VSD Closure Research Articles

Valved homograft replacement of aneurysmal pulmonary arteries for severely symptomatic absent pulmonary valve syndrome

Background. Patients with absent pulmonary valve syndrome (APVS) with respiratory distress (RD) have previously had a high mortality. In 1990 we adopted a strategy of primary repair including total replacement of the aneurysmal central pulmonary arteries (PAs) for patients with RD. Methods. Retrospective review was made of 54 consecutive patients with APVS between 1960 and 1998. Median age and weight were 4 months and 4.8 kg. RD was present in 23 patients (10 neonates, 16 required ventilation). Fifteen patients had repair with homograft replacement of the PAs and VSD closure (group 1). Twenty-seven patients had transannular patch with VSD closure with PA-plasty (group 2, n = 21) or without PA plasty (group 3, n = 6). Twelve had miscellaneous procedures (group 4); in 6 the VSD was left open. Results. Operative, 1-, 5-, and 10-year survivals were 83%, 80%, 78%, and 78%, respectively. Risk factors for operative mortality in multivariate analysis were RD ( p = 0.04), neonates ( p = 0.02), weight less than 3 kg ( p = 0.02), open VSD ( p = 0.02) and surgery before 1990 ( p = 0.04). Since 1990 operative mortality has decreased to 11% ( p = 0.04). RD was the only time-related predictor of survival in multivariate analysis ( p = 0.004). In patients with RD, survival with homograft was 73% versus 41% with other techniques ( p = 0.2). Mean follow-up was 72 ± 50 months. There were no significant differences in freedom from reintervention rates among the surgical groups ( p = 0.08). Conclusions. Aggressive homograft replacement of the central pulmonary arteries has been associated with improved survival in patients with APVS especially in neonates with severe RD.

Use of small stents for rehabilitation of hypoplastic pulmonary arteries in pulmonary atresia with ventricular septal defect.

Branch pulmonary artery stenosis frequently occurs in pulmonary atresia with ventricular septal defect (PA/VSD). Balloon dilation alone is often unsuccessful in patients with severely hypoplastic pulmonary arteries with residual stenoses after surgical repair. In an attempt to promote distal pulmonary artery growth, 17 stents were placed in 12 severely stenotic pulmonary artery lesions in 10 patients with PA/VSD. All had prior surgery, including pulmonary artery repair, right ventricle to pulmonary artery homograft, and, in 6 of 10, closure of VSD. Median age at stent placement was 16.8 months (range, 13.2-56). Stents were placed using 3.0, 3.5, or 4.0 mm balloons in all but one lesion, in which a 7 mm balloon was used. Following stent placement, there was an increase in the lesion diameter from 1.5 to 3.4 mm (P < 0.05) and an increase in flow to the affected lung from 27% to 34% (P < 0.05). Repeat catheterization 2 to 6 months after stenting in six patients revealed complete occlusion in two of eight lesions. In the other six vessels, there was an increase in distal vessel diameter from 2.96 to 3.94 mm (P < 0.05) even though four had severe restenosis requiring restenting. Two patients underwent surgical pulmonary artery reconstruction and stent removal because of adequate distal vessel growth. Stenting of hypoplastic pulmonary arteries in PA/VSD results in immediate improvement in vessel size and blood flow. Stent restenosis is common although distal vessel growth can be achieved. Stenting of these lesions should be reserved only for those patients unresponsive to other interventions.

心室中隔欠損閉鎖術後の僧帽弁および三尖弁閉鎖不全症に合併した蛋白漏出性胃腸症 僧帽弁・三尖弁修復による１治験例

症例は37歳男性. 学童時に心室中隔欠損症で2度の手術を受け, 31歳頃から僧帽弁閉鎖不全兼三尖弁閉鎖不全症の診断で通院していた. 安静時にも呼吸困難が出現するようになり入院した. 両下肢の浮腫と腹部の著明な膨隆を認めた. 強心剤・利尿剤の投与により心不全症状は改善した. しかし, アルブミンの補充にもかかわらず総蛋白3.7g/dl, アルブミン1.9g/dlと低蛋白血症と低アルブミン血症が持続し, 胸水・腹水も減少しなかった. 消化管シンチにて蛋白の消化管内への漏出を認め, 蛋白漏出性胃腸症を合併した僧帽弁閉鎖不全兼三尖弁閉鎖不全症の診断で手術を施行した. 手術は両弁とも形成術を施行し, 術後II度の三尖弁逆流が残ったが, 中心静脈圧は低下し腸管への蛋白漏出は改善し腹水も消失した. 三尖弁閉鎖不全症に伴う蛋白漏出性胃腸症の報告は少なく, 報告した.

Interventional Versus Surgical Closure of Atrial and Ventricular Septal Defects: Advantages and Limitations of the Catheter‐Based Approach

New techniques and devices have revolutionized the transcatheter techniques used to close congenital intracardiac shunts. The advantages, compared to surgery, are the avoidance of a thoracotomy, postoperative pain and morbidity, a long hospital stay, and most often general anesthesia. Atrial septal defect closure has become a routine procedure in many centers. It is amenable in about 80% of the patients with a secundum‐type defect. The success rate today is dx &gt; 99% and the rate of any complication is &lt; 0.5%. Ventricular septal defect closure, however, is still in its infancy. Apical, mid‐muscular, and selected perimembraneous VSDs with a significant septal rim between the defect and the aortic valve can be closed with the devices currently available. Analysis is still needed to prove the long‐term safety and efficacy of ASD or VSD closure.

The Role of Transesophageal Echocardiography During Catheter Closure of ASD and VSD

Transcatheter closure has developed into a significant alternative for surgery in the treatment of atrial septal defects (ASDs). Before the choice can be made between the two treatment options, patients should be selected who have a septal defect that is suitable for catheter closure. Transthoracic echocardiography has proven to be unreliable in this respect. Therefore, a diagnostic transesophageal echocardiogram (TEE) is mandatory prior to an intervention session. In adults, this can be done during a routine outpatient clinic visit. In children, a TEE has to be done under general anesthesia. Therefore, it is practical to plan a diagnostic TEE under general anesthesia first, with the possibility of a subsequent catheter intervention in the same session. During the procedure, the role of TEE is to provide additional information to the fluoroscopy images that the interventional cardiologist is used to working with. TEE gives detailed information on the position of the catheter and the device in relation to vital intracardiac structures, like the atrioventricular valves, the pulmonary veins and, most important, the atrial septum itself. Good collaboration between the interventionalist and echocardiographer has proven to be beneficial for successful nonsurgical closure of ASDs. The role of transcatheter closure of ventricular septal defects is limited. Only defects for which surgical treatment is impossible or unattractive are thought to be candidates for transcatheter closure. TEE is helpful also in this procedure.

Re-do cardiac surgery in patients over 70 years old

This study was conducted in order to determine the outcome of cardiac re-operations in patients over the age of 70. All patients who underwent 're-do' cardiac surgery at our institution, between January 1987 and October 1995 were identified. The case notes of patients over the age of 70 were reviewed retrospectively and follow-up was by telephone. A total of 687 re-do operations were performed during this 8 years and 9 months period. Operations, 110 (16%) were on patients aged 70 years and over (CABG 54, MVR 32, AVR 9, AVR + MVR 5, MVR + CABG 4, AVR + CABG 3, repair of paraprosthetic leak 2 and closure of VSD 1). Operations, 63 (57%) were elective and 42 (38%) were urgent. The median age was 73 years (range 70-82) and 64 patients (58%) were male. Pre-operatively, 78 patients (72%) were NYHA functional class III/IV and 55 (50%) had angiographically impaired left ventricular function (ejection fraction < 50%). The overall operative mortality was 7% (8/110). Median ITU stay was one night (range 1-21) and hospital stay was 7 days (range 5-35). Major in-hospital complications included resternotomy in five patients (5%), permanent stroke in three (3%), renal failure requiring haemodialysis in two (2%) and heart block requiring permanent pacing in two (2%). At a median follow-up of 34 months (range 2-101), 69 of the 77 patients alive at follow-up (90%) were NYHA functional class I/II. 'Re-do' cardiac surgery in patients over the age of 70 carries an acceptable operative morbidity and mortality with a good functional improvement at medium term follow-up.

Is the arterial switch operation still a challenge in small centers?

In the last years, major changes as regards timing for operation, surgical technique, and perioperative care determined a great improvement in the arterial switch operation (ASO) allowing excellent mid-term results in a few leading centers. This stimulated the widespread adoption of ASO as procedure of choice for transposition of the great arteries (TGA), even in small institutions. We reviewed our early experience with ASO in an attempt to evaluate its safety in a small center. Since April 1992, 39 consecutive patients underwent TGA repair by ASO in our department. There were 27 patients with simple TGA, 8 with TGA and VSD and 4 with Taussig-Bing heart and aortic coarctation. Median age and weight at operation were 7 days and 3.5 kg, respectively. Neonatal repair was performed in 34 patients. In accordance with the Planché coronary classification, type I was encountered in 21 patients, type II in 4 and type III in 14. Several modifications of the original technique were used, mainly regarding coronary relocation, pulmonary artery reconstruction and approaches for associated VSD closure and aortic arch repair. Early mortality was 2.6% (n = 1), the only operative death being related to unsatisfactory coronary relocation. Since modified ultrafiltration was adopted, mean ICU stay decreased from 5 +/- 4 days (n = 21) to 2 +/- 1 days (n = 17) (P < 0.05). Three patients required reoperation for residual ASD and/or VSD closure. There were no late deaths. After a mean follow-up of 26 +/- 15 months all survivors are thriving and are currently asymptomatic. Although this series is rather small, most of the major coronary anomalies and complex anatomic associations were encountered. This experience suggests that neonatal repair of TGA by ASO can be safely accomplished even in small centers. Modified ultrafiltration appears to improve the early outcome of neonates undergoing ASO.

985-66 Cardiorespiratory Exercise Function After Surgical Closure of a Large Ventricular Septum Defect

The aim of the study was to assess late cardiac and pulmonary function after closure of a large non-restrictive VSD during infancy. We evaluated 15 patients 9.3 ± 1.5 years after closure of a large VSD during the first year of life (Qp/Qs: 3.1 ± 0.8, mean preoperative pulmonary artery pressure 63 ± 15 mmHg). A Doppler echocardiographic examination showed no residual shunting nor evidence of residual pulmonary hypertension at rest. Exercise testing was performed on a treadmill and respiratory gas exchange was measured using breath-by-breath analysis. Aerobic capacity was assessed by determination of the ventilatory anaerobic threshold (VAT). VAT reflects the highest aerobic exercise level prior to a disproportionate increase of VCO 2 and ventilation relative to oxygen uptake. The steepness of the slope of the upper segment of CO 2 vs. VO 2 above VAT (S2) was calculated to assess aerobic and anaerobic exercise function. The ratio VE/V CO 2 under VAT was used as index for residual pulmonary hypertension during exercise. Results were compared with values of an age and gender matched population (for VAT: n = 234; for S2: n = 17). VAT (ml 0 2 /kg/min) S 2 slope VE/VCO 2 slope patients 27.5 ± 4.3 0.94 ± 0.10 34.7 ± 7.1 control 30.0 ± 3.4 0.98 ± 0.10 32.1 ± 6.0 p NS NS NS We conclude that the aerobic capacity and the pulmonary artery pressure are both normal during exercise after closure of a large VSD during infancy.

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.

702-3 Factors Associated With Arrhythmias After Mustard Operation—30 Year Experience with 534 Patients

To determine factors associated with survival and arrhythmias, we reviewed 534 (359 males) consecutive patients after Mustard operation (MUST) for transposition of the great arteries (TGA) from 1963 to 1993. TGA was isolated for 354 pts, associated with VSD in 73, pulmonary obstruction (PS) in 50, VSD with PS in 46 and complex anomalies in 11. Median age at MUST was 16 months (range, 21 days to 19 yrs). There were 52 hospital deaths (9.7%). Late death occurred in 76 of 482 operative survivors (15.8%) with up to 31 years follow-up (mean 12.6 ± 6.8 yrs). Late survival was 89% at 5 yr, 88% at 10 yr, 82% at 15 yr and 76% at 20 yr. Mode of late death included: Sudden, 39%; myocardial failure, 27%; pulmonary vascular disease, 10%; reoperation, 7%; pulmonary venous obstruction, 4%; non-cardiac, 4%; and other, 9%. Cox's proportional hazard modelling was used to assess independent factors associated with late death. Significant factors included: earlier date of operation (Odds Ratio, OR, 0.75 per 5 yrs). VSD closure at MUST (OR 2.5), and peri-operative atrial tachyarrhythmias at MUST (OR 1.9). Instantaneous risk (hazard) of late death declined, with a late peak and decline. Loss of sinus rhythmn (LSR) was noted in 29% of survivors: freedom from LSR was 82% at 5 yr, 67% at 10 yr, 60% at 15 yr and 52% at 20 yr. Significant independent factors associated with LSR included: pre-MUST surgical atrial septectomy (OR 1.7), peri-operative bradyarrhythmias (OR 1.7) and occurrence of atrial flutter (AFL) during follow-up. Instantaneous hazard of LSR showed a gradual decline after MUST with a second late peak. AFL was noted in 15% of survivors; freedom from AFL was 92% at 5 yr, 89% at 10 yr, 82% at 15 yr and 71% at 20 yr. Patients who were on digoxin vs. no medication at the time of their first AFL episode were less likely to have symptoms of presyncope or syncope (7% vs. 33%, P = 0.06). Independent factors associated with late AFL included: LSR (OR 2.6) and peri-operative arrhythmias including AFL (OR 3.1). bradyarrhythmias (OR 2.5) and permanent heart block (OR 12.2). Instantaneous hazard of AFL showed a gradual incline with a late peak. Late peaks in the risk of death, LSR and AFL necessitate ongoing fOllOW-Up in this population.

Early extubation with a mixture of frofofol and alfentanil in children undergoing ASP and VSD closure operations

Early extubation with a mixture of frofofol and alfentanil in children undergoing ASP and VSD closure operations

Atrial Repair for Transposition of the Great Arteries: Current Approach in Zürich Based on 24 Years of Follow-up

Long-term survival after atrial repair of a transposition of the great arteries between 1964 and 1988 is analyzed in 254 thirty-day survivors. For the complete series, overall survival is 99.6% after one year, 94.9% after 6 years, 89.6% after 12 years, 84.9% after 18 years, and 64.0% after 24 years. Broken down for simple (154/254) versus complex (95/254) transposition survival, it is 99.4% versus 100.0% for one year, 94.7% versus 99.5% for 6 years, 90.8% versus 88.3% for 12 years, 85.1% versus 85.8% for 18 years and 77.7% versus 46.8% at 24 years. Survival for patients without or with VSD is 95.3% versus 96.2% after 6 years, 91.2% versus 87.9% after 12 years, 87.5% versus 84.0% after 18 years, and 83.7% versus 52.5% after 24 years. Cumulative survival as a function of the surgical approach for VSD closure is 94.3% for transatrial versus 92.3% for transventricular at 6 years, 82.2% versus 92.3% after 12 years, 82.2% versus 83.0% after 18 years and 82.2% versus 41.5% after 24 years. Survival for patients operated upon before 1978 is 94.3% versus 96.0% thereafter at 6 years, and 90.7% versus 89.2% at 12 years (NS). Linearized mortality rates are 1.49% per patient year for the complete series, 0.93 for simple transpositions, 2.21% for complex transpositions (including VSD, obstruction of the left ventricular outflow tract, or both), 0.68% for transpositions without VSD, 1.98% for transpositions with VSD, 2.43% for transposition with transventricular repair of a VSD, 1.74% for transposition with transatrial closure of a VSD, and 0.90% for all cases operated upon after 1978.(ABSTRACT TRUNCATED AT 250 WORDS)

Correção cirúrgica para reversão de operação de Senning em caso de falência ventricular direita

Os autores apresentam uma nova proposta para tratar disfunção do ventrículo direito no pós-operatório tardio da transposição das grandes artérias associada a grande comunicação interventricular e que tenha sido tratada pela inversão em nível atrial. Apresentam o caso de um paciente com 12 anos de idade, que havia sido submetido a operação de Senning associada a fechamento de comunicação interventricular e alivio de estenose pulmonar há 8 anos. A operação de Senning foi desfeita, restabelecendo-se a concordância atrioventricular, o remendo que fechava a comunicação interventricular foi ressecado, conectando-se a aorta com o ventrículo esquerdo. A artéria pulmonar foi seccionada transversalmente, próximo ao plano valvar. O coto proximal foi suturado e o distai, conectado ao ventrículo direito através de tubo valvulado de pericárdio bovino. A evolução foi satisfatória, revertendo-se a situação do paciente do grupo funcional IV para grupo I/II.

高度左心機能低下をともなったＶＳＤ＋ＡＲの手術（経大動脈的ＶＳＤ閉鎖）

高度左心機能低下をともなったＶＳＤ＋ＡＲの手術（経大動脈的ＶＳＤ閉鎖）

Pulmonary arterial changes in patients with ventricular septal defects and severe pulmonary hypertension.

In 25 patients, aged eight months to 31 years, with ventricular septal defect (VSD; isolated in 15, the others with atrial septal defect, PDA, coarctation or patent ductus arteriosus + coarctation), each with severe pulmonary artery hypertension (pulmonary artery systolic pressure [Ppa] at least 75% of systemic and an elevated pulmonary vascular resistance), we related morphologic and morphometric data from open-lung biopsy to hemodynamic measurements obtained at cardiac catheterization during the same hospital admission. Of the hemodynamic features measured, only the ratios of pulmonary-to-systemic flow and pulmonary-to-systemic resistance correlated significantly with structure. Neither pulmonary artery pressure (Ppa) nor pulmonary vascular resistance correlated significantly with any structural feature studied. The increased external diameter of respiratory bronchiolar arteries in those with the more advanced Heath-Edwards grades reflects dilatation and suggests that it is in the small arteries of the distal arterial bed that the changes of pulmonary hypertension are most significant. Neither age nor body weight correlated significantly with the degree of structural or hemodynamic abnormality. In the ten patients who underwent VSD closure, Ppa was measured postoperatively. The Heath-Edwards grade (no more than one grade-III lesion) and arterial density (at least one-half that normal for age) were the best correlates of the difference between preoperative Ppa and Ppa immediately after corrective surgery. The presurgical catheterization data, including pulmonary resistance and the resistance ratio, did not correlate significantly with change in Ppa following VSD closure.(ABSTRACT TRUNCATED AT 250 WORDS)

An operated case of the mitral valve prolapse syndrome complicated with infective endocarditis and mitral regurgitation far after the VSD closure

An operated case of the mitral valve prolapse syndrome complicated with infective endocarditis and mitral regurgitation far after the VSD closure

129 SYNDROME OF ABSENT PULMONARY VALVE

This presentation reviews our experience with the syndrome of absent pulmonary valve (SAPV). Ten infants and children with SAPV seen during 1979–83 were analyzed. Their mean age was 11 months with a range of 1 day to 3 years. Five group I patients ( 6 mo.) presented with history of recurrent respiratory tract infection and a murmur. Clinical, x-ray, echocardiographic (ECHO) findings were classic for this anomaly. Two children were symptom-free on medical management, and two died following surgery. Plication of PAs was performed as the sole procedure in a 5-day-old respirator-dependent infant. Seven patients underwent closure of VSD and relief of PV ring stenosis; two of these had additional PA plication and two additional PV replacement. Follow-up of these patients ranged between 1.5 and 3.5 years and all underwent ECHO and catheterization studies. Symptomatic relief and normalization of cardiac structure and function were greatest in the patients who had plication of PAs as an integral part of total repair as compared with those who had other types of surgical correction or no surgical repair. Based on this experience, we recommend total surgical correction with PA plicaiton but without PV replacement as the procedure of choice in symptomatic patients with SAPV.

PREOPERATIVE AND POSTOPERATIVE EXERCISE RESPONSE IN PULMONARY ATRESIA

Patients (PTS) with pulmonary atresia (PA) subjectively may have increased exercise (EX) tolerance after 1st stage (RV to Pul. Art. conduit placement without VSD closure) or 2nd stage (RV to Pul. Art. conduit and VSD closure) repair. To measure precisely the degree of EX intolerance in PTS with PA and to assess improvement of EX tolerance after operation 10 PTS preop, 4 PTS after 1st stage and 7 PTS after 2nd stage repair performed graded cycle ergometry. The groups were similar in sex, age, ht. and BSA. As percent predicted, total work performed (P< 0.005), maximal power (P<0.01) and EX time (P<0.001) increased following either 1st or 2nd stage repair. EX performance was similar for PTS after 1st and 2nd stage repair. Resting and exercise blood pressures were similar among the three groups. As percent predicted, resting heart rate (HR) was lower (P<0.02) after 1st or 2nd stage repair than preop. Maximum EX HR was highest after 2nd stage repair (P<0.05). Both resting and EX oxygen saturation increased with degree of repair (P<0.05). Resting, respiratory rate, minute ventilation (Ve), oxygen uptake (VO2) and Ve/VO2 were similar among the groups. EX Ve and VO2 were greater (P<0.001 and Ve/VO2 less (P<0.001) for the two postop groups than the preop group.Graded cycle ergometry is a useful technique to evaluate the impact of surgery on congenital heart disease. By it we demonstrated that both 1st and 2nd stage repair of PA improves cardiorespiratory response to exercise and exercise tolerance.

Ventricular septal defect in infancy. Surgical criteria and experience.

The optimal surgical management of ventricular septal defects (SVD) in infancy and particularly in small babies, still remains controversial. Seventy-six infants with VSD as the major cardiac lesion were operated upon from March 1978 to December 1981. Forty-three underwent primary repair with a 9.3% mortality rate. Pulmonary artery banding (PAB) was performed in 33 infants without mortality. Sixteen of them had subsequent debanding and VSD closure, also without mortality. Based on our own experience, our current recommendations are as follows: PAB in severely ill infants under 3 months of age, in infants with multiple or "Swiss-cheese type VSD" and in some cases of VSD with associated anomalies. Early debanding and correction, except in cases with multiple VSDs. Primary repair in infants aged more than 3 months and in some selected younger cases, according to the anatomical location of the defect.

Left ventricular morphometric estimation of the coarctation complex in the first year of life.

Coarctation complex is a serious congenital cardiovascular malformation in infants. It is associated with severe congestive cardiac overload and high mortality even after surgical treatment. To investigate left ventricular performance, quantitative morphometry and histometry of the left ventricle were carried out in 19 autopsied patients who died without surgical intervention. The following results were obtained: 1. Coarctation of the aorta was found to selectively affect the left ventricle, showing a volume overload response without effectively adapting to the pressure overload; the right ventricle showed a significant reaction to the pressure overload. 2. The coronary arterioles responded to the pressure load in the left ventricle. In order to promptly recover left ventricular function, simple coarctectomy without VSD closure or other procedures is advisable for treatment of the coarctation complex in the early months of life.