some patients still requires reoperation for re-obstruction from subvalvular or aorta arch. For some patients, the choice of aortic arch reconstruction depends on the specific situation.

Bronchial compression as adverse effect of right pulmonary artery stenting in a patient with truncus arteriosus communis and interrupted aortic arch: a case report

Aortic arch obstruction and bronchial compression are possible post-operative complications in patients with truncus arteriosus communis (TAC) with interrupted aortic arch (IAA). We present a case of bronchial compression as adverse effect of right pulmonary artery (PA) stenting in an infant with TAC (type 4A)-IAA (type B) repair. Due to growth potential, self-expandable metal stent was applied for postoperative proximal right PA stenosis, which caused bronchial compression. Later, we found patient having bronchomalacia. Surgical removal was needed. Stent insertion might be an option for postoperative PA stenosis, but bronchial compression might be a potential risk particularly in patients with bronchomalacia.

Long-Term Outcome of Interrupted Arch Repair With Direct Anastomosis and Homograft Augmentation Patch

This study analyzed outcomes of interrupted aortic arch (IAA) repair using a standardized technique to interpret the role of the arch repair on late outcomes in a complex and heterogeneous group of patients. This single institution study covered the period from 1988 to 2015. A total of 120 cases of IAA were divided into four groups: IAA with ventricular septal defect (VSD) (n= 38), IAA with a Norwood or Damus-Kaye-Stansel procedure (n= 41), IAA with truncus arteriosus (n= 24), and a miscellaneous group (n= 17). Arch repair was performed using a standard technique of direct anastomosis with homograft patch augmentation. IAAs were predominantly type B (n= 81, 68%), and type A (n= 34, 28%), with a significant association of type B with truncus arteriosus and of type A with an aortopulmonary window (p < 0.01). Survival was similar in all groups. The incidence of catheter or surgical reintervention was 18% (confidence interval [CI], 10% to 25%) at 5 years and 18% (CI, 10% to 25%) at 10 years, with catheter reintervention more common and occurring before 18 months. Surgical reintervention occurred in 7% (CI, 2% to 13%) at 5 and 10 years and at 10 years the reintervention rate was lower in the group with truncus arteriosus (0%) and in the group with a Norwood or Damus-Kaye-Stansel procedure (5%). There was no bronchial obstruction or aortic aneurysm. The Cox proportional hazard model showed that weight at surgery <2.5 kg and era of surgery were predictive of outcome, with surgical mortality rates in all variants dropping to 8.3% in the last 15 years of the study. Repair of IAA using direct anastomosis and patch augmentation is applicable to all variants and provides good long-term arch patency. Survival is strongly associated with weight at surgery.

Incidental Finding of Interrupted Aortic Arch in an Asymptomatic Adult: To Treat or Not to Treat?

Interrupted aortic arch (IAA) is a congenital anomaly that affects approximately 3 per million live-births. Adult presentation of complete aortic interruption is extremely rare. Surgical repair of IAA is the mainstay of treatment, however beneficial effects of intervention in the adult population are still debated. Late complications of surgical or percutaneous procedures have to be considered when managing asymptomatic adults.

Selective management strategy of interrupted aortic arch mitigates left ventricular outflow tract obstruction risk

BackgroundLeft ventricular outflow tract obstruction (LVOTO) is an important problem after interrupted aortic arch (IAA) repair, especially when early reoperation is required during infancy. Several anatomic factors have been identified that increase LVOTO risk; surgical strategies such as concomitant resection of the conal septum or left ventricular outflow tract (LVOT) bypass (single-stage Yasui operation, or staged Norwood procedure, followed by the Rastelli procedure) have been proposed for such patients. MethodsFrom 2002 to 2013, a total of 77 neonates underwent IAA repair. Based on the presence of anatomic substrate for LVOTO, patients underwent standard IAA repair and ventricular septal defect closure (n = 53; 69%), concomitant conal resection (n = 7; 9%), or LVOT bypass (n = 17; 22%, staged in 14). We analyzed anatomic details that influence procedure choice, and explored reoperation risk and survival after repair. ResultsNeonates who had conal resection or LVOT bypass had significantly smaller aortic valve and subaortic areas, as well as a trend toward a higher prevalence of type B IAA, aberrant right subclavian artery, and bicuspid aortic valve. Freedom from LVOT reoperation was 96% and 80%, at 1 and 8 years, respectively, and was lower after conal resection (P = .008). Most LVOT reoperations (73%) were for discrete subaortic obstruction. Survival was 86% at 8 years, and was not related to procedure choice, whereas freedom from all-cause reoperation was 65% at 8 years, and was higher after standard repair (P = .029). ConclusionsCompared with published reports, this selective management strategy, which is customized to the degree of aortic valve and subaortic area narrowing, has mitigated and delayed LVOTO risk. With this tailored approach, most LVOT reoperations occur after infancy and are commonly for discrete subaortic obstruction. The effect of aortic valve and LVOT narrowing on increased LVOTO risk is neutralized with LVOT bypass procedures; however, it continues to be the highest after conal resection, suggesting the superiority of LVOT bypass, compared with enlargement in neonates who are at risk of developing LVOTO.

Arterial-left ventricular-left atrial coupling late after repair of aortic coarctation and interruption.

This study aimed to explore the arterial-left ventricular (LV)-left atrial (LA) interaction in adolescents and young adults late after intervention for coarctation of the aorta (CoA) and interrupted aortic arch (IAA). Thirty-one (16 males) patients aged 23.4 ± 6.3, at 20.6 ± 5.2 years after intervention, and 31 controls were studied. Carotid arterial stiffness and intima-media thickness (IMT) and brachial-ankle pulse wave velocity were determined by radiofrequency-based echocardiography and oscillometry, respectively. Tissue Doppler and speckle tracking echocardiography (STE) were performed to assess, respectively, LV myocardial tissue velocities and linear and torsional deformation. Left atrial positive, negative, and total strain and strain rate at ventricular systole (aSRs), early diastole (aSRed), and atrial contraction (aSRac) were also determined using STE. Patients had significantly greater arterial stiffness and IMT than controls (all P < 0.05). Mitral annular systolic and diastolic velocities, LV longitudinal and radial strain and early diastolic strain rates, peak torsion and untwisting velocity, and LA peak positive and total strain, aSRs, aSRed, and aSRac were significantly lower in patients than in controls (all P < 0.05). Arterial stiffness correlated inversely with LV longitudinal strain and systolic and early diastolic strain rate (all P < 0.05), while LA total strain and aSRed were associated positively with LV diastolic annular velocity, longitudinal SRe, and peak untwisting velocity (all P < 0.05). Multiple linear regression further revealed arterial stiffness as an independent determinant of LA total strain (β = -1.3, P = 0.034). Our findings suggest impairment of arterial function and LV and LA mechanics in patients after CoA and IAA repair and implicate an abnormal arterial-LV-LA interaction.

Creating an Arc-Shaped Aorta: Use of the Subclavian Artery for Interrupted Aortic Arch Repair

With interrupted aortic arch (IAA), a direct anastomosis may produce an angular-shaped aortic arch instead of the normal arc-shaped aorta, when the discontinuity is considerably long. That may lead to aortic stenosis and to compression of the pulmonary artery or the main bronchus. If a tube graft is used, reoperation for graft exchange is inevitable. We demonstrate the results of using the subclavian artery for creating an arc-shaped aorta in IAA repair. Between February 2006 and October 2012, 23 patients underwent IAA repair using the subclavian artery. The subclavian artery was closed distally, divided, and longitudinally incised from the transected end to the aorta. This flap was used to bridge the gap of the IAA, by forming the posterior wall of a new aortic segment. The arch was completed using glutaraldehyde-fixed autologous pericardium (52%) or homograft (48%). Median follow-up time was 4.8 years (range, 1.3 to 6.9). There were no early deaths and 1 late death. On postoperative angiographic imaging, the aorta takes an arc-shaped course in all cases. Aortic arch stenosis developed in 7 patients (30%). Four patients were treated interventionally, and 3 surgically. During follow-up, there was no compression of the pulmonary artery or the main bronchus. By using the subclavian artery, an arc-shaped aorta can be accomplished without the use of tube grafts. With this technique, compression of the pulmonary artery or the main bronchus can be avoided. This technique is recommended if a direct anastomosis might be not applicable to bridge a long interruption.

Primary complete repair of interrupted aortic arch with associated lesions in infants.

Interrupted aortic arch (IAA) is a complicated congenital heart disease requiring an individualized management strategy. We reported the results for surgical repair of IAA with associated anomalies. This was a retrospective review of 119 patients undergoing one-stage biventricular repair of IAA with associated lesions at the median age of 18 days (range, 3 to 90) between 2000 and 2013. End-to-side anastomosis with patch augmentation was adopted in all patients. Left ventricular outflow tract obstruction (LVOTO) procedure was performed in 23 patients. Selective cerebral perfusion was used in 55 patients (46%). IAA types were A in 92 patients (77%) and B in 27 (23%). Associated anomalies were multiple including noncomplex lesions in 91 (76%) and complex lesions in 28 (24%). Mean follow-up was 98.7 ± 74.2 months. Follow-up was 80% completed. There were 19 in-hospital and six late deaths. The overall actuarial survival including early mortality was 84% at 30 day, 81% at five years, and 79% at 10 and 13 years. Cox proportional hazard model was used to determine risk factors for death: presence of complex lesions (p = 0.005), critical aortic valve stenosis (AVS) (p = 0.016), and long cardiopulmonary bypass (CPB) duration (p = 0.036). Eighteen patients required re-intervention, including 16 for subsequent LVOTO and two for arch restenosis. Single-stage repair using end-to-side anastomosis with patch augmentation is an effective approach for infants with IAA.

INTERMEDIATE TERM OUTCOMES IN PATIENTS WITH INTERRUPTED AORTIC ARCH

Studies of outcome following repair of interrupted aortic arch (IAA) have focused on mortality and rate of re-intervention. We sought to investigate the clinical status of subjects following IAA repair. A cross-sectional assessment of subjects with IAA was performed, with genetic testing,

Aortic arch reconstruction with reversed subclavian flap technique and patch augmentation for IAA: Use of pericardium patch increases rate of aortic arch stenosis

Purpose: To determine the results of a novel technique for interrupted aortic arch (IAA) repair in regard to survival and freedom from reintervention. With the spatulated subclavian artery a reversed flap is created to form the wall of the posterior aortic arch. Either a patch from autologous pericardium or homograft tissues are used to complete the continuity. Methods: We analyzed medical records of patients undergoing IAA repair using this technique. Results: Between April 2000 and July 2012, 27 patients have undergone IAA repair using the subclavian flap technique. Of these, 2 had an aortopulmonary window, 3 a common arterial trunk, and 3 a transposition of the great arteries. In patients with type B interruption (74%) the left subclavian artery (n = 17) or the right arteria lusoria (n = 3) were used. In type A interruption (26%) only the left subclavian artery was used as flap. Arch repair was completed using fixated autologous pericardium (41%) or a homograft patch (59%). Mean follow-up time was 4.1 ± 2.3 years. No patient was lost at late follow-up. In the early period from 2000 – 2005 (5 pts.) there was one early and one late death. Since 2006 no deaths occurred. Aortic arch stenosis requiring reintervention developed in 8 patients (30%). Four of them could be treated with balloon dilatation, four underwent surgical treatment. The rate of aortic arch stenosis was much lower in patients treated with a homograft patch versus those with a pericardial material (13% versus 55%, p = 0.038). Conclusions: The subclavian flap technique is a promising alternative to either direct anastomosis or prosthesis interposition. As a large part of the arch circumference entails use of patch material, its choice is crucial. Preliminary results raise concern about the use of autologous pericardial patch material.

Outcomes of Repair of Common Arterial Trunk With Truncal Valve Surgery: A Review of The Society of Thoracic Surgeons Congenital Heart Surgery Database

Previous studies have suggested truncal valve insufficiency may adversely affect outcome after common arterial trunk (CAT) repair. It is unknown if truncal insufficiency requiring truncal valve surgery (TVS) at the time of primary CAT repair impacts outcome. Patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing CAT repair from 2000 to 2009 were included. Outcomes were compared for patients with and without TVS at the time of CAT repair and were further stratified by interrupted aortic arch (IAA) repair. Of 572 patients (63 centers), median age at surgery was 12 days (interquartile range, 6 to 34). Twenty-three patients underwent concomitant TVS (n=22 repair, n=1 replacement) during CAT repair, and 4 patients underwent TVS later during the same hospitalization (n=1 repair, n=3 replacement). Thirty-nine patients underwent IAA repair at the time of CAT repair, 5 of whom had concomitant TVS. Mortality for CAT repair with TVS versus isolated CAT repair was 30% versus 10% (p=0.0002). All 4 patients who required TVS later during the admission died. Truncal valve surgery was associated with increased mortality among CAT patients both with and without IAA repair, with the highest mortality (60%) among CAT patients undergoing IAA repair and TVS (n=5). Common arterial trunk plus TVS had an increased risk of mechanical support and a longer hospital stay. Truncal valve surgery in patients undergoing CAT repair is associated with significant mortality. Repair of IAA and TVS at the time of CAT repair carries particularly high risk. Failure to address significant truncal insufficiency, necessitating early reoperation with TVS, had uniformly poor outcomes.

Invited Commentary

Invited Commentary

A New Technique for Interrupted Aortic Arch Repair: The Neville Tube

We have developed a new technique for interrupted aortic arch repair in which the pulmonary artery anterior wall is cut off and tailored so as to re-establish aortic continuity with an autologous tube. We are describing this method herein, with an 8-year follow-up of the first patient.