Coarctation of the aorta in infants: Does the aortic arch grow after repair?

doi:10.1016/0003-4975(92)90639-L

The Annals of Thoracic Surgery

Volume 54, Issue 5, November 1992, Pages 869-875

https://doi.org/10.1016/0003-4975(92)90639-L Get rights and content

Abstract

Infants with coarctation of the aorta frequently require a corrective operation during the first year of life. These patients frequently have a smaller than normal transverse aortic arch. Despite good repairs with different techniques, the proximal transverse aortic arch often remains smaller than normal. The hemodynamic molding theory predicts that growth of the aortic arch should occur when normal flow is established through the aortic arch. Preoperative and postoperative aortograms were reviewed in patients who underwent subclavian flap aortoplasty for the repair of coarctation. Patients were divided into two groups. Subclavian flap aortoplasty was performed at 1 month of age or earlier in group I, and at more than 1 month but less than 1 year of age in group II. Aortograms performed in patients without coarctation were used as age-matched controls (group III). The transverse aortic arch in groups I and II did grow and were compared with the control group. Group I patients achieved more growth than those in group II. No aortic arch gradients were present at postoperative follow-up.

References (18)

WG Williams et al.
Results of repair of coarctation of the aorta during infancy
J Thorac Cardiovasc Surg
(1980)
JL Harlan et al.
Coarctation of the aorta in infants
J Thorac Cardiovasc Surg
(1984)
DB Campbell et al.
Should elective repair of coarctation of the aorta be done in infancy?
J Thorac Cardiovasc Surg
(1984)
GS Kopf et al.
Repair of aortic coarctation in the first three months of life: immediate and long-term results
Ann Thorac Surg
(1986)
PAS Penkoske et al.
Subclavian arterioplasty: repair of coarctation of the aorta in the first year of life
J Thorac Cardiovasc Surg
(1984)
F Lacour-Gayet et al.
Hypoplastic transverse arch and coarctation in neonates
J Thorac Cardiovasc Surg
(1990)
JJ Amato et al.
A method of enlarging the distal transverse arch in infants with hypoplasia and coarctation of the aorta
Ann Thorac Surg
(1977)
WE Pae et al.
Subclavian flap angioplasty
J Thorac Cardiovasc Surg
(1981)
JA Waldhausen et al.
Repair of coarctation of the aorta with a subclavian flap
J Thorac Cardiovasc Surg
(1966)

There are more references available in the full text version of this article.

Cited by (37)

Growth of unrepaired hypoplastic proximal aortic arch and reintervention rate after aortic coarctation repair
2023, Journal of Thoracic and Cardiovascular Surgery
Treatment of tubular hypoplasia of the aortic arch (THAA) associated with aortic coarctation (CoA) remains controversial. We aimed to evaluate growth of unrepaired hypoplastic proximal aortic arches (PAAs) after surgical repair for CoA.
Preoperative and follow-up echocardiographic images of 139 patients who underwent CoA repairs from 2005 to 2012 were reviewed. THAA was defined as PAA z-score <−3 and non-THAA group z-score ≥−3. Reintervention rates due to aortic obstruction were assessed using competing risk models and diameters of the aorta were compared with Mann–Whitney U tests.
Fifty patients (36%) had THAA and 89 (64%) had non-THAA. The survival rate was 94% at 10 years. The overall reintervention rate at 10 years was 9% in the THAA group and 16% in the non-THAA group (P = .54). The catheter reintervention rate at ten years was 2% in the THAA group and 16% in the non-THAA group (P = .031). The surgical reintervention rate at ten years was 7% in the THAA group and 0% in the non-THAA group (P = .016). All 4 patients who required surgical reintervention were in the THAA group and 3 patients with PAA obstruction had preoperative PAA z-scores −3.6, −4.2, and −4.3. Follow-up echocardiograms showed PAA catch-up growth in the THAA group compared with the non-THAA group (preoperative z-score of −3.6 vs −2.3, and at 7 years of −1.1 vs −1.2; P < .001).
Unrepaired PAA hypoplasia grows after CoA repair. Reintervention rates were comparable between groups but those with THAA had higher surgical reintervention rates.
Improved Results of Aortic Arch Reconstruction in the Norwood Procedure
2016, Annals of Thoracic Surgery
Despite several surgical modifications, the reported incidence of neoaortic coarctation after stage 1 palliation (S1P) of hypoplastic left heart syndrome remains high. A modification of aortic arch reconstruction that may decrease the incidence of neoaortic coarctation after S1P is described.
Between January 2008 and May 2013, 114 patients with hypoplastic left heart syndrome underwent S1P. The hospital records of the 101 surviving patients (89%) were reviewed. Demographic data and perioperative variables for S1P were collected. A modified technique for aortic arch reconstruction that contains a bovine pericardial patch tailored and sutured in a specific way was used in 51 patients (group MT), whereas the traditional technique was used in 50 patients (group TT). Clinical echocardiographic and cardiac catheterization data were analyzed to determine the incidence and location of neoaortic coarctation.
There were no significant differences in the baseline characteristics, the intraoperative course, or hospital mortality between the two groups of subjects. Duration of ventilation, intensive care unit stay, and hospitalization were significantly shorter in group MT. The mean follow-up was 2.02 ± 0.63 years and 3.98 ± 0.66 years in each group, respectively. Coarctation developed in 4 of 51 patients (7.8%) in group MT compared with 10/50 patients (20%) in group TT. Multivariable logistic regression analysis showed that the estimated odds of coarctation for group MT were 0.41 (95% confidence interval: 0.04, 4.32) times the estimated odds of coarctation for group TT.
The described technique may decrease the incidence of recoarctation after S1P by minimizing aortic arch and descending aorta distortion and providing ample enlargement of the aorta at its narrowest diameter.
Cardiovascular Surgery at The Children's Hospital of Philadelphia
2016, Seminars in Thoracic and Cardiovascular Surgery
Surgery for congenital heart disease at The Children’s Hospital of Philadelphia began in the earliest days of cardiac surgery. In a rapidly advancing field, surgeons at Children’s Hospital of Philadelphia are recognized as innovators in the field. The Division of Cardiac Surgery is dedicated to providing outstanding clinical care, educating the next generation of congenital cardiac surgeons, and advancing the specialty through clinical and translational research.
Fate of the hypoplastic proximal aortic arch in infants undergoing repair for coarctation of the aorta through a left thoracotomy
2014, Annals of Thoracic Surgery
Citation Excerpt :
Although repair techniques employing a sternotomy approach yielded similar results in terms of reintervention, the effect of CPB and DHCA on long-term neurologic outcomes has yet to be determined in long-term follow-up studies. A few studies have shown growth of the hypoplastic aortic arch after EEEA [6, 12–14]. Siewers and colleagues [12] observed changes in the diameter of the transverse aortic arch in 18 infants who underwent end-to-end anastomosis or subclavian flap technique.
Extended end-to-end anastomosis (EEEA) through a left thoracotomy for coarctation of the aorta (CoA) and tubular hypoplasia of the aortic arch (THAA) leaves an unaugmented hypoplastic proximal aortic arch (PAA) segment, which may increase late reintervention for PAA obstruction. We sought to assess PAA growth and reintervention for PAA obstruction after EEEA.
Preoperative and follow-up echocardiographic images of 140 patients who underwent EEEA for CoA from 2005 to 2012 were reviewed. Patients were divided into two groups on the basis of preoperative PAA z-scores: THAA group, z-score less than −3; non-THAA group, z-score greater than or equal to −3.
Eighty (57%) patients were identified as having THAA. There were three surgical reinterventions (PAA in 2 patients and distal aortic arch in 1 patient) and nine catheter reinterventions (all related to anastomotic stenosis) during a median follow-up period of 18 months. Both patients who required PAA reintervention had preoperative PAA z-scores below −8. Freedom from reintervention at 3 years was comparable between the groups (THAA group, 90.0% vs non-THAA group, 87.9%, p = 0.483). Follow-up echocardiography revealed PAA catch-up growth in the THAA group (z-score, preoperative −4.63 vs follow-up −1.17, p < 0.001); however, there was a nonsignificant trend toward smaller PAA in the THAA group (z-score: THAA, −1.17 vs non-THAA, −0.55, p = 0.057). All but 2 patients with preoperative PAA z-scores above −6 did not have any PAA obstruction.
The hypoplastic PAA segment in patients with CoA/THAA grew significantly after EEEA but remained smaller than in those without THAA. Our data support that CoA and PAA with z-scores as small as −6 can be repaired through a thoracotomy approach with a low risk of reintervention.
Twenty-four-hour ambulatory blood pressure monitoring detects a high prevalence of hypertension late after coarctation repair in patients with hypoplastic arches
2012, Journal of Thoracic and Cardiovascular Surgery
To determine by 24-hour blood pressure monitoring the risk of hypertension late after coarctation repair in patients with arch hypoplasia.
Sixty-two of 116 consecutive patients (age, ≥10 years) who had coarctation repair and were quoted subjectively by the surgeon or the cardiologist to have arch hypoplasia at the time of the repair underwent a transthoracic echocardiogram and 24-hour blood pressure monitoring. Median age at repair was 11 days (range, 6-48 days). Mean preoperative z score of the proximal transverse arch was −2.43 ± 0.46. Eight patients had a repair via sternotomy (6 end-to-side anastomoses, 2 patch repairs) and 54 had a conventional repair via thoracotomy.
After a follow-up of 18 ± 5 years, 27% of the patients (17/62) had resting hypertension and 60% (37/62) had abnormal ambulatory blood pressure. Sensitivity of high resting blood pressure in detecting an abnormal 24-hour ambulatory blood pressure was 41%. Twenty patients had arch obstruction at last follow-up. Eighteen of them (90%) had abnormal ambulatory blood pressure. None of the patients operated on with end-to-side repair via sternotomy had reobstruction compared with 33% (18/54) of those repaired via thoracotomy.
Patients with a hypoplastic arch operated via thoracotomy have an alarming prevalence of hypertension. Regular follow-up with 24-hour ambulatory blood pressure monitoring is warranted, especially in patients who have had a smaller aortic arch at the time of the initial operation.
Prediction of recurrent coarctation by early postoperative blood pressure gradient
2011, Journal of Thoracic and Cardiovascular Surgery
Blood pressure gradients that are noted early after repair of coarctation in neonates and infants are often attributed to proximal arch hypoplasia. Rapid growth of the hypoplastic proximal arch is usually observed, although in some individuals an early gradient predicts the subsequent need for reintervention. To define the predictive reliability of blood pressure gradients between arms and legs and to identify predictors of arch growth, we undertook a retrospective study.
Between January 2000 and June 2008, 77 infants underwent surgical repair of coarctation. Data collected included preoperative dimensions of aortic segments. Blood pressure gradients between arms and legs determined by cuff were compared intraoperatively and postoperatively, as well as 2-dimensional echocardiographic dimensions of the aorta between those who did not require reintervention for recoarctation (group A) and those who did (group B). Receiver operating characteristic curve analysis was applied to evaluate discrimination of the systolic gradient in differentiating the 2 groups of patients.
At surgery, patients’ median age was 10 days and weight was 3.3 kg. There was 1 early death. Median follow-up was 40 months (interquartile range, 24–63 months). Recoarctation developed in 11 patients (14.3%), defined as a resting blood pressure gradient of greater than 20 mm Hg with a corresponding decrease in the diameter of the aorta by 50%. Freedom from recoarctation was 87% at 1 year and 85% at 5 years. Multivariable logistic regression analysis identified the size of the ascending aorta as a risk factor for recoarctation. Blood pressure gradient at the end of surgery was not predictive of recoarctation. The ascending aorta and transverse arch showed rapid growth in group A, and this was associated with a decrease in blood pressure gradient over time. In comparison, the growth of the ascending aorta and arch in group B was significantly less than in group A and associated with worsening of gradients. Receiver operating characteristic curve analysis revealed that gradients at the time of hospital discharge (>13 mm Hg) had excellent discriminative accuracy in identifying patients in whom subsequent recoarctation developed.
Small size of the ascending aorta is a risk factor for recoarctation. Limb gradient in the operating room at completion of surgery is not a reliable tool to assess repair of coarctation, although the gradient at the time of hospital discharge can be used to accurately predict recoarctation. Rapid growth of both the ascending and the transverse aorta is frequently observed and associated with improvement in gradients over time.

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^☆: Presented at the Twenty-eighth Annual Meeting of The Society of Thoracic Surgeons, Oriando, FL, Feb 3–5, 1992.

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Original articleCoarctation of the aorta in infants: Does the aortic arch grow after repair?☆

Abstract

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original article
Coarctation of the aorta in infants: Does the aortic arch grow after repair?☆