Primary repair of coarctation of the thoracic aorta by patch graft aortoplasty. A three-decade experience and follow-up in 60 patients

15-Year Analysis of Surgical Approaches and Outcomes for Coarctation in 132 Neonates and Infants

A variety of surgical approaches exist to treat aortic coarctation in neonates and infants. Our institutional approach is designed to match the surgical approach to the individual anatomy of the patient. The objective of this study is to evaluate operative characteristics and outcomes of all neonates and infants who underwent surgical repair of coarctation of the aorta or hypoplastic aortic arch at University of Florida from 2006 to 2021, inclusive, either in isolation or with concomitant repair of atrial septal defect (ASD) and/or ventricular septal defect (VSD). A retrospective review was performed of 132 patients aged 0-1 year who underwent surgical repair of aortic coarctation or hypoplastic aortic arch between 2006 and 2021, inclusive, either in isolation or with concomitant repair of ASD and/or VSD. Patients were divided into two groups based on the surgical approach: Group 1 = Median Sternotomy and Group 2 = Left Lateral Thoracotomy. Continuous variables are presented as median (minimum-maximum); categorical variables are presented as N (%). The most common operative technique in Group 1 was end-to-side reconstruction with ligation of the aortic isthmus. The most common operative technique in Group 2 was extended end-to-end repair. Operative Mortality was one patient (1/132 = 0.76%). Transcatheter intervention for recurrent coarctation was performed in seven patients (7/132 = 5.3%). Surgical re-intervention for recurrent coarctation was performed in three patients (3/132 = 2.3%). From these data, one can conclude that a strategy of matching the surgical approach to the anatomy of neonates and infants who underwent surgical repair of aortic coarctation or hypoplastic aortic arch, either in isolation or with concomitant repair of ASD and/or VSD, is associated with less than 1% Operative Mortality and less than 3% recurrent coarctation requiring reoperation.

Surgical Management of Aortic Coarctation from Infant to Adult

Objective

In the present study, we aimed to retrospectively investigate the early and late results of different surgical treatment techniques applied in different age groups with coarctation of the aorta (CoA).

Materials and Methods

Between January 2007 and February 2017, 26 patients (12 males, 14 females; mean age: 12.2±12.4 years; range: 29 days-34 years) who underwent surgery with the diagnosis of CoA were evaluated. Overall, 11 of these patients (42.3%) were in the infantile period, whereas 15 patients (57.7%) aged between 6 and 34 years. Resection and end-to-end anastomosis were performed in 13 patients (50%). Bypass grafting was performed in six patients (23.1%), and patch plasty was performed in seven patients (26.9%).

Results

A patient (3.8%) who was operated on during the infantile period died early, whereas another patient (3.8%) died 2 years after the surgery. Recoarctation was detected in two patients. A patient underwent balloon dilatation, whereas another patient underwent balloon dilatation and stenting. In patients who underwent re-section and end-to-end anastomosis based on postoperative echocardiography results during follow-up, a lower statistically significant gradient was observed compared with the preoperative period. Despite the decrease in the left ventricular systolic diameter (LVSD) and the increase in the ejection fraction (EF) the decrease in LVSD and increase in EF were not statistically significant. In patients who underwent patch plasty or graft interposition, the low values of the gradient and left ventricular diastolic diameter in the postoperative follow-up were statistically significant. However, the decrease in LVSD and increase in EF were not statistically significant.

Conclusions

Our clinical experience suggests that repairing with resection and end-to-end anastomosis is a more appropriate treatment option during the infancy, whereas patch plasty or bypass grafting may be preferred in advanced ages.

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.

Aortic aneurysms: delayed complications of coarctation of the aorta repair using Dacron patch aortoplasty

Coarctation of the aorta is a diaphragmlike ridge narrowing the lumen of the proximal descending aorta. Although surgical repair has proven to be a successful treatment of coarctation of the aorta, immediate and delayed postoperative complications are not rare. Of particular interest is the occurrence of aneurysms after Dacron patch aortoplasty--often decades after surgery. Delayed complication rates of up to 50% have been reported. We describe the clinical-radiologic presentations of 3 late complications of Dacron patch angioplasty: aortobronchopleural fistula, leaking pseudoaneurysm, and giant descending aortic aneurysm--all successfully treated with bypass grafts. Because of the high incidence of delayed complications, lifelong surveillance is necessary. The chest x-ray may be the first clue to a delayed complication. Knowledge of radiologic findings is helpful in the detection of complications-before they become symptomatic. Transesophageal echocardiography, computed tomography angiography, or magnetic resonance imaging with multiplanar reconstruction is diagnostic.

Single-stage repair of aortic arch obstruction and associated intracardiac defects with pulmonary homograft patch aortoplasty

OBJECTIVE

Intracardiac malformations associated with coarctation and aortic arch hypoplasia have traditionally been repaired in 2 stages, with a high mortality rate. We review our experience with single-stage biventricular repair of intracardiac defects associated with aortic arch hypoplasia by means of pulmonary homograft patch aortoplasty.

METHODS

Between October 1988 and October 1997, 39 of 40 consecutive patients underwent single-stage biventricular repair for aortic arch obstruction and associated intracardiac defects. The median age at operation was 17 days and the mean weight was 3.71 +/- 1.09 kg. Nineteen patients had either dextrotransposition of the great arteries or the Taussig-Bing anomaly. Sixteen patients had multiple left-sided obstructive lesions (2 cases of critical aortic stenosis, 3 of subaortic stenosis and ventricular septal defect, and 11 of hypoplastic left heart complex). One patient had an associated complete atrioventricular septal defect. Four patients had only an associated ventricular septal defect. Through a median sternotomy, the hypoplastic aortic arch was enlarged with a pulmonary homograft patch in 36 patients. In 4 patients an extended end-to-end anastomosis was performed.

RESULTS

There were 2 early deaths (5%) and 2 late deaths (5%). One late death was not cardiac related. The mean follow-up time was 36 months (range 1 month-9 years). The recoarctation rate after pulmonary homograft patch aortoplasty was 8. 3%, but after exclusion of those patients with associated left-sided obstructive lesions this decreased to 0%. No aneurysm formation in the aorta has occurred. The actuarial survival at 8 years is 89% +/- 10%.

CONCLUSIONS

Single-stage biventricular repair of aortic arch obstruction and associated intracardiac defects can achieve excellent survival. We recommend pulmonary homograft patch aortoplasty because it achieves complete relief of anatomic afterload with a tension-free anastomosis and low incidence of recoarctation.