Surgical Treatment of Coarctation of the Aorta and Hypoplastic Aortic Arch_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIZhi-qiang , LIUYang , LIUAi-jun , LIBin , SUJun-wu , CHENGPei ,  LIUYing-long

Department of Pediatric Cardiac Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, P. R. China;

Corresponding?author：

LIUYing-long, Email: liuyinglong@vip.sina.com

Keywords：

Coarctation of the aorta; Hypoplastic aortic arch; Patch aortoplasty; Extended side-to-end anastomosis

DOI：

10.7507/1007-4848.20140017

Video：

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Objective To evaluate the advantages and disadvantages of patch aortoplasty and extended side-to-end anastomosis for the treatment of coarctation of the aorta (CoA) and hypoplastic aortic arch, and provide a more reasonable surgical choice. Methods Clinical data of 45 patients who underwent surgical correction for CoA and hypoplastic aortic arch in Beijing Anzhen Hospital from June 2008 to June 2013 were retrospectively analyzed. According to different surgical strategies for aortic arch hypoplasia, all the 45 patients were divided into 2 groups. In group I, there were 26 patients including 15 males and 11 females with their age of 0.5-6.8 (0.9±2.5) years and body weight of 5.0-20.3 (9.5±7.3) kg, who received patch aortoplasty and whose preoperative pressure gradient between right upper and lower limbs was 38.3±15.6 mm Hg. In groupⅡ, there were 19 patients including 14 males and 5 females with their age of 0.6-7.5 (1.0±2.7) years and body weight of 5.5-21.5 (10.2±6.6) kg, who received extended side-to-end anastomosis and whose preoperative pressure gradient between right upper and lower limbs was 40.7±16.1 mm Hg. Postoperative changes of pressure gradient between right upper and lower limbs of the 2 groups were examined and compared with preoperative values. Results Two patients died postoperatively (4.4%) including 1 patient with low cardiac output syndrome and the other patient with severe lung infection. None of the patients in either group had renal failure or neurological complications. Postoperatively, there were 28 patients whose systolic blood pressure (SBP) of lower extremities was 10-20 mm Hg higher than that of upper extremities, 13 patients whose SBP gradient between upper and limbs was less than 10 mm Hg, and 4 patients whose upper limb SBP was 20 mm Hg higher than lower limb SBP. Postoperative average pressure gradient of right upper and lower extremities was 3.2±13.5 mm Hg and significantly lower than preoperative value (P < 0.05). Postoperative pressure gradient of upper and lower extremities was significantly lower than preoperative value in both groups (P < 0.05). There was no statistical difference in preoperative and postoperative changes of pressure gradient of upper and lower extremities between the 2 groups (P > 0.05). Thirty-eighty patients (88.4%) were followed up from 3 months to 5 years. During follow-up, there was 1 patient whose blood flow velocity of the descending aorta was increasingly accelerated. Pressure gradient across the aortic arch was larger than 40 mm Hg. Computer tomography showed aortic arch restenosis. This patient received reoperation 8 months after the first discharge. Three patients whose aortic pressure gradient was larger than 20 mm Hg were still followed up. Aortic arch pressure gradient was less than 20 mm Hg in all the other patients. Conclusion Both patch aortoplasty and extended sideto-end anastomosis are ideal surgical methods for the treatment of CoA and hypoplastic aortic arch. Appropriate surgical method should be chosen according to individual conditions of pediatric patients.

Citation： LIZhi-qiang, LIUYang, LIUAi-jun, LIBin, SUJun-wu, CHENGPei, LIUYing-long. Surgical Treatment of Coarctation of the Aorta and Hypoplastic Aortic Arch. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(1): 62-66. doi: 10.7507/1007-4848.20140017 Copy

1.	Abbruzzese PA, Aidala E.Aortic coarctation:an overview.J.Cardiovasc Med (Hagerstown), 2007, 8 (2):123-128.
2.	Vergales JE, Gangemi JJ, Rhueban KS, et al.Coarctation of the aorta-the current state of surgical and transcatheter therapies.Curr Cardiol Rev, 2013, 9 (3):211-219.
3.	Prêtre R.Coarctation of the aorta.HSR Proc Intensive Care Cardiovasc Anesth, 2012, 4 (2):95-96.
4.	Kobayashi M, Ando M, Wada N, et al.Outcomes following surgical repair of aortic arch obstructions with associated cardiac anomalies.Eur J Cardiothorac Surg, 2009, 35 (4):565-568.
5.	Thomson JD, Mulpur A, Guerrero R, et al.Outcome after extended arch repair for aortic coarctation.Heart, 2006, 92 (1):90-94.
6.	Moulaert AJ, Bruins CC, Heimer-Dekker A.Anomalies of the aortic arch and ventricular septal defects.Circulation, 1976, 53 (6):1011-1015.
7.	Karl TR, Sano S, Brawn W, et al.Repair of hypoplastic or interrupted aortic arch via sternotomy.J Thorac Cardiovasc Surg, 1992, 104 (3):688-695.
8.	Kappetein AP, Zwinderman AH, Bogers AJ, et al.More than thirtyfive years of coarctation repair.An unexpected high relapse rate.J Thorac Cardiovasc Surg, 1994, 107 (1):87-95.
9.	Tomoyasu T, Oka N, Miyamoto T, et al.Surgical strategy for severe aortic hypoplasia and aortic stenosis with ventricular septal defect and normal left ventricle.Pediatr Cardiol, 2013, 34 (5):1107-1111.
10.	Brouwer MH, Cromme-Dijkhuis AH, Ebels T, et al.Growth of the hypoplastic aortic arch after simple coarctation resection and end-to-end anastomosis.J Thorac Cardiovasc Surg, 1992, 104 (2):426-433.
11.	Murthy KS, Coelho R, Roy C, et al.One-stage repair of cardiac and arch anomalies without circulatory arrest.Asian Cardiovasc Thorac Ann, 2003, 11 (3):250-254.
12.	Sakurai T, Stickley J, Stümper O, et al.Repair of isolated aortic coarctation over two decades:impact of surgical approach and associated arch hypoplasia.Interact Cardiovasc Thorac Surg, 2012, 15 (5):865-870.
13.	Liu JY, Kowalski R, Jones B, et al.Moderately hypoplastic arches:do they reliably grow into adulthood after conventional coarctation repair? Interact Cardiovasc Thorac Surg, 2010, 10 (4):582-586.
14.	Rakhra SS, Lee M, Iyengar AJ, et al.Poor outcomes after surgery for coarctation repair with hypoplastic arch warrants more extensive initial surgery and close long-term follow-up.Interact Cardiovasc Thorac Surg, 2013, 16 (1):31-36.
15.	Langley SM, Sunstrom RE, Reed RD, et al.The neonatal hypoplastic aortic arch:decisions and more decisions.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu, 2013, 16 (1):43-51.
16.	Yamashiro M, Takahashi Y, Ando M, et al.End-to-side anastomosis for coarctation of the aorta and type A aortic arch interruption with hypoplastic aortic arch.Jpn J Thorac Cardiovasc Surg, 2006, 54 (7):273-277.
17.	魯亞南, 劉錦紛, 徐志偉, 等.主動脈弓補片成形術治療嬰幼兒主動脈縮窄合并主動脈弓弓發育不良.中國胸心血管外科臨床雜志, 2010, 17 (6):455-458.
18.	Schoenhoff FS, Berdat PA, Pavlovic M, et al.Off-pump extraanatomic aortic bypass for the treatment of complex aortic coarctation and hypoplastic aortic arch.Ann Thorac Surg, 2008, 85 (2):460-464.
19.	陶麒麟, 陳張根, 賈兵, 等.嬰兒主動脈縮窄合并心內畸形的一期矯治.中國胸心血管外科臨床雜志, 2007, 14 (3):165-168.
20.	Jhang WK, Park J J, Seo DM, et al.Perioperative evaluation of airways in patients with arch obstruction and intracardiac defects.Ann Thorac Surg, 2008, 85 (5):1753-1758.
21.	Hager A, Schreiber C, Nutzl S, et al.Mortality and restenosis rate of surgical coarctation repair in infancy:a study of 191 patients.Cardiology, 2009, 112 (1):36-41.
22.	Roussin R, Belli E, Lacour-Gayet F, et al.Aortic arch Reconstruction with pulmonary autograft patch aortoplasty.J Thorac Cardiovasc Surg, 2002, 123 (3):443-448.
23.	Berdat PA, G?ber V, Carrel T.Extra-anatomic aortic bypass for complex (re-) coarctation and hypoplastic aortic arch in adolescents and adults.Interact Cardiovasc Thorac Surg, 2003, 2 (2):133-137.
24.	Sugimori H, Abe M, Kato H, et al.A modification of extended aortic arch anastomosis augmented with subclavian flap aortoplasty for interrupted or hypoplastic aortic arch.J Card Surg, 2009, 24 (5):561-563.
25.	Arrieta EJ, Martínez FS, Mayol J, et al.Treatment of complex coarctation of aorta with hypoplastic transverse aortic arch using left carotid artery flap.Interact Cardiovasc Thorac Surg, 2009, 8 (5):581-583.
26.	Sakurai T, Stickley J, Stümper O, et al.Repair of isolated aortic coarctation over two decades:impact of surgical approach and associated arch hypoplasia.Interact Cardiovasc Thorac Surg, 2012, 15 (5):.

1. Abbruzzese PA, Aidala E.Aortic coarctation:an overview.J.Cardiovasc Med (Hagerstown), 2007, 8 (2):123-128.
2. Vergales JE, Gangemi JJ, Rhueban KS, et al.Coarctation of the aorta-the current state of surgical and transcatheter therapies.Curr Cardiol Rev, 2013, 9 (3):211-219.
3. Prêtre R.Coarctation of the aorta.HSR Proc Intensive Care Cardiovasc Anesth, 2012, 4 (2):95-96.
4. Kobayashi M, Ando M, Wada N, et al.Outcomes following surgical repair of aortic arch obstructions with associated cardiac anomalies.Eur J Cardiothorac Surg, 2009, 35 (4):565-568.
5. Thomson JD, Mulpur A, Guerrero R, et al.Outcome after extended arch repair for aortic coarctation.Heart, 2006, 92 (1):90-94.
6. Moulaert AJ, Bruins CC, Heimer-Dekker A.Anomalies of the aortic arch and ventricular septal defects.Circulation, 1976, 53 (6):1011-1015.
7. Karl TR, Sano S, Brawn W, et al.Repair of hypoplastic or interrupted aortic arch via sternotomy.J Thorac Cardiovasc Surg, 1992, 104 (3):688-695.
8. Kappetein AP, Zwinderman AH, Bogers AJ, et al.More than thirtyfive years of coarctation repair.An unexpected high relapse rate.J Thorac Cardiovasc Surg, 1994, 107 (1):87-95.
9. Tomoyasu T, Oka N, Miyamoto T, et al.Surgical strategy for severe aortic hypoplasia and aortic stenosis with ventricular septal defect and normal left ventricle.Pediatr Cardiol, 2013, 34 (5):1107-1111.
10. Brouwer MH, Cromme-Dijkhuis AH, Ebels T, et al.Growth of the hypoplastic aortic arch after simple coarctation resection and end-to-end anastomosis.J Thorac Cardiovasc Surg, 1992, 104 (2):426-433.
11. Murthy KS, Coelho R, Roy C, et al.One-stage repair of cardiac and arch anomalies without circulatory arrest.Asian Cardiovasc Thorac Ann, 2003, 11 (3):250-254.
12. Sakurai T, Stickley J, Stümper O, et al.Repair of isolated aortic coarctation over two decades:impact of surgical approach and associated arch hypoplasia.Interact Cardiovasc Thorac Surg, 2012, 15 (5):865-870.
13. Liu JY, Kowalski R, Jones B, et al.Moderately hypoplastic arches:do they reliably grow into adulthood after conventional coarctation repair? Interact Cardiovasc Thorac Surg, 2010, 10 (4):582-586.
14. Rakhra SS, Lee M, Iyengar AJ, et al.Poor outcomes after surgery for coarctation repair with hypoplastic arch warrants more extensive initial surgery and close long-term follow-up.Interact Cardiovasc Thorac Surg, 2013, 16 (1):31-36.
15. Langley SM, Sunstrom RE, Reed RD, et al.The neonatal hypoplastic aortic arch:decisions and more decisions.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu, 2013, 16 (1):43-51.
16. Yamashiro M, Takahashi Y, Ando M, et al.End-to-side anastomosis for coarctation of the aorta and type A aortic arch interruption with hypoplastic aortic arch.Jpn J Thorac Cardiovasc Surg, 2006, 54 (7):273-277.
17. 魯亞南, 劉錦紛, 徐志偉, 等.主動脈弓補片成形術治療嬰幼兒主動脈縮窄合并主動脈弓弓發育不良.中國胸心血管外科臨床雜志, 2010, 17 (6):455-458.
18. Schoenhoff FS, Berdat PA, Pavlovic M, et al.Off-pump extraanatomic aortic bypass for the treatment of complex aortic coarctation and hypoplastic aortic arch.Ann Thorac Surg, 2008, 85 (2):460-464.
19. 陶麒麟, 陳張根, 賈兵, 等.嬰兒主動脈縮窄合并心內畸形的一期矯治.中國胸心血管外科臨床雜志, 2007, 14 (3):165-168.
20. Jhang WK, Park J J, Seo DM, et al.Perioperative evaluation of airways in patients with arch obstruction and intracardiac defects.Ann Thorac Surg, 2008, 85 (5):1753-1758.
21. Hager A, Schreiber C, Nutzl S, et al.Mortality and restenosis rate of surgical coarctation repair in infancy:a study of 191 patients.Cardiology, 2009, 112 (1):36-41.
22. Roussin R, Belli E, Lacour-Gayet F, et al.Aortic arch Reconstruction with pulmonary autograft patch aortoplasty.J Thorac Cardiovasc Surg, 2002, 123 (3):443-448.
23. Berdat PA, G?ber V, Carrel T.Extra-anatomic aortic bypass for complex (re-) coarctation and hypoplastic aortic arch in adolescents and adults.Interact Cardiovasc Thorac Surg, 2003, 2 (2):133-137.
24. Sugimori H, Abe M, Kato H, et al.A modification of extended aortic arch anastomosis augmented with subclavian flap aortoplasty for interrupted or hypoplastic aortic arch.J Card Surg, 2009, 24 (5):561-563.
25. Arrieta EJ, Martínez FS, Mayol J, et al.Treatment of complex coarctation of aorta with hypoplastic transverse aortic arch using left carotid artery flap.Interact Cardiovasc Thorac Surg, 2009, 8 (5):581-583.
26. Sakurai T, Stickley J, Stümper O, et al.Repair of isolated aortic coarctation over two decades:impact of surgical approach and associated arch hypoplasia.Interact Cardiovasc Thorac Surg, 2012, 15 (5):.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Surgical Treatment of Coarctation of the Aorta and Hypoplastic Aortic Arch

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