Proximal Arch in Left Thoracotomy Repair of Neonatal and Infant Coarctation—How Small Is Too Small?

Abstract

Background: We sought to evaluate the relationship between proximal arch hypoplasia and reintervention for left thoracotomy repair of coarctation of the aorta. Methods: This was a retrospective review of 153 consecutive neonates and infants undergoing left thoracotomy and extended end-to-end repair of coarctation from January 1, 2000, to January 1, 2014, at a single center with exclusion of single ventricle–palliated patients. Primary outcome was reintervention evaluated with respect to five definitions of proximal arch hypoplasia. Results: Median follow-up was 7.2 years. Reintervention occurred in eight (5.2%) patients, with 50% of patients undergoing re-intervention in the first six months after their index operation. Using Kaplan-Meier analysis and log-rank test, with hypoplasia defined by weight, hypoplasia was not associated with increased reintervention for arch size < patient weight (in kilograms; P = .24) or for arch size < patient weight (in kilograms) +1 ( P = .02, higher freedom from reintervention in hypoplasia group). For each of the five comparison groups, freedom from reintervention was similar between the groups with and without proximal arch hypoplasia: (1) z-score < −2 versus ≥−2 ( P = .72), (2) z-score < −3 versus ≥−3 ( P = .95), and (3) z-score < −4 versus ≥−4 ( P = .17). Conclusion: In our cohort of patients with left thoracotomy and extended end-to-end repair of coarctation, proximal arch hypoplasia, defined by various weight-based or z-score thresholds, was not associated with reintervention. While this may imply value to a more liberal use of thoracotomy, confirmation requires longer term follow-up with a more comprehensive evaluation of the patients and their arches.

Reconstruction of the Aortic Arc through Left Thoracotomy in Patients with Isolated Coarctation and Aortic Arch Hypoplasia

“…Наше дослідження засвідчує можливість успішного хірургічного лікування ізольованої гіпоплазії дуги аорти з бокового доступу, навіть при гіпоплазії проксимального відділу дуги аорти. Відсоток реоперацій у досліджуваній групі не є вищим порівняно з літературними даними про реінтервенції після реконструкції дуги аорти із серединного доступу [6,7]. Важливим питанням віддаленого періоду є артеріальна гіпертензія.…”

Effectiveness of Repair of Aortic Coarctation in Neonates: A Long-Term experience

“…Surgical planning is influenced by the need for concomitant repair of associated CHD [ 6 ]. In particular, the presence of HAA can be determinant for choosing the surgical approach (i.e., sternotomy vs. thoracotomy) or use of cardio-pulmonary bypass (CPB), deep hypothermic circulatory arrest (DHCA) [ 7 ], or selective antegrade cerebral perfusion (ACP) [ 5 , 8 ].…”

“…Currently, the optimal surgical approach for CoAo repair in neonates, especially when associated with HAA, is controversial. Undoubtedly, an EEEA through a thoracotomy avoids CPB and the risk of adverse events (AE) related to DHCA or selective ACP [ 6 , 13 , 14 ]. However, a possible disadvantage is leaving the proximal HAA untreated, with a potential need of a future re-intervention.…”