[show abstract][hide abstract] ABSTRACT: Human cardiac stem cells (CSCs) promote myocardial regeneration in adult ischemic myocardium. The regenerative capacity of CSCs in very young patients with nonischemic congenital heart defects has not been explored. We hypothesized that isolated neonatal-derived CSCs may have a higher regenerative ability than adult-derived CSCs and might address the structural deficiencies of congenital heart disease.
Human specimens were obtained during routine cardiac surgical procedures from right atrial appendage tissue discarded from 2 age groups: neonates and adults patients. We developed a reproducible isolation method that generated cardiosphere-derived cells (CDCs), regardless of starting tissue weight or age. Neonatal-derived CDCs demonstrated increased number of cardiac progenitor cells expressing c-kit(+), flk-1, and Islet-1 by flow cytometry and immunofluorescence. When transplanted into infarcted myocardium, neonatal-derived CDCs had a significantly higher ability to preserve myocardial function, prevent adverse remodeling, and enhance blood vessel preservation and/or formation when compared with adult-derived CDCs. Last, neonatal-derived CDCs were more cardiomyogenic than adult-derived CDCs when cocultured with neonatal cardiomyocytes and displayed enhanced angiogenic function compared with adult-derived CDCs.
Neonatal-derived CDCs have a strong regenerative ability when compared with adult-derived CDCs that may depend on angiogenic cytokines and an increase prevalence of stem cells. This has important implications in the potential use of CDCs in future clinical trials.
[show abstract][hide abstract] ABSTRACT: Cameral coronary artery fistulae (C-CAFs) are common after heart transplantation (HTx) and typically drain into the right ventricle. The development of CAFs to non-cameral structures after HTx has not been systematically investigated. We studied the incidence, anatomic distribution, and natural history of non-cameral CAFs (NC-CAFs) in a multicenter pediatric population.
Medical records from pediatric HTx patients at 2 centers from January 1, 1999, to August 31, 2009 were reviewed. A classification system for CAF size was developed, and serial angiograms were evaluated for CAF presence, size, and anatomy. Risk factors and outcomes were determined.
Identified were 100 patients with a median age at HTx of 8.7 years. Median follow-up was 4.2 years. NC-CAFs occurred in 52 patients, C-CAFs in 20, with both types noted in 11. NC-CAFs originated from coronary arteries and drained predominantly into ipsilateral recipient pulmonary vasculature. Multiple NC-CAFs occurred in 19 patients (19%) for a total of 77 fistulae in 52 patients. Fistulae were classified as small (56%), moderate (36%), and large (8%). NC-CAFs were present at the first post-HTx angiogram in 95% of cases (median 1 year after HTx). Longer donor ischemic time was associated with the development (p = 0.043) and size (p = 0.05) of NC-CAFs. NC-CAFs were not associated with rejection, death, re-transplantation, or coronary revascularization, and none required intervention.
Fistulae from donor coronary arteries to recipient pulmonary vasculature develop frequently and early after pediatric HTx. These correlate with graft ischemic time, but are not associated with early graft loss or death.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 03/2012; 31(7):744-9. · 3.54 Impact Factor
[show abstract][hide abstract] ABSTRACT: We have used cardiopulmonary bypass with left pulmonary artery reimplantation for pulmonary artery sling repair since 1985. This review presents our current results with this technique, emphasizing the importance of diagnosis and treatment of frequently associated tracheal stenosis.
Since 1985, 34 patients have undergone pulmonary artery sling repair using a median sternotomy and cardiopulmonary bypass. Age ranged from 9 days to 43 years (mean 2.1 ± 7.5 years, median 0.2 years). Twenty-seven patients (79%) had tracheal stenosis secondary to complete cartilage tracheal rings. All patients had preoperative airway imaging with rigid bronchoscopy, and since 2000 all patients have had computed tomography imaging of the chest with 3-dimensional reconstruction (n = 14). Tracheal repair has included pericardial patch tracheoplasty (n = 7), tracheal autograft (n = 10), tracheal resection (n = 4), and slide tracheoplasty (n = 5). All patients had an echocardiogram, and cardiac lesions repaired simultaneously included atrial septal defect (4), tetralogy of Fallot (2), and ventricular septal defect (1). One patient had a severely hypoplastic right lung, and 3 patients had an absent right lung. In these patients, the left pulmonary artery was translocated anterior to the trachea. In all other patients, the left pulmonary artery was reimplanted into the main pulmonary artery.
There have been no early deaths or complications related to the use of cardiopulmonary bypass. Median hospital stay was 24 days. There have been 4 late deaths. Two late deaths were the result of complications of tracheal surgery (1 pericardial patch [6 months postoperatively] and 1 autograft [1.7 years postoperatively]). One child died of biliary atresia (0.2 years postoperatively), and 1 child died of pneumonia (5.8 years postoperatively). All recent tracheal stenosis repairs have been with slide tracheoplasty. All left pulmonary arteries are patent with a mean percent flow by perfusion scan of 41% ± 13%. Older patients (n = 2) have noted a significant improvement in exercise tolerance.
Pulmonary artery sling is best repaired with median sternotomy, cardiopulmonary bypass, and left pulmonary artery reimplantation. This resulted in uniformly patent left pulmonary arteries in all patients. Preoperative computed tomography imaging, echocardiography, and bronchoscopy are essential for precise operative planning. The frequently associated tracheal stenosis is best repaired with slide tracheoplasty.
The Journal of thoracic and cardiovascular surgery 11/2011; 143(1):144-51. · 3.41 Impact Factor
[show abstract][hide abstract] ABSTRACT: At our institution, the arterial switch operation for transposition of the great arteries has transitioned from the Gore-Tex patch (W.L. Gore & Associates, Flagstaff, AZ) for pulmonary artery reconstruction to redundant pantaloon pericardial patch (RPPP). The (U-shaped) coronary artery button was used for coronary reimplantation. This study investigates overall mortality and factors for neopulmonary artery, neoaortic, and coronary artery surgical reintervention.
We performed a retrospective chart review of all patients who underwent arterial switch between 1983 and 2007. Our surgical database, operative reports, and cardiology clinic charts were reviewed. Time to event was plotted as Kaplan-Meier curves. Predictors of time-to-event were examined using Cox proportional hazard modeling.
A total of 258 patients underwent arterial switch during the study. Mortality declined from 15% (era I: 1983 to 1990) to 11% (era II: 1991 to 1998) to 7% (era III: 1999 to 2007). Era III had a significantly later time to death compared with era I (hazard ratio [HR] 0.62, p = 0.04). The RPPP had a lower neopulmonary artery reintervention rate compared with Gore-Tex; 9 of 225 (4%) versus 3 of 21 (14%), p = 0.008. Complex anatomy increased risk for neopulmonary reintervention (HR 3.3, p = 0.03). Surgical reintervention rate for coronary arteries was 2%. Complex coronary anatomy (HR 17.9, p = 0.01) predicted coronary reintervention. Predictors of neoaortic reintervention were prior pulmonary artery band (HR 4.3, p = 0.03), complex anatomy (HR 3.5, p = 0.01), and coronary artery anatomy (HR 3.5, p = 0.04).
Arterial switch operation mortality has decreased. Conversion to RPPP reduced neopulmonary artery reintervention. The (U-shaped) coronary artery button technique is associated with low coronary reintervention rates. Complex coronary anatomy increases coronary and aortic reintervention. Prior pulmonary artery banding and complex anatomy increase aortic reintervention.
The Annals of thoracic surgery 09/2011; 92(5):1742-6. · 3.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus of Valsalva is a rare congenital anomaly with the potential for myocardial ischemia and sudden death. This review evaluated our series of AAOCA patients, who underwent coronary artery unroofing, to test our hypothesis that the intramural length of the anomalous coronary artery correlates with symptoms.
A retrospective analysis of symptoms, preoperative imaging (computed tomography and magnetic resonance imaging), intraoperative assessment, perioperative course, and follow-up were reviewed.
From 2005 to 2010, 27 patients (70% male) underwent surgical AAOCA repair. Mean age was 14.3±12 (range, 6 to 52) years. In 25 patients with right AAOCA, 14 had chest pain and 4 had syncope. Both patients with left AAOCA had chest pain. AAOCA unroofing was done in 25 and side-to-side anastomosis in 2. The intramural coronary artery length measured intraoperatively correlated with preoperative symptoms (symptoms=10±3.58 mm, no symptoms=5.2±1.5 mm, p<.002), as did preoperative imaging measurements (symptoms=7.8±2.8 mm, no symptoms=5.3±0.8 mm, p<.001). Preoperative imaging strongly predicted the intraoperative measurement (r=0.81, p=0.00001). There were no deaths, significant morbidity, or recurrence of symptoms.
Coronary unroofing for AAOCA is a safe method of enlarging the coronary orifice and eliminating the intramural course. Symptomatic patients had a longer intramural course than asymptomatic patients, as assessed by preoperative imaging and intraoperative measurements. These results may have important clinical implications in determining indications for operation.
The Annals of thoracic surgery 09/2011; 92(3):986-91; discussion 991-2. · 3.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: Human mesenchymal stem cells (hMSC) have proven beneficial in the repair and preservation of infarcted myocardium. Unfortunately, MSCs represent a small portion of the bone marrow and require ex vivo expansion. To further advance the clinical usefulness of cellular cardiomyoplasty, derivation of "MSC-like" cells that can be made available "off-the-shelf" are desirable. Recently, human embryonic stem cell-derived mesenchymal cells (hESC-MC) were described. We investigated the efficacy of hESC-MC for cardiac repair after myocardial infarction (MI) compared to hMSC. Because of increased efficacy of cell delivery, cells were embedded into collagen patches and delivered to infarcted myocardium. Culture of hMSC and hESC-MCs in collagen patches did not induce differentiation or significant loss in viability. Transplantation of hMSC and hES-MC patches onto infarcted myocardium of athymic nude rats prevented adverse changes in infarct wall thickness and fractional area change compared to a non-viable patch control. Hemodynamic assessment showed that hMSCs and hES-MC patch application improved end diastolic pressure equivalently. There were no changes in systolic function. hES-MC and hMSC construct application enhanced neovessel formation compared to a non-viable control, and each cell type had similar efficacy in stimulating endothelial cell growth in vitro. In summary, the use of hES-MC provides similar efficacy for cellular cardiomyoplasty as compared to hMSC and may be considered a suitable alternative for cell therapy.
Biotechnology and Bioengineering 08/2011; 109(1):274-83. · 3.65 Impact Factor
[show abstract][hide abstract] ABSTRACT: Adequate exposure of a ventricular septal defect (VSD) is critically important to obtaining a satisfactory repair. Some surgeons have advocated a circumferential incision on the tricuspid valve. For 20 years we have used a radial incision of the tricuspid valve when added exposure is required.
All patients undergoing VSD repair at Children's Memorial Hospital (Chicago, IL) were identified from our database. Operative records were reviewed to determine details of exposure. Follow-up patient and echocardiography data were obtained from the medical record.
Between January 1995 and March 2010, 366 isolated VSDs were repaired, including 341 perimembranous, 15 muscular, 5 inlet, and 5 inlet-muscular VSDs. A radial tricuspid valve incision was used in 230 patients (63%). Mean times (minutes) were 97±24 for cardiopulmonary bypass and 66±18 for cross-clamp, with no significant difference between groups (p=0.59 and p=0.96, respectively). No operative deaths occurred. Follow-up echocardiograms were available for 150 patients at a mean of 3.5 years. Tricuspid regurgitation was rated as none or trivial in 97 (65%), mild in 45 (30%), and moderate in 8 (5%). The degree of tricuspid regurgitation was similar between patients whose tricuspid valve was and was not incised.
Radial incision of the tricuspid valve enhances exposure for safe VSD closure and adds little complexity to the case. Its use in our series did not lead to increased tricuspid valve dysfunction, and it was durable at midterm echocardiographic assessment.
The Annals of thoracic surgery 06/2011; 92(2):685-90; discussion 690. · 3.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: A bioresorbable polymeric film reduces the extent and severity of postoperative adhesions in infants undergoing repeat sternotomy. Resorption of the bioresorbable polymeric film, however, leaves no barrier between the sternum and the epicardium. A sheet of expanded polytetrafluoroethylene is used by many surgeons to create a physical barrier between the sternum and the cardiac structures. We hypothesized that placing bioresorbable polymeric film beneath an expanded polytetrafluoroethylene pericardial membrane would both decrease pericardial adhesions and provide a physical barrier.
A novel combination of bioresorbable polymeric film underneath an expanded polytetrafluoroethylene membrane was tested in an established rabbit model of pericardial adhesion formation. After sternotomy, a portion of pericardium was resected and the epicardium was abraded. Rabbits (n = 36) were randomly assigned to 4 treatment groups: control group, no bioresorbable polymeric film or expanded polytetrafluoroethylene; bioresorbable polymeric film group; expanded polytetrafluoroethylene group; and bioresorbable polymeric film + expanded polytetrafluoroethylene group. At 4 weeks post-sternotomy, pericardial adhesions were scored grossly for area and density of adhesions using an established 4-point (0-3) grading system.
The bioresorbable polymeric film group had a significant reduction in mean adhesion score compared with the control group (control = 2.86 ± 0.37 vs bioresorbable polymeric film = 0.57 ± 0.53, P < .0001) and expanded polytetrafluoroethylene group (expanded polytetrafluoroethylene = 2.75 ± 0.46 vs bioresorbable polymeric film = 0.57 ± 0.53, P < .0001). The bioresorbable polymeric film + expanded polytetrafluoroethylene group had a low adhesion profile similar to the bioresorbable polymeric film group (bioresorbable polymeric film + expanded polytetrafluoroethylene = 1.0 ± 0, vs bioresorbable polymeric film = 0.57 ± 0.53), but a considerably lower mean adhesion score than the expanded polytetrafluoroethylene group (expanded polytetrafluoroethylene = 2.75 ± 0.46, vs bioresorbable polymeric film + expanded polytetrafluoroethylene = 1.0 ± 0, P < .0001).
Placement of bioresorbable polymeric film resulted in minimal pericardial adhesions compared with controls. The placement of bioresorbable polymeric film underneath expanded polytetrafluoroethylene at the time of sternal closure provides a novel combination to reduce the extent and severity of pericardial adhesions while providing a physical barrier between the sternum and the cardiac structures.
The Journal of thoracic and cardiovascular surgery 03/2011; 141(3):789-95. · 3.41 Impact Factor
[show abstract][hide abstract] ABSTRACT: This report describes a neonate with heart failure resulting from bilateral coronary artery fistulas and left ventricle noncompaction. The patient underwent successful surgical ligation of the fistulas.
[show abstract][hide abstract] ABSTRACT: Human cardiac progenitor cells (hCPCs) may promote myocardial regeneration in adult ischemic myocardium. The regenerative capacity of hCPCs in young patients with nonischemic congenital heart defects for potential use in congenital heart defect repair warrants exploration.
Human right atrial specimens were obtained during routine congenital cardiac surgery across 3 groups: neonates (age, <30 days), infants (age, 1 month to 2 years), and children (age, >2 to ≤13 years). C-kit(+) hCPCs were 3-fold higher in neonates than in children >2 years of age. hCPC proliferation was greatest during the neonatal period as evidenced by c-kit(+) Ki67(+) expression but decreased with age. hCPC differentiation capacity was also greatest in neonatal right atrium as evidenced by c-kit(+), NKX2-5(+), NOTCH1(+), and NUMB(+) expression. Despite the age-dependent decline in resident hCPCs, we isolated and expanded right atrium-derived CPCs from all patients (n=103) across all ages and diagnoses using the cardiosphere method. Intact cardiospheres contained a mix of heart-derived cell subpopulations that included cardiac progenitor cells expressing c-kit(+), Islet-1, and supporting cells. The number of c-kit(+)-expressing cells was highest in human cardiosphere-derived cells (hCDCs) grown from neonatal and infant right atrium. Furthermore, hCDCs could differentiate into diverse cardiovascular lineages by in vitro differentiation assays. Transplanted hCDCs promoted greater myocardial regeneration and functional improvement in infarcted myocardium than transplanted cardiac fibroblasts.
Resident hCPCs are most abundant in the neonatal period and rapidly decrease over time. hCDCs can be reproducibly isolated and expanded from young human myocardial samples regardless of age or diagnosis. hCPCs are functional and have potential in congenital cardiac repair.
[show abstract][hide abstract] ABSTRACT: This article was prepared to summarize the points made in a debate that the first author (C.L.B.) had with Dr. Richard Jonas at the American Association for Thoracic Surgery 90th Annual Meeting. The topic of the debate was the optimal surgical approach for functional single-ventricle patients: extracardiac versus intra-atrial lateral tunnel Fontan. My role was to take the viewpoint that the extracardiac Fontan is better. This review summarizes our results at Children's Memorial Hospital (Chicago, IL) with 180 patients undergoing a primary Fontan procedure and 126 patients undergoing an extracardiac Fontan as part of a Fontan conversion. The world literature was reviewed on outcomes following the Fontan procedure, focusing on six main areas supporting the superiority of the extracardiac Fontan: hemodynamics, arrhythmias, applicability to complex anatomy, use of cardiopulmonary bypass, complications of fenestration and thromboembolism, and operative mortality. Based on this review, it is our conclusion that the extracardiac Fontan is the procedure of choice for patients with a functional single ventricle based on a very low operative mortality, a lower incidence of early and late arrhythmias, improved hemodynamics, fewer postoperative complications, and applicability to a wide variety of complex cardiac anatomy.
Pediatric Cardiac Surgery Annual of the Seminars in Thoracic and Cardiovascular Surgery 01/2011; 14(1):4-10.
[show abstract][hide abstract] ABSTRACT: This study aimed to compare the incidence of gastrointestinal complications among infants with single-ventricle heart defects after three first-stage palliation strategies: Norwood-modified Blalock-Taussig shunt (mBTS), Norwood right ventricle-to-pulmonary artery conduit (Sano), and hybrid procedures. A retrospective chart review was performed in a pediatric cardiac intensive care unit at a tertiary care medical center. The subjects were 32 neonates who had undergone single-ventricle palliation including 13 Norwood-mBTS, 11 Sano, and 8 hybrid procedures. The measurements included baseline as well as pre- and postoperative patient characteristics. The primary outcome was postoperative intraabdominal complications, and the secondary outcomes were feeding intolerance and necrotizing enterocolitis (NEC). Intraabdominal complications occurred for 34%, feeding intolerance for 13%, and NEC for 13% of the patients. The hybrid patients had a higher incidence of intraabdominal complications (75%) than the Norwood-mBTS (31%) or Sano (9%) patients (P = 0.01). The relative risk for intraabdominal complications in the hybrid group was 3.6 (95% confidence interval [CI], 1.5-8.7). In the multivariate analysis, the hybrid procedure remained an independent predictor of intraabdominal complications (hazard ratio, 8.4; 95% CI, 2.0-34.5). The hybrid, Norwood-mBTS, and Sano patients did not differ significantly in terms of feeding intolerance (25, 15, and 0%, respectively; P = 0.25) or NEC (25, 8, and 9%; P = 0.46). Gastrointestinal morbidity was common regardless of the palliative approach, although the hybrid patients had the highest incidence of intraabdominal complications. This supports the need for caution in using enteral nutrition with all single-ventricle patients, including the hybrid population. Patients undergoing the hybrid procedure may benefit from implementation of standardized feeding protocols.
[show abstract][hide abstract] ABSTRACT: A 7-day-old male with tricuspid atresia, pulmonary atresia, and D-transposition of the great vessels underwent surgical placement of a modified Blalock-Taussig (mBT) shunt and was found to have a pseudoaneurysm on the follow-up echocardiogram. Surgical exploration identified a pseudoaneurysm arising from the right subclavian artery and not from the innominate artery at the site of the mBT shunt. It was concluded that this was caused by an inadvertent needlestick during central line placement. The fistula tract between the right subclavian artery and the false aneurysm was oversewn, and the postoperative course was unremarkable.
[show abstract][hide abstract] ABSTRACT: Surgical techniques for repair of supravalvular aortic stenosis (SVAS) include McGoon's one-patch, Doty's two-patch, and Brom's three-patch method. In this review we evaluated mid-term clinical outcomes of these techniques at our institution.
Our cardiac surgery database identified patients with SVAS repair from 1990 to 2008. Follow-up records, reintervention and reoperation data, and most recent echocardiograms were obtained.
From 1990 to 2008, 20 patients (70% male) underwent surgery for SVAS. Mean age was 3.6 +/- 5.6 years. In chronological sequence, 8 patients had single-patch aortoplasty, 4 had the Doty procedure, and 8 received Brom's symmetric three-patch aortoplasty. Of the Brom patients, 6 had Williams syndrome. Aortic cross-clamp times were 40.1 +/- 13.6 minutes (one-patch), 60.3 +/- 38.8 minutes (Doty), and 104 +/- 20.5 minutes (Brom). Perioperative mortality was 5.0% (1 patient in one-patch group). Mean postoperative length of stay was 10 +/- 10.6 days. Follow-up data were available for all survivors (mean follow-up, 6.3 +/- 6.0 years; range, 6 months to 16 years). There were no late deaths. Follow-up echocardiograms revealed a peak Doppler gradient across the aortic outflow tract of 33 +/- 18.0 mm Hg (one-patch), 10 +/- 1 mm Hg (Doty), and 18 +/- 12 mm Hg (Brom). All patients in the Doty and Brom groups had less than moderate aortic insufficiency. Reoperations were required in 5 of 8 one-patch patients (62%) for residual aortic stenosis (n = 3), aortic insufficiency (n = 1), and subvalvar stenosis (n = 1). No Doty or Brom patient has required aortic reoperations, which was nearly statistically associated with freedom from reoperation (p = 0.06). Subvalvar stenosis was the only risk factor associated with reoperation (p = 0.0028).
Despite a longer cross-clamp time, SVAS repair by Doty or Brom aortoplasty restores normal hemodynamics and reduces the need for reoperation when compared with the classic one-patch technique. Our current preference for SVAS repair is the Brom three-patch symmetric aortoplasty.
The Annals of thoracic surgery 05/2010; 89(5):1371-7. · 3.74 Impact Factor
[show abstract][hide abstract] ABSTRACT: Surgical repair of total anomalous pulmonary venous connection is associated with significant mortality and morbidity, especially in patients with single-ventricle physiology. This study analyzes total anomalous pulmonary venous connection surgical repair results at one institution to identify trends and indicators of positive outcome.
Our cardiac surgery database identified 100 patients undergoing surgical repair of total anomalous pulmonary venous connection (1990-2008): supracardiac (52), cardiac (15), infracardiac (23), and mixed (10). The median age at repair was 14.6 days (range, 0-4 years), and the median weight was 3.5 kg (range, 1.3-15 kg). Patients were divided into 2 groups: biventricular (n = 83) or single-ventricle (n = 17) physiology. All but 1 of the patients with single-ventricle physiology had heterotaxy syndrome (94%), and 13 of 17 patients had supracardiac anatomy.
There were 12 operative deaths (4 in the biventricular group [5%] and 8 in the single-ventricle group [47%], P < .01) and 9 late deaths (6 in the biventricular group [7%] and 3 in the single-ventricle group [18%], P < .05). Death by total anomalous pulmonary venous connection type was supracardiac (12/52; 23.1%), cardiac (1/15; 6.7%), infracardiac (3/23; 13.0%), and mixed (5/10; 50%). Pulmonary venous obstruction was present in 22 patients in the biventricular group (27%) and in 7 patients in the single-ventricle group (41%; P = .25). Mortality was 9 of 29 (31%) in those with pulmonary venous obstruction and 12 of 71 (17%) in those with nonpulmonary venous obstruction (P = .23). Deep hypothermic circulatory arrest was used in 38 patients (27 in the biventricular group, 32.5%; 11 in the single-ventricle group, 64.7%). Mean deep hypothermic circulatory arrest time was 31.4 +/- 10.7 minutes (P = not significant between groups). Median postoperative length of stay was 11 days (range, 0-281 days). Nineteen patients required reoperation for pulmonary venous stenosis (14 in the biventricular group and 5 in the single-ventricle group. P = .045); the median time to reoperation was 104 days (range, 4-753 days).
Patients with total anomalous pulmonary venous connection with biventricular anatomy have good outcomes. Patients with single-ventricle anatomy have higher mortality and increased risk for pulmonary vein stenosis requiring reoperation. Mortality is highest in patients with mixed-type total anomalous pulmonary venous connection.
The Journal of thoracic and cardiovascular surgery 04/2010; 139(6):1387-1394.e3. · 3.41 Impact Factor
[show abstract][hide abstract] ABSTRACT: We began using the technique of resection with extended end-to-end anastomosis for infants and children with coarctation of the aorta in 1991. The purpose of this review is to evaluate the midterm outcomes of this technique, specifically determining the incidence of and risk factors for transcatheter or surgical reintervention.
A retrospective analysis of the cardiac surgery database was performed to identify all patients who had a diagnosis of coarctation of the aorta with or without ventricular septal defect and had resection with extended end-to-end anastomosis from 1991 to 2007. Perioperative course and follow-up with physical examination, echocardiogram, and cardiology evaluation were obtained.
From 1991 through 2007, 201 patients had repair of coarctation of the aorta with resection with extended end-to-end anastomosis. The median age was 23 days, and the median weight was 4.0 kg. Surgical approach was by left thoracotomy in 157 patients (78%) with a mean cross-clamp time of 18 +/- 4 minutes. Median sternotomy approach was used in 44 patients (22%) to repair a hypoplastic transverse aortic arch (n = 16) or because of associated ventricular septal defect (n = 28) with a mean circulatory arrest time of 14 +/- 9 minutes. Early mortality occurred in 4 patients (2.0%). Three patients (1.5%) required early arch revision: 2 intraoperatively and 1 on postoperative day 1. Follow-up data were available for 182 patients (91%) with a mean follow-up of 5.0 +/- 4.3 years (908 patient-years). Reinterventions (n = 8; 4.0%) included three balloon angioplasties and five reoperations; 75% of the reinterventions occurred in the first postoperative year. Hypoplastic transverse aortic arch was not a risk factor for reintervention (p = 0.36), but was a risk factor for mortality (p = 0.039). Aberrant right subclavian artery was the only risk factor for recoarctation (p = 0.007).
Repair of coarctation of the aorta with resection with extended end-to-end anastomosis has a low early mortality, effectively addresses transverse arch hypoplasia, and at midterm follow-up has a low rate of reintervention for recurrent coarctation.
The Annals of thoracic surgery 12/2009; 88(6):1932-8. · 3.74 Impact Factor