Pediatr Cardiol 28:355–357, 2007 DOI: 10.1007/s00246-005-0986-4
Modified Extended End-To-End Repair of Coarctation in Neonates and Infants S.Y. Deleon, A. Desikacharlu, J.G. Dorotan, J. Lane, D.R. Cvetkovic, J.L. Myers Department of Surgery and Anesthesia, Tulane University Medical Center, 1430 Tulane Avenue SL-22, New Orleans, LA 70112, USA
Abstract. Although the classic extended end-to-end repair is the procedure of choice in most neonates and infants with coarctation of the aorta, there is a problem of distance despite extensive mobilization and impairment of growth of the arch because of scarring in some patients. Since December 1999, 15 neonates and infants without significant arch hypoplasia have undergone a modified extended end-toend repair of coarctation of the aorta at our institution. The anastomosis was performed between the posterior wall of the isthmus and base of the subclavian artery and anterior wall of the descending aorta, resulting in an anastomosis that was usually 1½ times the diameter of the descending aorta. All patients survived and were followed up to 57 months (average, 34). Two patients developed significant gradients 3 months and 1 year postoperatively, respectively, probably from luxurious tissue growth at the suture line. Both were treated successfully with balloon dilatation. The modified extended end-to-end repair provides another option for repair of coarctation in neonates and infants. It requires less mobilization of the arch and descending aorta. It is particularly useful in patients with long isthmus. Key words: Coarctation — Aortic arch Extended end-to-end repair has become the procedure of choice in the repair of coarctation in neonates and infants. Because a wider anastamosis is created and ductal tissue and coarctation ridges are excised, the recurrence rate is quite low [1, 3, 4–6, 8–11]. The technique of classic extended end-to-end repair submarining the distal aorta to the under portion of the arch requires more extensive mobilization of the aortic arch and descending aorta [4, 9]. Additionally, because the suture line involves the arch, scarring in the arch can cause impairment of growth
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of the arch in some patients without significant arch hypoplasia. In December 1999, we started performing a modification of the extended end-to-end repair by creating an anastamosis between the posterior segment of the isthmus and base of the subclavian artery and the anterior segment of the descending aorta. This modification requires less mobilization of the arch and descending aorta and avoids a suture line involving the arch. This is a report of our experience.
Materials and Methods Since December 1999, we have performed a modified extended endto-end repair in 15 neonates and infants with coarctation of the aorta without significant arch hypoplasia. PatientÕs age ranged from 4 to 63 days and weight ranged from 1.5 to 5.2 kg. Seven patients presented with signs of congestive heart failure. Five patients required prostaglandin and dopamine infusion preoperatively. Two required preoperative intubations and ventilation, All patients underwent preoperative echocardiography and 3 had cardiac catheterization. All patients had gradients of more than 40 mmHg. A patent ductus arteriosus was present in 11 patients. Bicuspid aortic valve was present in 8 patients, with 2 having a Shone complex, Two patients had a ventricular septal defect (small to moderate) and 1 patient had an atrial septal defect. Five patients had a patent foramen ovale with left-to-right shunts.
Surgical Technique Standard monitoring included a right radial arterial catheter and a blood pressure cuff on the left or right leg. Positioning the patient in the lateral decubitus position followed inhalation induction of general endotracheal anesthesia. A short left posterolateal thoracotomy was performed and the pleural cavity was entered via the third or fourth intercostal space. The mediastinal pleura was opened after identifying the recurrent laryngeal nerve and the coarcted segment of the aorta was exposed. The ductus arteriosus was either clipped or sutured and divided. Mobilization of the subclavian artery, the distal aortic arch, and the descending aorta was accomplished. All patients were heparinized with 100 units per
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kilogram. Clamps were placed proximally on the distal aortic arch, including the left subclavian artery, and distally on the proximal descending aorta (Fig. 1). The ductul tissue and coarctation ridge were completely excised. The incision was made posteriorly on the isthmus and base of the subclavian artery. The incision on the descending aorta was made anteriorly. The descending aorta was then anastamosed to the isthmus and base of the subclavian artery, thereby producing an anastamosis almost 1½ times the diameter of the descending of aorta. In six patients, running prolene suture was used, and in nine patients an absorbable suture was used. The average clamps time was 36 minutes.
Results All patients survived. Postoperative course was essentially uneventful in all patients. Two patients who were intubated and ventilated preoperatively required ventilation for 2 days. One patient developed a minimal pericardial effusion, which subsided without intervention. Two patients with small or closed ductus had paradoxical hypertension and required treatment. Patients were followed up from 6 to 57 months (average, 34). Thirteen patients had minimal or no gradients. Two patients developed significant gradients 3 months and 1 year postoperatively, respectively, probably from luxurious tissue growth at the suture line. Both patients were treated successfully with balloon dilatation. One patient had subaortic stenosis resection 2 years postoperatively. Discussion Although the classic extended end-to-end repair has been used in most neonates and infants with coarctation of the aorta, it is particularly useful in patients with hypoplasia of the distal aortic arch. In patients without arch hypoplasia, a small number may have impairment of growth of the arch because of the suture line following the classic extended end-to-end repair. Our modification shares some of the advantages of the classic extended end-to-end repair that contribute to a low recurrence rate, such as wide anastomosis and compete excision of the coarctation ridge and ductal tissues. However, this procedure can only be performed in patients without significant hypoplasia of the arch. In these patients, it has an advantage over the classic extended end-to-end repair because of the avoidance of suture line involving the arch. Our modification is particularly useful in patients with long isthmus proximal to the coarctation. In these patients, despite extensive mobilization of the arch and descending aorta, there may still be tension in the anastomosis when the classic extended end-toend repair is used.
Fig. 1. (A) Typical juxtaductal coarctation with or without patent ductus arteriosus (PDA). (B) The PDA has been divided. The coarctation ridge and ductal tissues have been excised. The incision is made on the posterior segment of the isthmus and base of the subclavian artery. The incision is made on the descending aorta anteriorly. (C) The anastomosis is performed with running suture.
With regard to infants, especially those less than 3 months old there remains a small number of
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patients who will have recurrent obstruction regardless of the type of repair [2, 7, 9, 10]. This is probably due to luxurious growth of scar tissue at the suture line and/or unrecognized residual ductal tissue since there is usually no gradient in the immediate postoperative period. However, this recurrent obstruction can be treated successfully with balloon dilatation.
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