Which surgical techniques are used in the repair of coarctation of the aorta (CoA) in infancy and what are the outcomes?

Updated: Nov 20, 2018
  • Author: Syamasundar Rao Patnana, MD; Chief Editor: Stuart Berger, MD  more...
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Answer

In a review of 1337 patients undergoing repair of coarctation in infancy, the following findings were reported [27] :

  • Subclavian flap aortoplasty was performed in 763 patients (57%). Resection in end-to-end anastomosis was used in 406 patients (30%), and patch aortoplasty was used in 133 patients (9.9%). In addition, 20 patients underwent placement of an interposition graft or bypass graft.

  • In the series, the mortality risk was highest in neonates in whom surgery was performed during the first week of life, whereas only 8 of 279 infants aged 3 months to 1 year who underwent surgery died. Mortality associated with surgery was also higher in smaller infants, particularly in infants who weighed less than 3 kg and infants with associated cardiac anomalies.

  • The presence of a ventricular septal defect (VSD) with or without minor associated anomalies increased the risk of death from 0.9% (no anomalies) to 6.8% (with VSD). Complex associated anomalies, such as a single ventricle or transposition of the great arteries, greatly increased the mortality rate to 16.6%. Similarly, the surgical mortality rate in neonates who required surgery early was high at 45%. Urgent surgery may be required if the patent ductus arteriosus cannot be opened and the patient continues to have poor urine output and acidosis.

In the presence of a hemodynamically significant VSD, historically, placement of a pulmonary artery band was performed to limit pulmonary blood flow at the time of left thoracotomy for coarctation repair. Current surgical approach uses a single-stage repair of the coarctation and VSD, usually through a sternotomy, even in the small neonate.

In severe transverse arch hypoplasia that results in significant residual obstruction following coarctation repair, an ascending-to-descending aortic conduit may be placed. This is usually a less favorable approach because the patient may be obligated to undergo subsequent surgeries for conduit replacement.

In most centers, associated defects may be addressed at the time of surgery for coarctation by proceeding with a median sternotomy to repair lesions such as mitral stenosis or subaortic obstruction or to accomplish left ventricular (LV) outflow tract enlargement. Occasionally, the adequacy of the LV volume is called into question, and the patient may require a modified Norwood repair. Decision making about this issue is addressed in Hypoplastic Left Heart Syndrome. However, note that hypoplasia of the left heart structures, particularly the LV, associated with isolated CoA usually improves following relief of aortic obstruction. [43]

Repair of coarctation in the asymptomatic child or adolescent is usually undertaken on an elective basis after assessment of associated anomalies and appropriate preoperative evaluation. The timing of intervention in the otherwise asymptomatic patient has been debated. The rationale for delaying surgery until age 3-5 years has been based on the size of the aorta in childhood relative to the anticipated adult size. Because significant obstruction occurs when the diameter of the aorta is reduced by 50% or more, delaying surgery until age 3-5 years allows the aorta to be larger than half the anticipated adult size at operation, theoretically reducing the risk of significant residual obstruction in the event that the surgical repair site does not grow over time. However, issues of hypertension, progressive LV hypertrophy, or LV dysfunction mandate earlier repair.


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