Repair Of Isolated Coarctation Research Articles

Abstract 18989: Neonatal Arch Reconstruction via Sternotomy or Thoracotomy: A Propensity Score Matched Analysis

Introduction: For neonatal repair of coarctation of the aorta, patients may either undergo thoracotomy or sternotomy with cardiopulmonary bypass. While some guidance exists, the optimal approach remains poorly defined. Methods: This is a single center retrospective cohort study from 7/05 through 5/22 including patients who underwent neonatal aortic arch reconstruction for isolated coarctation of the aorta and excluding genetic syndromes, heterotaxy, and right aortic arch. Propensity score was estimated using demographic and anatomic variables and 1:1 optimal matching was performed. Primary outcomes were reintervention, either open or catheter-based, and survival. A hazard spline was constructed in order to assess the effect of varying distal arch size on hazard of reoperation (Figure 1). ICU and Hospital length of stay were secondary outcomes. Results: There were 263 patients who underwent isolated coarctation repair during the given time period. Matching yielded 50 patient pairs (n = 100). In the propensity matched population, one patient died and 11 patients underwent reintervention, with 2 of these patients undergoing 2 reinterventions. The interaction between distal transverse arch size and operative approach (sternotomy vs. thoracotomy) was statistically significant, p < 0.05 for interaction. Among patients with a distal arch z-score < -3.5, there appeared to be an advantage to sternotomy. With a distal arch z-score > -3.5, patients undergoing sternotomy appeared to have a disadvantage with respect to risk for reintervention. ICU length of stay was greater for patients undergoing sternotomy, 5.9 days [IQR: 4 to 12.6] vs 2.8 days [IQR: 1.7 to 4.2], p < 0.001, as was hospital length of stay, 14.3 days [IQR: 11 to 23.7] vs 6.5 days [IQR: 5.2 to 9.8], p < 0.001. Conclusions: Patients with a distal arch z-score larger than -3.5 may benefit from thoracotomy, and those with a distal arch z-score smaller than -3.5 may benefit from sternotomy.

Isolated coarctation repair through a left thoracotomy in children.

Isolated aortic coarctation performed through a left thoracotomy resection and end-to-end anastomosis results in low mortality and morbidity rates. Recoarctation and late hypertension are among the most important complications after such repairs. In this study, we reviewed the results of children who underwent left-side thoracotomy to correct an isolated aortic coarctation. A consecutive sample of 90 patients who underwent resection and extended end-to-end anastomosis through a left-side thoracotomy in our centre between 2011 and 2021 was retrospectively analysed. The patients' preoperative characteristics, operative data, and post-operative early and long-term results were examined. All patients underwent resection and extended end-to-end anastomosis. A pulmonary artery band was applied simultaneously to three (3.3%) patients, and an aberrant right subclavian artery division was applied to one (1.1%) patient. The mean cross-clamp time was 29.13 ± 6.97 minutes. Two (2.2%) patients required reoperation in the early period. Mortality was observed in one (1.1%) patient in the early period. Eight (8.8%) patients developed recoarctation, of whom four (4.4%) underwent reoperation and four (4.4%) underwent balloon angioplasty. Twenty-two (26.8%) patients received follow-up antihypertensive treatment. The mean follow-up period was 41.3 ± 22.8 months. No mortality was observed in the late period. Isolated coarctation is successfully treated with left-side thoracotomy resection and an extended end-to-end anastomosis technique with low mortality, morbidity, and low long-term recoarctation rates. Long-term follow-up is required due to the risks of early and late post-operative recoarctation, which requires reintervention.

Extubation delays and the associated prostaglandin and opiate dose following coarctation of the aorta repair

BackgroundCoarctation of the aorta (COA) is one of the most common congenital heart lesions. Most patients undergoing repair extubate without complication. A subset of patients are unable to extubate within 24 h postoperatively. ObjectiveWe examined risk factors determined a priori and their association with delays in extubation. MethodsThis is a retrospective single-center study at an academic quaternary children's hospital. All neonates (0–28 days) who underwent isolated coarctation repair via lateral thoracotomy between January 2008 – December 2019 were included. Delay in extubation was defined as duration from cardiac intensive care unit admission to time of extubation >24 h. Risk factors examined were total preoperative prostaglandin dose and total perioperative opiate dose following repair. Logistic regression analyses were performed using appropriate statistics with significance level set at p = 0.05. ResultsThere were 149 patients who met inclusion criteria, 102 (68.5 %) were intubated for >24 h. We found that patients who were smaller (3.2 kg vs. 3.4 kg, p = 0.012) and patients who were in the intensive care unit preoperatively (p = 0.048), were more likely to remain intubated >24 h. There was also a statistically significant difference between those that were extubated before 24 h postoperatively and those that were not with respect to the total amount of oral morphine milligram equivalent received (1.5 mg vs. 2.82 mg, p = 0.005). ConclusionsOf the 149 patients in our study, the majority (102 patients, 68.5 %) were unable to be extubated within 24 h of surgery following coarctation repair via lateral thoracotomy. Risk factors for delayed extubation were smaller neonates and patients who received greater amounts of opiates.

Abstract 11778: Comparison of Prenatal Diagnosis Rates and Cardiac Morphometry in Fetal Coarctation by Ultimate Surgical Repair Type

Background: Fetal diagnosis of coarctation of aorta is challenging, with limited data examining prenatal detection rates in patients requiring simple vs. extensive arch reconstruction. This study aims to evaluate prenatal detection rate s and fetal cardiac morphometric differences in neonates requiring simple vs. complex coarctation repair. Methods: Pre- and postnatal records of neonates with isolated coarctation repair from the Society of Thoracic Surgeons database from Jan 2010 - Dec 2020 at our center were reviewed. Patients were classified as requiring discrete (Group 1) or extended arch repair (Group 2). Fetal echocardiograms were measured by a single observer blinded to repair type. Results: Of 228 neonates requiring repair, 67 (29%) had a prenatal diagnosis. The proportion with prenatal diagnosis was not different in group 1 (28%) vs. group 2 (32%) (χ2 = 0.45, p = 0.5). At the first fetal echo (median gestational age (GA) of 21.9 wks in group 1 vs 23.6 wks in group 2, p = 0.2), there were no differences between groups when comparing right ventricular (RV) and left ventricular (LV) dimensions, valvular dimensions, or aortic arch dimensions. At the final fetal echo (median GA of 33.7 wks in both groups, p = 0.6), there were statistical differences between group 1 and 2 in RV geometry with ratio of RV minor to major axis (0.72 vs 0.83, p = 0.03) and ratio of LV to RV minor axis (0.68 vs 0.59, p = 0.02), ascending aorta Z score (-2.6 vs -3.4, p = 0.03), distal arch Z score (-3.9 vs -4.6, p = 0.048), and ratio of isthmus to distal arch dimension (0.88 vs 1.02, p = 0.045) (Figure). Conclusion: The rate of prenatal diagnosis in fetuses requiring neonatal coarctation repair remains low, regardless of ultimate surgical repair type. Fetuses ultimately requiring extensive arch repair have smaller aortic sizes, and greater RV/LV size disproportion in the third trimester. This data may be useful in counseling families with regard to postnatal surgical management in fetuses with suspected coarctation.

Isolated Coarctation Repair in Neonates and Infants Through Left Thoracotomy: Short-Term Outcomes.

Introduction End-to-end anastomosis and extended end-to-end anastomosis are typically used as surgical approaches to coarctation of the aorta (CoAo) with access at the subclavian artery or an interposition graft. The objective of this study is to analyze the impact of surgical and anatomical characteristics and techniques on early outcomes after surgical treatment of CoAo without cardiopulmonary bypass through left thoracotomy.Methods This is a quantitative, observational, and cross-sectional analysis of patients who underwent repair of CoAo between July 1, 2010 and December 31, 2017. Seventy-two patients were divided into three groups according to age: 34 in group A (≤ 30 days), 24 in group B (31 days to one year), and 14 in group C (≥ 1 year to 18 years).Results Aortic arch hypoplasia was associated in 30.8% of the cases, followed by ventricular septal defect (13.2%). The preductal location was more frequent in group A (73.5%), ductal in group B (41.7%), and postductal in group C (71.4%). Long coarcted segment was predominant in groups A and C (61.8% and 71.4%, respectively) and localized in group B (58.3%). Extended end-to-end anastomosis technique was prevalent (68%), mainly in group A (91.2%). Mortality in 30 days was 1.4%.Conclusion Most of the patients were children under one year of age, and extended end-to-end anastomosis was the most used technique, secondary to arch hypoplasia. Further, overall mortality was low in spite of moderate morbidity in the first 30 postoperative days.

Rate of Recurrence After Isolated Coarctation Repair: A Retrospective Study in a Single Tertiary Centre

Rate of Recurrence After Isolated Coarctation Repair: A Retrospective Study in a Single Tertiary Centre

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.

Preoperative Aortic Arch Size and Late Outcome After Coarctation Repair by Lateral Thoracotomy

The approach (lateral thoracotomy versus median sternotomy) to repair coarctation of the aorta is frequently based on arch dimensions from the preoperative echocardiogram. Few studies have assessed the relationship between preoperative arch dimensions and late postoperative outcome. This study aimed to define how preoperative arch dimensions relate to late outcomes and identify long-term predictors of a successful operation. We performed a retrospective review of 102 neonates and infants undergoing isolated coarctation repair by lateral thoracotomy between 2003 and 2012. Long-term surgical success was defined based on the following five factors: corrected arch gradient below 20 mm Hg, blood pressure cuff gradient below 15 mm Hg, systolic blood pressure below the 95th percentile during the clinic visit, no antihypertensive medication use, and freedom from reintervention. Regression analysis was performed to identify factors that would predict the need for reintervention and long-term success. At a median of 6 years of follow-up, long-term success was achieved in 63% (56 of 89) of patients, and 94% (96 of 102) were free of reintervention. Bivariate analysis showed that patients requiring reintervention had smaller absolute isthmus dimension (p= 0.04). No significant predictors for reintervention or long-term success could be identified, although a larger distal transverse arch dimension may play a role in long-term success (hazard ratio, 0.7; 95% confidence interval, 0.05 to 1.0; p= 0.06). Aortic arches of various dimensions were successfully repaired by lateral thoracotomy. No significant predictors for reintervention or long-term success could be identified, although the distal transverse arch dimension may play a role in long-term success.

Invited Commentary

Reoperation is an important outcome to track and understand and is increasingly being used as a quality metric. For the present study, the authors used data from the United Kingdom National Congenital Heart Disease Audit Database to conduct a retrospective cohort study of reoperations occurring within 30 days of index operations [1Fiorentino F. Stickley J. Dorobantu D. et al.Early reoperations in a 5-year national cohort of pediatric patients with congenital heart disease.Ann Thorac Surg. 2016; 101: 1522-1529Abstract Full Text Full Text PDF Scopus (10) Google Scholar]. They found that, like another common quality metric, mortality, the incidence of reoperation was low, with only 3.5% of patients being affected. They also found that the patterns of reoperation were dictated by the index operations. Very young patients undergoing palliative procedures were most likely to undergo reoperations, and these patients experienced a higher mortality rate than patients who did not undergo reoperation. The low overall incidence of reoperation and its distribution across the spectrum of congenital heart operations influences its utility as a quality measure. A reduction in the incidence of reoperation would affect a minority of patients. Also, the clustering of reoperations in a small number of index operations limits one's ability to use reoperation broadly as a measure of quality. Thirty-one percent of reoperations occurred after just seven index operations. Thirty-seven percent of reoperations were redo arterial shunt procedures, and an additional 9% were arterial shunt procedures after Norwood procedures. This may reflect the incidence of shunt thrombosis and be an area for directed improvement. Perhaps reoperation would be best used as a quality metric for selected groups, whereas outcomes such as functional and neurologic status that are experienced by all patients are used to measure success in the broader population. In addition to calculating the incidence of reoperation, the authors hoped to determine whether operations subsequent to the index operations were planned or unplanned. However, they decided that this was not possible because the data did not allow for a retrospective understanding of the clinicians’ thought processes that resulted in the operation sequences. This issue is common to large databases, both administrative and clinical. Instead, reoperations were designated as “related” or “unrelated.” Related was defined so as to include operations technically similar to the index operation. Unrelated was defined as both technically dissimilar and not a direct consequence of a surgical step of the index operation. The authors appropriately noted the difficulty in determining whether a reoperation was planned or unplanned from a retrospective viewpoint; however, how useful is the concept of related/unrelated for measuring quality? Successful surgical outcomes rely on both planning and execution. Not only must A be sewn to B adequately, but the decision to sew A to B must be appropriate. The related/unrelated concept may capture most errors related to the former, but it may miss those related to the latter. As defined by the authors, the index procedure of “Norwood operation” and the reoperation of “isolated coarctation repair” are unrelated. However, this reoperation could be the result of a technical error that caused a residual coarctation at the distal aortic anastomosis. The index operations “aortic valve repair” and “interrupted aortic arch repair“ were both considered unrelated to the reoperation of “Norwood procedure”; yet, these reoperations could both result from the failed choice of a two-ventricle repair in a marginal patient. In the second example, there may have been no technical errors, but the reoperations were necessary as a result of unsuccessful decision making. These examples highlight the difficulty of using the related/unrelated concept to determine whether or not a reoperation is the consequence of an index procedure. What we want to know is whether a reoperation was planned or unplanned. Rather than spending too much time creating an imperfect construct, effort should be directed toward modifying databases to include the information necessary to answer the question of interest. Early Reoperations in a 5-Year National Cohort of Pediatric Patients With Congenital Heart DiseaseThe Annals of Thoracic SurgeryVol. 101Issue 4PreviewThe exact types, frequency, and consequences of early congenital cardiac reoperations are not well known. We aim to describe them and evaluate the potential of early reoperations as a metric for quality of care. Full-Text PDF

Aortic Aneurysms Remain a Significant Source of Morbidity and Mortality After Use of Dacron® Patch Aortoplasty to Repair Coarctation of the Aorta: Results from a Single Center

Aortic aneurysm formation after coarctation repair is a serious and life-threatening complication. Repairs using synthetic materials such as Dacron(®) may carry the highest risk of aneurysm formation and rupture. The authors sought to determine the prevalence of aneurysm formation in patients who previously underwent coarctation repair using Dacron(®) patch aortoplasty at their institution. Between 1977 and 1994, 63 patients underwent isolated coarctation repair using Dacron(®) patch aortoplasty. Aneurysms were defined as an aortic dimension 1.5 times that of the aorta at the level of the diaphragm as shown by angiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI). Of 61 early survivors, 29 (47 %) experienced an aneurysm in the area of previous repair. Nine patients (31 %) had spontaneous rupture of the aneurysm, which caused death in seven cases. Elective or emergent aneurysm repair was performed for 20 patients without complication, and 2 patients are being monitored at this writing. The mean interval from patch placement to aneurysm repair was 15 years (range, 4-27 years). Overall freedom from the development of an aortic aneurysm was 97 % at 5 years, 90 % at 10 years, 69 % at 20 years, and 42 % at 25 years. After repair of coarctation using Dacron(®) patch aortoplasty, the risk for aneurysm formation in the area of repair and death from rupture is extremely high. Therefore, in accordance with the 2008 American Heart Association/American College of Cardiology (AHA/ACC) guidelines, all patients with repaired aortic coarctation should undergo either CT or MRI imaging at least every 5 years to assess for aortic aneurysm formation. More frequent imaging should be obtained for patients previously repaired with Dacron(®) patch aortoplasty.

Repair of isolated aortic coarctation over two decades: impact of surgical approach and associated arch hypoplasia

A variety of surgical approaches and techniques are used for isolated coarctation repair. We have retrospectively reviewed our results of isolated repair of coarctation over the last 20 years, to establish whether the approach affects clinical outcome and the need for re-intervention. Two hundred and eighty-eight patients who underwent isolated repair for coarctation of the aorta at Birmingham Children's Hospital between 1991 and 2010 were enrolled in this study. Chart review and the Departmental database were used to determine demographics, operative details and complications. The majority of patients (n = 237, 82%) underwent surgical repair via thoracotomy techniques, whereas median sternotomy was used in patients where there was associated arch hypoplasia (n = 51, 18%). For all 288 patients, median age at operation was 24 days (range 0-14 years). Between 1991 and 2000, ten patients (6%) underwent repair through midline sternotomy, increasing to 41 patients (36%) between 2001 and 2010. Overall early mortality was 1% and late mortality was 3%. There was a statistically higher re-intervention rate (16%) in the decade 1991-2000, compared to 5% in the period 2001-10 (P = 0.02). In patients with hypoplastic arch, the midline approach has a lower re-intervention rate than thoracotomy (P < 0.001). In our institution, there has been a trend in recent years towards increased use of median sternotomy to repair the aortic arch, which has been associated with a reduced rate of re-intervention. The midline sternotomy approach for coarctation with arch hypoplasia significantly reduces the risk of re-coarctation.

Risk of recoarctation should not be a deciding factor in the timing of coarctation repair

To determine whether early coarctation repair is a significant risk for recoarctation in the modern era, 120 patients, including 87 infants, who underwent isolated coarctation repair at a single institution, were reviewed. At a mean follow-up of 44.4 months, there have were no late reoperations, and 2 patients required balloon aortoplasty. The overall incidence of late reintervention was 1.7%, with only 2.4% (2 of 83) in those <1 year old.

Surgical management of transposition of great arteries associated with multiple ventricular septal defects.

The presence of associated multiple ventricular septal defects (VSDs) increases the risk of the anatomic repair for transposition of the great arteries (TGA). The aim of this study was to define the optimal management of this complex anomaly. Between January 1988 and December 1998, 45 patients underwent anatomic repair of TGA associated with multiple VSDs. The median age was 50 days and the median weight 4 kg. Eighteen (40%) had undergone previous palliation including 17 pulmonary artery banding procedure (PAB), seven associated with coarctation repair and one isolated coarctation repair. The perimembraneous septum was involved in 24 patients, the trabecular in 43, the inlet in seven and the infundibular in two. Closure of the VSDs included Dacron or pericardial patchs and matress sutures. The initial approach was through right atriotomy which was sufficient in 15 patients. VSDs were closed through right ventriculotomy in 13 patients, through pulmonary artery in six, through the aorta in one and in the remaining (n = 10) combined approaches were used. Only one patient required left apical ventriculotomy. There were five hospital deaths (11%; 70% CL: 6-18%) including the one early reoperation for residual VSD closure. Five patients had successful early reoperation for secondary PAB for residual VSD. Three late deaths occurred (7%; 70% CL: 3-13%). At the last visit, 95% of survivors were asymptomatic and without any cardiac medication. Mid-term survival with good quality of life can be achieved following either one or two-stage repair of this complex anomaly. In the presence of VSD closure failure a secondary PAB may be the procedure of choice.

Discrepancies in aortic growth explain aortic arch gradients during exercise

Objectives. This study was conducted to evaluate the incidence and etiology of hypertension and aortic arch gradients during exercise in patients who have apparent good coarctation repair assessed at rest.Background. The reported incidence of recurrent aortic arch obstruction (rest gradient >20 mm Hg) after previous successful surgical repair varies from 0% to 60% and usually is associated with recurrent stenosis at the site of surgical repair.Methods. Maximal treadmill exercise with Doppler echocardiographic gradient estimation was performed in 28 patients with a good coarctation repair at rest (normal blood pressure and arch gradient <20 mm Hg) who had isolated coarctation repair a mean of 7.8 years previously.Results. Eight (29%) developed systolic hypertension for age and a mean Doppler gradient of 45 ± 13 mm Hg. At cardiac catheterization, the rest peak to peak systolic gradient (6 ± 6 to 28 ± 7 mm Hg, p < 0.001), peak systolic instantaneous gradient (16 ± 11 to 48 ± 9 mm Hg, p < 0.01) and cardiac index (3.5 ± 0.7 to 5.9 ± 1.1 liters/m per m2, p < 0.001) all increased during isoproterenol infusion. Angiographic systolic aortic arch measurements proximal to the innominate artery, left common carotid artery, left subclavian artery and the narrowest dimension at the coarctation repair site demonstrated hypoplasia at the left common carotid artery (11.8 ± 1.7 vs. 16.7 ± 2.9 mm/m2, p < 0.01) and left subclavian artery (11.6 ± 1.7 vs. 15.4 ± 3.1 mn/m2, p < 0.05) compared with findings in 10 patients with normal aortograms. Transverse aortic arch ratios were also smaller in the eight patients with abnormal findings. Preoperative angiographic ratios were not predictive of late postoperative findings.Conclusions. Exercise testing detects hypertension and arch gradients in patients with a good coarctation repair as assessed at rest. The hypertension and arch “obstruction” appear to be related to discrepancies in the growth of the transverse aortic arch proximal to the repair site, rather than a “recoarctation” of the aorta.