Original article
Congenital heart surgery
Aortic Arch Advancement for Aortic Coarctation and Hypoplastic Aortic Arch in Neonates and Infants

Presented at the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014.
https://doi.org/10.1016/j.athoracsur.2014.04.051Get rights and content

Background

The optimal treatment for infants with aortic coarctation and hypoplastic aortic arch is controversial. The goal of this study was to report the short-term and mid-term outcomes of aortic arch advancement (AAA) in infants with hypoplastic aortic arch.

Methods

All infants who underwent AAA at our institution from 1995 to 2012 were included. AAA consisted of coarctectomy and end-to-side anastomosis of the descending aorta to the distal ascending aorta/proximal arch through a median sternotomy. The cohort was divided into four groups: (1) isolated AAA (n = 29, 11%), (2) AAA with closure of ventricular septal defect (n = 56, 20%), (3) AAA with other biventricular repairs (n = 115, 42%), and (4) AAA as part of single-ventricle palliation (n = 75, 27%).

Results

The cohort included 275 patients: 125 (45%) were female, and the median age was 14 days (interquartile range, 7–34 days). Genetic abnormalities were present in 48 patients (17%). Neurologic adverse events occurred in 3 patients (1%), all in group 4. Left bronchial compression was seen in 2 patients (0.7%); only one required intervention. Vocal cord dysfunction was noted in 36 of 95 patients (38%) on routine laryngoscopy. Only 1 patient had clinical residual dysfunction at the last follow-up visit. Perioperative mortality was 3% (n = 8). At a median follow-up time of 6 years, 8 patients (3%) had reinterventions at a median time of 5 months (3–17 months) after repair.

Conclusions

AAA is a safe, effective, and durable operation with low rates of adverse events and mid-term reintervention. The advantages include native tissue-to-tissue reconstruction and preserved potential for growth. As such, it is the ideal technique for the management of hypoplastic aortic arch in neonates and infants.

Section snippets

Study Population

The study cohort included all patients younger than 1 year who underwent an AAA for the initial treatment of CoA with HAA or concomitant treatment of CoA and associated intracardiac anomalies at Texas Children's Hospital from 1995 to 2012.

The population was divided into four groups: (1) isolated AAA (with or without atrial septal defect repair), (2) AAA with closure of ventricular septal defect (VSD), (3) other biventricular procedures, and (4) non-Norwood single-ventricle palliation.

Surgical Technique

All

Patient Characteristics

A total of 275 patients, 125 of whom were female (45%), with a median age of 14 days (interquartile range 7 to 34 days) and a weight of 3.3 ± 0.9 kg, underwent AAA during the study period (Table 1). Cardiogenic shock was the presenting feature in 43 patients (16%). Preoperative echocardiographic measurements of the proximal transverse arch were available for 233 patients (85%). The median z score for the proximal transverse arch was −5.1 (−12 to −0.31).

A total of 48 patients (17%) had

Comment

Recurrent arch obstruction is an adverse event in 2% to 31% of cases after CoA repair 3, 14, 15, 16, 17, 18, 19, 20, 21. Some of the factors that seem to be associated with a higher rate of recurrent obstruction include younger age 14, 22, 23, lower weight 24, 25, the presence of an aberrant subclavian artery [15], small aortic arch [14], and the type of surgical technique 18, 21, 26.

In a recent study by Pedersen and colleagues, 133 patients who were operated on for CoA between 1965 and 1985

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