Subclavian Flap Research Articles

Vascular and neuroendocrine components in altered blood pressure regulation after surgical repair of coarctation of the aorta.

To investigate potential vascular and neuroendocrine determinants of altered blood pressure (BP) regulation in patients previously operated on for aortic coarctation. We prospectively re-evaluated 45 patients operated on for aortic coarctation at Strasbourg University Hospital over a 13-year period. Four of these patients were less than 2 years old at the time of the operation and four were older than 20 years. Patient age and time since the operation were on average 21+/-13 years and 8+/-3 years, respectively. Surgery consisted of a resection with end-to-end anastomosis for 18 patients, angioplasty (8), prosthesis (4) or sub-clavian flap (15). Despite repair of the coarctation, about 40% of the patients showed an abnormal BP status at rest. The majority of these patients had uncomplicated borderline hypertension. The orthostasis test as well as the BP circadian rhythm were frequently abnormal. While the ankle/arm systolic pressure index measured at rest was generally within the normal range, diminished carotid-femoral pulse wave velocity was observed. Plasma adrenaline and aldosterone levels were elevated in about 50% of the patients examined. These new findings suggest that there are 'cause and effect' relationships between aortic structural and functional vascular abnormalities, and augmented plasma adrenaline and aldosterone in some patients after coarctation repair. These phenomena are likely to be involved in altered BP regulation and might result in recurrent hypertension.

Modified subclavian flap aortoplasty for coarctation repair in patients less than three months of age

Subclavian flap aortoplasty is one of the best procedures for coarctation repair, but recoarctation still remains a problem in neonates and infants. We employed subclavian flap aortoplasty with resection of the whole layer of aortic ductal tissue in 9 patients less than 3 months of age with coarctation of the aorta and obtained satisfactory results.

Congenital diaphragmatic hernia associated with aortic coarctation

Congenital diaphragmatic hernia (CDH) may be associated with other anomalies, most frequently cardiovascular in nature. Despite fetal echocardiography, diagnosis of an accompanying cardiac malformation often is not made until after birth and sometimes not until after extracorporeal membrane oxygenation (ECMO) has been instituted. Aortic coarctation associated with CDH may occur as an isolated, surgically correctable malformation or it may be a component of the usually fatal left heart “hypoplasia” or “smallness” syndrome. The authors present two cases of aortic coarctation associated with CDH requiring ECMO that illustrate the management challenges of these coincident diagnosis. In one case, the accompanying coarctation was suspected and required precannulation angiography for confirmation, whereas in the other case, the diagnosis of coarctation was not made until after ECMO cannulation. Depending on its anatomic location and severity, an aortic coarctation associated with life-threatening CDH may limit the physiological efficacy of venoarterial ECMO. Furthermore, arterial cannulation for extracorporeal support requires that flow through the remaining cartotid artery be maintained during aortic reconstruction, which may prove difficult for lesions best treated by subclavian flap angioplasty. When the diagnosis of coincident aortic coarctation and CDH is suspected or proven before institution of extracorporeal support, serious consideration should be given to venovenous bypass, because this may provide better postductal oxygenation and facilitate aortic repair with the option of left carotid artery inflow occlusion.

Coarctation Repair: Modification of End-to-End Anastomosis With Subclavian Flap Angioplasty

Background. Subclavian angioplasty and resection and end-to-end anastomosis for coarctation repair carry a substantial risk of recurrence of coarctation. The combined technique using both these methods has shown good results but requires a longer period of continuous cross-clamping of the aorta. Methods. A modified technique using intermittent cross-clamping with a period of reperfusion between cross-clamping periods was used. After the end-to-end anastomosis the clamps are released for 10 minutes and reapplied to do the subclavian angioplasty. Between 1991 and 1996 this was done in 26 infants (mean age, 5 weeks; range, 1 day to 6 months; median, 3 weeks). Mean weight was 3.85 kg (range, 1.5 to 8.4 kg). Mean length of follow-up was 23 months. Twenty-two patients (85%) had associated anomalies, excluding patent ductus arteriosus, and 5 patients (19%) had another procedure performed at the same time. Results. There was no mortality. The mean echocardiographic gradient was 4 mm Hg in the immediate postoperative period and 2.9 mm Hg during follow-up. Residual or recurrent coarctation as detected by significant echocardiography or blood pressure gradient did not develop in any infant. Conclusions. This modified technique of anastomosis is an effective way of relieving coarctation with excellent intermediate-term results.

Long-Term Follow-Up Results of Balloon Angioplasty of Postoperative Aortic Recoarctation

Immediate- and short-term follow-up results of balloon dilatation of aortic recoarctation following surgery have been well documented, but there is sparse data on long-term follow-up. During a 10-year period ending in August 1995, 33 children, aged 2 months to 14 years old, underwent balloon angioplasty of aortic recoarctation. Prior surgery included resection and end-to-end anastomosis (n = 9), subclavian flap (n = 16) or prosthetic (Dacron or Gore-Tex) patch (n = 5) angioplasty, and repair of an interrupted aortic arch (n = 3). Recoarctation developed 1 month to 14 years (mean ± SD 29 ± 44 months) after surgery. The indications for angioplasty were peak-to-peak systolic gradients >20 mm Hg and systemic hypertension and/or congestive heart failure. After balloon angioplasty, the peak-to-peak systolic pressure gradient across the coarctation decreased from 48 ± 22 to 13 ± 15 mm Hg (p <0.01), and the size of the coarcted segment increased from 3.3 ± 1.4 to 6.5 ± 2.3 mm (p <0.01). Follow-up angiography and/or magnetic resonance imaging were performed in 20 children 17 ± 12 months after angioplasty. No aneurysms were observed and improvement in the diameter of the coarcted aortic segment (9 ± 3 mm) persisted. One- to 10-year (median 5) clinical follow-up was available in 32 children. During follow-up, 2 children required surgery to repair a long tubular isthmic narrowing. The residual gradients, determined by arm-leg systolic blood pressure difference, were 5 ± 8 mm Hg. No patient was symptomatic and only 1 patient (3%) was hypertensive, controlled with antihypertensive medications. We conclude that balloon angioplasty of aortic recoarctation following all types of surgical repair is feasible, safe, and effective with good long-term results. We recommend balloon angioplasty as the procedure of choice in the management of postsurgical recoarctation with hypertension and/or congestive heart failure.

Spinal cord protection using hypothermic cardiocirculatory arrest in extended repair of recoarctation and persistent hypoplastic aortic arch.

In recurrent coarctation collateral circulation may not be sufficient to maintain adequate perfusion of the lower body during the period of surgical repair. Different techniques such as interposition of a Gott-shunt, use of left heart bypass or hypothermic cardiocirculatory arrest are used to prevent spinal cord injury. Twenty-eight operations for recurrent coarctation were performed in 26 patients following end-to-end anastomosis (58%), patch plasty (21%), subclavian flap aortoplasty (14%) and graft interposition (7%). Associated cardiac defects were present in 77% of the patients. Eleven patients who had adequate (> 50 mmHg) distal perfusion pressure during a test occlusion were operated on using simple cross-clamping (group I, mean age 8.5 +/- 3.8 years). In group I, end-to-end anastomosis was performed in nine patients and graft interposition in two patients. In 17 cases (including two patients from group I) with insufficient collateral circulation and with persistent hypoplasia of the arch, hypothermic cardiocirculatory arrest was used (group II, mean age 12.8 +/- 9.6 years). In group II end-to-end anastomosis was performed in three patients and graft interposition in 14 patients. Mean bypass-time was 116 +/- 36 min and arrest-time 33 +/- 16 min. Hypothermic cardiocirculatory arrest was begun when nasopharyngeal temperature was below 20 degrees C, corresponding to a rectal temperature of 24 +/- 3 degrees C. Hypothermic cardiocirculatory arrest allowed open reconstruction of the arch and/or complete or partial replacement of the arch and the coarctation segment. In-hospital mortality was 0 and 5.9% in group I and II, respectively. The one patient who died in group II had simultaneous correction of an anomalous pulmonary venous connection and death was unrelated to the method of coarctation repair. Reversible laryngeal nerve paresis was observed in two patients in group II, no other neurologic complications were observed in either group. Postoperative gradients over the repair site were less than 20 mmHg by Doppler-echocardiography. Two patients of group I had to have a second, early reoperation because of stenosis at the anastomotic site. Reconstruction of the distal aortic arch was then performed during hypothermic cardiocirculatory arrest. The use of hypothermic cardiocirculatory arrest in this special indication is a safe method which allows open reconstruction of the coarctation site and the aortic arch and protection of the spinal cord. The need for early reoperation because of inadequate repair may be reduced.

Aortic coarctation--long-term follow-up in adults

Surgical repair of coarctation of the aorta has been performed since 1945. Although surgical techniques have improved, problems such as restenosis and aneurysm at the operation site or hypertensive cardiovascular disease, still remain. To evaluate the long-term results after surgical repair of coarctation, 41 patients, 25 male and 16 female patients (mean age: 28 +/- 11 years, range 14-57 years), were studied 16 +/- 8 years after surgery (range 3-44 years). Mean age at surgery was 12 +/- 9 years (range 0.5-35 years). In 24 patients resection and end-to-end anastomosis had been performed, patch graft aortoplasty in nine patients, tube interposition graft in seven patients and one patient had undergone the subclavian flap technique. All patients were assessed by exact physical examination, the resting arm-to-leg systolic pressure gradient was measured by Doppler sonography, a bicycle exercise test and an echocardiogram were performed. Twenty-one patients reported postoperative symptoms such as dizziness (n = 12), headache (n = 3), cold legs (n = 10) and/or dyspnea (n = 8). In two patients the resting arm-to-leg pressure gradient was greater than 30 mm Hg, in two patients it was greater than 20 mm Hg. Gradient calculated by Doppler echocardiography ranged from 0 to 80 mm Hg (21 +/- 17 mm Hg) and showed poor correlation with the arm-to-leg pressure difference. The mean functional capacity was 89 +/- 18% (range 42-110%). In 18 patients exercise-induced hypertension was found, while in only eight patients arterial hypertension had already been known. To evaluate the morphology of the aorta MRI was performed in 28 patients. No aneurysm was found. In five patients a minimal lumen diameter as small as 9-11 mm was measured. Patients were divided into two groups according to their age at operation, group I: < 9 years (n = 19) and group II: > 9 years (n = 22). Resting blood pressure was significantly higher in group II (135 +/- 27 mm Hg vs 114 +/- 20 mm Hg, p < 0.009), anti-hypertensive medication (43% vs 11%, p < 0.04) and symptoms were more frequent in these patients (15/22 vs 6/19, p < 0.04). However at time of follow-up examination the age of patients of group II was significantly higher (33 +/- 12 vs 22 +/- 5 years, p < 0.0005). Between these two groups there was no difference in follow-up time and results of echocardiography or stress test. In conclusion, despite good long-term results after surgical repair of coarctation of the aorta, patients should be followed on a regular basis primarily in order to recognize systemic hypertension as early as possible and to improve the long-term outcome in these patients by antihypertensive treatment.

Late aneurysm after subclavian flap aortoplasty for coarctation of the aorta

Late aneurysms are common after repair of coarctation of the aorta by prosthetic patch aortoplasty but are rare after subclavian flap aortoplasty. We present the case of a 14-year-old boy who underwent a grafting procedure for a descending thoracic aortic aneurysm after subclavian flap aortoplasty for coarctation of the aorta when he was 2 years old. This is the fifth report of late aneurysm formation after subclavian flap aortoplasty.

Management of coexisting coarctation of the aorta and oesophageal atresia

The combination of neonatal coarctation of the aorta (CoA) and oesophageal atresia (oA) is rare and the optimum approach to surgical correction uncertain. Of 84 consecutive neonates with CoA over an 8-year period, 2 had coexisting oA. We consider that CoA repair by subclavian flap should be performed first to improve the environment for healing of the oesophageal anastomosis. A carefully co-ordinated approach between paediatric and cardiac surgical teams is recommended.

Early and moderate long-term results of a new surgical technique for repair of aortic coarctation.

From June 1987 to September 1995, 53 patients underwent a new technique of coarctation repair. This technique consists of complete mobilization of the left subclavian artery so that it can be pulled down as far as possible. After all the necessary clamping, the anterior wall of the aorta is incised longitudinally beginning on the anterior wall of the left subclavian artery and extending distally to the descending aorta 1-2 cm past the coarctation. The left subclavian artery is pulled down so that the proximal end of the incision can reach the distal end. Then, this longitudinal incision is sutured transversely with 5/0 or 6/0 polydioxanone and continuous technique, enlarging the coarctation site and also preserving the blood flow to the left upper limb. The ages of the patients ranged from 16 days to 20 years (mean 3.7 years). Thirty patients were younger than 1 year old. One patient (1.9%) died postoperatively due to persistent pulmonary hypertension. There was no pressure gradient perioperatively through the coarctation site after the repair. The mean follow-up was 34.4 +/- 27.5 months (range 1-99 months). All patients but one were in class I effort capacity (NYHA). Doppler echocardiographic studies were performed in 45 patients postoperatively. There was no restenosis or aneurysm formation at the coarctation site and the mean pressure gradients were between 19.8 +/- 16.2 mmHg. The authors experience indicates that this technique could be a good alternative to the subclavian flap aortoplasty because of the preservation of blood flow to the left arm.

Surgical Repair of Coarctation of the Aorta in Neonates: Factors Affecting Early Mortality and Re-Coarctation

Between October 1979 and January 1993, 85 Chinese neonates in Hong Kong underwent surgical repair for coarctation of the aorta. Their mean(s.e.) age and body weight at operation was 15.6(8.5) days and 3.06(0.56) kg, respectively. Simple coarctation was present in 17 babies, while 36 had additional ventricular septal defect and 31 had associated major complex intracardiac lesions. Subclavian flap aortoplasty was performed in 56 babies, resection with end-to-end anastomosis in 18 and aortoplasty with the use of a GORETEX patch in 11. The overall early mortality rate was 16.5%. To identify risk factors for early operative mortality. various clinical variables, surgical options, associated heart lesions and dimensions of the aortic arch at different sites for each patient were reviewed. Univariate analysis identified statistically significant differences between the survivors and non-survivors for the following factors: preoperative body-weight, arterial pH and base excess, serum urea and creatinine levels. Stepwise logistic regression further distinguished serum creatinine levels and the period of operation as two significant risk factors. Contrary to previous reports, the dimensions of the aortic arch and type of surgery did not affect early operative mortality. Among the 71 hospital survivors followed for 38.2(38) months, residual or recurrent coarctation of the aorta was detected in 12(17%). The different surgical operations were not related to the incidence of late complication. The size of the distal transverse arch, however, was different ( P= 0.05) in those who did and did not develop aortic sequela. Successful balloon angioplasty was subsequently performed in 11 patients. In an era of echocardiography with prenatal diagnosis and therapeutic catheterization, early recognition of the disease with prompt prostaglandin infusion should prevent collapse of the baby, thus avoiding renal impairment and severe metabolic acidosis. Balloon angioplasty would offer a simple effective treatment for patients who developed aortic re-coarctation.

Standards for Data Collection from Human Skeletal Remains.Jane E. Buikstra , Douglas H. Ubelaker

Previous articleNext article No AccessNew Biological BooksStandards for Data Collection from Human Skeletal Remains. Jane E. Buikstra , Douglas H. Ubelaker Mark SkinnerMark Skinner Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by The Quarterly Review of Biology Volume 70, Number 4Dec., 1995 Published in association with Stony Brook University Article DOIhttps://doi.org/10.1086/419244 Views: 55Total views on this site Citations: 2Citations are reported from Crossref Copyright 1995 The University of ChicagoPDF download Crossref reports the following articles citing this article:Mark R. Dennis, Anne Cusick, Jacinta Borilovic, Calum Nicholson, Tanya Derwin, Rajesh Puranik, David S. Celermajer Left arm structure and function late after subclavian flap repair of aortic coarctation in childhood, Cardiology in the Young 29, no.77 (Jun 2019): 856–861.https://doi.org/10.1017/S1047951119000386Teimuraz Vashakmadze, Emil Martirosyan, Anastasia Sergeeva (Model of Stakeholders Management in Mergers and Acquisitions), SSRN Electronic Journal (Jan 2014).https://doi.org/10.2139/ssrn.2599457

Surgical repair of coarctation of the aorta in neonates: factors affecting early mortality and re-coarctation

Between October 1979 and January 1993, 85 Chinese neonates in Hong Kong underwent surgical repair for coarctation of the aorta. Their mean(s.e.) age and body weight at operation was 15.6(8.5) days and 3.06(0.56) kg, respectively. Simple coarctation was present in 17 babies, while 36 had additional ventricular septal defect and 31 had associated major complex intracardiac lesions. Subclavian flap aortoplasty was performed in 56 babies, resection with end-to-end anastomosis in 18 and aortoplasty with the use of a GORETEX patch in 11. The overall early mortality rate was 16.5%. To identify risk factors for early operative mortality, various clinical variables, surgical options, associated heart lesions and dimensions of the aortic arch at different sites for each patient were reviewed. Univariate analysis identified statistically significant differences between the survivors and non-survivors for the following factors: preoperative body-weight, arterial pH and base excess, serum urea and creatinine levels. Stepwise logistic regression further distinguished serum creatinine levels and the period of operation as two significant risk factors. Contrary to previous reports, the dimensions of the aortic arch and type of surgery did not affect early operative mortality. Among the 71 hospital survivors followed for 38.2(38) months, residual or recurrent coarctation of the aorta was detected in 12(17%). The different surgical operations were not related to the incidence of late complication. The size of the distal transverse arch, however, was different ( P = 0.05) in those who did and did not develop aortic sequela. Successful balloon angioplasty was subsequently performed in 11 patients. In an era of echocardiography with prenatal diagnosis and therapeutic catheterization, early recognition of the disease with prompt prostaglandin infusion should prevent collapse of the baby, thus avoiding renal impairment and severe metabolic acidosis. Balloon angioplasty would offer a simple effective treatment for patients who developed aortic re-coarctation.

Reoperation for recurrent aortic coarctation

Recurrence of stenosis is a complication of coarctation repair associated with major long-term morbidity. Persistent or exercise-provoked hypertension may indicate recurrent coarctation. Patients failing or not amenable to balloon dilation should be managed surgically. A retrospective chart review was performed. Forty-three patients were identified as having undergone repeat surgical intervention for recurrent aortic coarctation between the years 1976 and 1993 at The Hospital for Sick Children in Toronto. Seventy percent of the children had other congenital cardiac anomalies. Eighty-six percent of patients initially treated by subclavian flap aortoplasty or end-to-end anastomosis were managed at reoperation by patch aortoplasty, and 26% of patients also required augmentation of the transverse arch (under hypothermic circulatory arrest) for accompanying hypoplasia. Three patients underwent a second reoperation; all were treated at this reoperation with tube graft interposition. No ischemic spinal injury occurred in patients managed with either simple proximal aortic cross-clamping or cardiopulmonary bypass. No patient treated with transverse arch augmentation required further surgical intervention. Mortality at reoperation was 7% (3 patients), similar to that of first-time coarctation repair. At follow-up (mean duration, 4.5 years), 57% of patients are normotensive, with no measurable arm-leg gradient.

Reoperation after the arterial switch operation for transposition of the great arteries

Although most children after an arterial switch operation for transposition of the great arteries have normal development and cardiac function, a few require reoperation. During the last 10 years, 68 of 753 patients who underwent arterial switch operations (9.3%) underwent 75 reoperations. Thirty underwent early reoperation (< 30 days or during the same hospital stay) and 38 underwent late reoperation. Causes for reoperation included pacemaker insertion (n = 5), left diaphragm plication (n = 4), revision for hemostasis (n = 1), mediastinitis (n = 2), superior vena cava thrombosis (n = 9), subvalvular pulmonic stenosis (n = 5), supravalvular pulmonic stenosis (n = 16), residual atrial (n = 2) or ventricular (n = 8) septal defects, isolated mitral valve insufficiency (n = 2), aortic valve insufficiency (either isolated [n = 1] or in association with mitral incompetence [n = 1] or stenosis [n = 1]), left coronary artery ostial stenosis (n = 1), and recurrent aortic (n = 6) or neoaortic (n = 4) aortic coarctation. In all but 27 patients, the residual defects were already present immediately after the completion of the arterial switch operation; however, only patients with critical lesions were reoperated on early. Interventional catheterization procedures were performed when indicated; however, they only postponed inevitable reoperation. Successful relief of superior vena cava thrombosis was achieved by atriojugular bypass grafting in two patients, by early open thrombectomy in six patients, and by direct patch angioplasty of the superior vena cava once. Patch plasty for subvalvular or supravalvular pulmonic stenosis was carried out in 21 patients, septal defect closure was carried out in nine patients, and pulmonary artery banding was performed in one patient with criss-cross atrioventricular relationship and multiple ventricular septal defects. Valve repair was performed in all five patients with either isolated or combined aortic and mitral valve dysfunction. One patient with left coronary ostial stenosis underwent a patch enlargement of this ostium. Recoarctation was repaired by end-to-end anastomosis in eight patients and by a subclavian flap and a patch angioplasty in one patient each. Seven patients underwent a second reoperation for supravalvular pulmonary stenosis (n = 3), mitral valve replacement (n = 1), ventricular septal defect closure (n = 1), and recurrent coarctation (n = 2). There were six intraoperative (8.8%) and two late deaths. All early deaths occurred after early reoperations.(ABSTRACT TRUNCATED AT 400 WORDS)

Can concordant criss-cross heart be ameliorated by hemodynamic changes?

A 2-year-old female child with "ameliorated" concordant criss-cross heart, complicated superior-inferior ventricles, complete transposition of great arteries, hypoplastic right ventricle, ventricular septal defect, and aortic coarctation is described. The patient underwent subclavian flap, pulmonary artery banding, and balloon atrioseptostomy at age 1 month. The ameliorated concordant criss-cross anatomy was obtained after 2 years of follow-up. This dynamic morphologic change allowed us to perform a subsequent anatomic correction.

A postoperative follow-up study of infantile coarctation of the aorta.

Follow-up investigations were performed in 16 patients operated on for coarctation during infancy. The follow-up period ranged from 4.5 to 11 years (median 5.5 years). Four different surgical techniques were used: resection with end-to-end anastomosis (REE) (4 patients), subclavian flap aortoplasty (SFA) (10 patients), patch aortoplasty (1 patient) and resection and SFA (1 patient). One patient developed recoarctation (6%). She had been operated on by REE at 7 days of age. The other three patients operated on by REE had equal pulses in the arms and legs; none had hypertension and all had normal arm/leg pressure gradients at rest. Seven (58%) of the 12 patients operated on by SFA or aortoplasty had weak radial pulses in the left arm but no limitation of left arm function. The left a rm showed a normal bone age but was smaller and shorter than the right arm in 9 (81%) of the patients. None of the patients operated on by SFA had hypertension and the arm/leg gradient at rest was normal.

Repair of neonatal aortic coarctation

From 1981 to 1991, 146 infants under 1 month of age underwent repair of aortic coarctation. Forty-two had isolated coarctation, 53 had associated ventricular septal defect, and 51 had complex cardiac defects. The principal mode of presentation was congestive heart failure. The mean age at operation was 10.6 days. The technique for repair was left subclavian artery flap angioplasty in 126, resection with end-to-end anastomosis in 14, and a variety of repairs in 6 patients. Concomitant pulmonary artery banding was performed in 62 patients. The overall hospital mortality rate was 11%, and there was a strong association with pre-existing renal failure. The mean aortic clamp time in survivors was 23.9 minutes; mean hospital stay was 13.4 days. Significant restenosis occurred in 16 patients (11%) with an incidence of 10% after subclavian artery flap angioplasty. Eleven patients have undergone reoperation, and 5 were managed successfully with balloon dilatation.

732-6 Resection of Aortic Coarctation and Modified Extended Anastomosis of Descending Aorta to Undersurface of Aortic Arch: Effect on Recurrence

Recurrent aortic coarctation is a frequent complication requiring reintervention following surgical repair of coarctation of the aorta (COA) in infants and neonates. Recoarctation is most commonly seen within the first year of life and is reported to be as high as 30%. Inadequate removal of ductal tissue, failure of growth in the primary anastomosis, and tension on the suture line have been cited as important factors using standard techniques of resection and end to end anastomosis (RETE) and subclavian flap arterioplasty (SFA). To address these issues, we have employed a technique of coarctation resection and modified extended anastomosis of the descending aorta to the undersurface of the aortic arch (RMEDA) since 1992. The salient features of this technique include extensive mobilization of the aortic arch and neck vessels, resection of the coarctation, careful trimming of all ductal tissue, and ligation of the isthmus just beyond the left subclavian artery (LSCA) allowing the distal arch to serve as an end vessel to the LSCA, and end to side anastomosis of the descending aorta to a separate incision in the undersurface of the proximal aortic arch. Fourteen neonates (median age = 12.5 days) and 5 infants (median age = 62 days) with a mean peak systolic gradient of 33 ± 13 torr across the coarctation segment, underwent RMEDA repair of discrete COA and tubular hypolasia of the arch. Two of these infants had recurrent COA following an initial operation performed elsewhere in the neonatal period. Other procedures performed at the time repair of COA include PDA ligation (14), pulmonary artery banding (3), VSD closure (3), and ASD closure (2). Mean (±SD) aortic cross-clamp time was 19 (±6) minutes and mean intraoperative post-repair peak systolic gradient measured 2.3 (±4.7) torr. Early postoperative complications included a recurrent laryngeal nerve injury and a transient focal tonic clonic seizure. There was one early death from a subsequent surgical procedure. Eighteen late survivors at median follow-up of 12 months (range 3 to 24 monts) were free of recurrent COA by echocardiography and clinical examination and required no catheter or surgical reinterventions. In summary, the technique described herein eliminates the ductal tissue from the anastomotic site, and circumvents distal arch hypoplasia. In our experience, there has been no recurrence at midterm followup; however, further evaluation is needed to ascertain its efficacy in preventing late recurrence of coarctation.

Single-stage repair of aortic arch obstruction and associated intracardiac defects in the neonate

The effectiveness of a single-stage anterior approach for the repair of aortic arch obstruction and associated intracardiac defects has not been well evaluated. We therefore reviewed our experience with 60 neonates (median age 8 days, range 1 to 28) who under-went a single-stage repair by way of a median sternotomy at our institution between 1986 and 1994. Nineteen (32%) had coarctation with ventricular septal defect, 18 (30%) had interrupted aortic arch with ventricular septal defect, and 23 (38%) had coarctation or interrupted aortic arch with complex intracardiac anatomy. The arch obstruction was repaired using resection and primary anastomosis in 54 patients, synthetic patch aortoplasty in 3, subclavian flap aortoplasty in 2, and an interposition gortex graft placement in 1. Total circulatory arrest time was 48 ± 3 minutes (mean ± SEM). There were 7 early postoperative deaths (11.7%; 70% confidence limit 8% to 16.6%). The 53 survivors were followed for a mean of 23 months (range 1 to 78), for a total of 1, 219 patient-months. Recurrent arch obstruction ≥20 mm Hg has occurred in 2 of 53 patients (3.8%; 70% confidence limit 1.9% to 7.5%); both underwent successful balloon angioplasty. There were 2 late deaths, 1 of which was noncardiac. We conclude that repair of aortic arch obstruction and intracardiac defects by a single-stage approach through median sternotomy can be accomplished with low mortality in infancy, even with associated complex intracardiac anatomy. Recurrent coarctation is relatively uncommon and can be successfully managed with balloon angioplasty.