Aortic arch obstruction neonates with biventricular physiology: left-open compared to closed inter-atrial communication during primary repair – a retrospective study

Abstract

BackgroundLeaving an inter-atrial communication (IAC) open for left atrial decompression is often recommended in neonates with aortic arch obstruction undergoing primary repair. In this study, outcomes in these patients were compared to those with intact atrial septum after repair.MethodsBetween 2000 and 2013, 53 consecutive neonates with severe aortic arch obstruction (hypoplasia: n = 45, interruption: n = 8) underwent primary repair from an anterior approach. Median age and weight were 8 days (range: 2–30) and 3.2 kg (range: 2.4-4.4), respectively. Cardiac morphology included a ventricular septal defect (VSD, large: n = 28, small: n = 7), malposition of great arteries (n = 10), and severe left ventricular outflow tract obstruction (LVOTO, n = 10). During corrective surgery IAC was closed (group-I, n = 37) or partially left-open (group-II, n = 16). Primary endpoints were hospital death, and re-intervention (surgery and/or balloon) due to aortic arch re-coarctation or recurrent LVOTO. Statistically significant variables by univariate analysis were incorporated in the corresponding multivariable regression model.ResultsRegarding morphological discrepancies more patients in group-II presented with LVOTO (p = 0.05), or the combination of arch hypoplasia, intact ventricular septum and normal ventriculo-arterial connection (p = 0.017). Hospital mortality was 8.1% in group-I and 37.5% in group-II (p = 0.016). Re-intervention was performed in 13 patients (group-I: n = 6 vs. group-II: n = 7) due to aortic arch re-coarctation (n = 12) and/or recurrent LVOTO (n = 3), and resulted in a Kaplan-Meier freedom from re-intervention of 87 ± 6% and 79 ± 8% in group-I, and 64 ± 14% and 64 ± 14% in group-II after 1 and 5 years, respectively (p = 0.016). Multivariate analysis revealed LVOTO as an independent risk factor for hospital death (p = 0.042), whereas both LVOTO and left-open IAC (p = 0.001 and 0.01) were independent risk factors for re-intervention.ConclusionsA left-open IAC increases risk of re-intervention at the left heart aorta complex. Sustained left-to-right shunting on atrial level seems to induce preload reduction of the often restrictive left ventricle leading to decreased aortic blood flow.

Temporary Single Ventricle Palliation for Severe Diastolic Dysfunction in a Biventricular Heart

“…Left ventricular involution due to flow diversion and hampering of right ventricle function by a normal-or nearnormal-sized LV in HLHS have both been described. [7][8][9] Fortunately, in our case, LV recovery (including diastolic function) was fairly rapid as evidenced by a low LV end-diastolic pressure during cardiac catheter study at four months and normalization of echocardiography indices.…”

Continuous Cerebral and Myocardial Selective Perfusion in Neonatal Aortic Arch Surgery

“…Of note, median sternotomy enables us to simultaneously close any associated atrial septal defect, thereby improving left ventricular preload. Optimizing this preload further improves left ventricular development, and that of the aorta downstream, potentially reducing reoperation rates (6). The Sakurai and colleagues' study involved 288 patients treated for CoA and HAA without VSD over two decades.…”

Perioperative and Anesthetic Considerations in Interrupted Aortic Arch

“…Last, interatrial communications are addressed with either partial or complete closure in order to limit or eliminate left-to-right intracardiac shunting in the setting of a relatively small and noncompliant left ventricle. 22…”