Ann Thorac Surg 1996;61:1212-1216
© 1996 The Society of Thoracic Surgeons
Original Article: Cardiovascular
Growth Potential in the New Aortic Arch After Non–End-to-End Repair of Aortic Arch Interruption in Infancy
James L. Monro, FRCS,
David J. Delany, FRCR,
Bruce C. Ogilvie, FRCR,
Anthony P. Salmon, FRCP,
Barry R. Keeton, FRCP
Department of Cardiac Surgery, The General Hospital, Southampton, England
Accepted for publication December 22, 1995.
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Abstract
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Background. Complete repair of infants with interrupted arch and ventricular septal defect through a midline incision has been the preferred method for more than 20 years. End-to-end anastomosis can result in restenosis if there is excess tension. Two methods of reducing this tension have been described, and the subsequent growth of the new aortic arch is demonstrated.
Methods. In 2 infants (5 and 9 months old) the duct was used to create a new aortic arch. In 3 other younger infants the left carotid artery was divided, turned down, and anastomosed to the descending aorta to form the new arch. These operations were performed through the midline at the same time as the ventricular septal defect was closed.
Results. All 5 patients are well now 8 to 19 years postoperatively. One patient required reoperation for stenosis at the anastomotic site, but all have subsequently shown good growth on follow-up angiographic and magnetic resonance imaging studies.
Conclusions. Although end-to-end repair is best, these alternative methods have shown very satisfactory aortic growth into adult life.
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Introduction
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Aortic arch interruption is a rare condition, accounting for about 1% of infants with critical congenital heart disease [1], and is almost always associated with a large perimembranous ventricular septal defect. The natural history is poor, and 80% of children die within the first month without operation [2]. The ideal method of surgical repair was reported by Trusler and Isukawa in 1975 [3], with the direct anastomosis of the descending to ascending aorta and closure of the ventricular septal defect at the same operation through the front of the chest. Despite this, many surgeons have only recently adopted this policy. We have always held the view that early correction was the best method and still try to use Trusler and Isukawa's technique wherever possible. However, to avoid tension on the anastomosis, which in turn probably predisposes to stenosis of the anastomosis, other methods have occasionally been used. The purpose of this report is to demonstrate the growth of the aortic arch in 5 patients who had correction by two other methods in infancy more than 8 years ago (Table 1
). These 5 patients were among the early experience of one of us [4–6], and all had type B interruption [7].
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Material and Methods
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In all patients surface cooling, further bypass cooling, and circulatory arrest at a temperature of 16°C with bypass rewarming was used. Further periods of recirculation were used in patients 1, 3, and 4 with further circulatory arrest for closure of the ventricular septal defect. All patients have had postoperative cardiac catheterization, in some patients on multiple occasions. In addition, magnetic resonance imaging has been performed in 4 patients. The patients have been followed up regularly for between 8 and 19 years.
Repair Using the Ductus Arteriosus
PATIENT 1.
This 5-month-old girl, who underwent repair on April 27, 1976, is the subject of a previous report [4]. In this patient the duct together with a continuous pulmonary artery flap folded as a tube was used in continuity to join the ascending to descending aorta. This girl has now had five postoperative cardiac catheterization procedures and a magnetic resonance imaging investigation. These have shown steady growth of the aortic arch and no gradient across the anastomosis. Angiography on October 12, 1976, (Fig 1) showed a satisfactory arch 5 months after repair. Repeat angiography on February 21, 1986, (Fig 2) showed growth of the arch but severe subaortic stenosis, which was resected. Further angiography on February 2, 1994, (Fig 3) showed the growth of the arch. The bicuspid aortic valve has a gradient of 40 mm Hg across it. Magnetic resonance imaging performed at the same time (Fig 4) confirmed the angiographic findings.
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Fig 1. . Aortograms of patient 1 five months after operation in the anteroposterior view (A) and the lateral view (B) show that the arch is of adequate size. The left subclavian artery marks the limit of the new arch. (Reprinted with permission from Monro JL, Brawn W, Conway N. Correction of type B interrupted aortic arch with ventricular septal defect in infancy. J Thorac Cardiovasc Surg 1977;74:618–23.)
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Fig 2. . This shows the situation in patient 1 ten years postoperatively. There has been appropriate growth in the size of the arch, but now a marked subaortic stenosis has developed. (Reprinted with permission from Monro JL, Bunton RW, Sutherland GR, Keeton BR. Correction of interrupted aortic arch. J Thorac Cardiovasc Surg 1989;98:421–7.)
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Fig 3. . The most recent angiogram in patient 1, 18 years postoperatively, shows that the true diameter of the aortic arch has increased three times. The bicuspid valve is also well demonstrated.
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Fig 4. . Magnetic resonance image of patient 1 shows similar findings to the aortogram shown in Figure 3 .
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PATIENT 2.
This 9-month-old boy had correction on March 21, 1978, using the duct for the arch repair. The duct was narrow and was patched with pericardium. He also had a bicuspid aortic valve, and he had repeat cardiac catheterization followed by aortic valvotomy on March 12, 1980. Growth in the aortic arch has been demonstrated by repeat catheterization on September 27, 1990, and the region of duct tissue has been shown to grow (Fig 5). Subsequent aortic valve replacement with a St. Jude valve was performed on March 13, 1991.
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Fig 5. . Aortogram of patient 2, 13 years after repair, shows that the arch is somewhat dilated; this is presumably where the duct was originally patched.
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Repair Using the Left Carotid Turndown
This technique was described in 1980 [5]. The aortic arch repair was achieved by dividing the left carotid artery about 1.5 cm beyond its origin, turning the proximal segment down, and anastomosing it to the descending aorta after all duct tissue has been removed. The distal segment of the left carotid artery was anastomosed to the right carotid artery, and the ventricular septal defect was then repaired. The left carotid artery must be of adequate size; it was 4 mm in diameter in our 3 patients.
PATIENT 3.
This 33-day-old boy underwent correction by this method on December 3, 1979. He also had a bicuspid aortic valve and aberrant right subclavian artery coming from the descending aorta. Angiography on April 29, 1980 (Fig 6), showed the differential growth in the proximal left carotid artery forming the new aortic arch, and the distal left carotid artery anastomosed to the right carotid artery. Magnetic resonance imaging performed in 1993 (Fig 7) showed the growth of the arch.
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Fig 6. . Postoperative angiogram 4 months after repair in patient 3 shows that the proximal left carotid artery forms the new aortic arch. Both subclavian arteries can be seen coming off the descending aorta just beyond the anastomosis. The distal left carotid artery was anastomosed to the right carotid artery, and differential growth is seen in the two parts of the left carotid artery according to the flow in them. (Reprinted with permission from Monro JL, Bunton RW, Sutherland GR, Keeton BR. Correction of interrupted aortic arch. J Thorac Cardiovasc Surg 1989;98:421–7.)
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Fig 7. . This magnetic resonance image taken 12 years postoperatively in patient 3 shows a satisfactory sized aortic arch.
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PATIENT 4.
This 2-day-old boy had repair on February 17, 1985, and also had a bicuspid aortic valve. Ten years later magnetic resonance imaging (Fig 8) shows a satisfactory aortic arch.
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Fig 8. . Anteroposterior magnetic resonance image of patient 4 demonstrates the almost normal-sized aortic arch compared with the normal-sized left carotid artery, which was anastomosed to the right carotid artery.
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PATIENT 5.
This 6-day-old girl had repair on December 10, 1986. Angiography on August 21, 1987 (Fig 9), demonstrated a severe stenosis at the anastomosis of the left carotid artery to the descending aorta. This was repaired with a patch on September 7, 1987, and her subsequent progress has been excellent. Magnetic resonance imaging in 1995 showed a satisfactory arch and repair (Fig 10).
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Fig 9. . Stenosis developed at the site of anastomosis between the left carotid artery and the descending aorta 4 months after correction in patient 5. (Reprinted with permission from Monro JL, Bunton RW, Sutherland GR, Keeton BR. Correction of interrupted aortic arch. J Thorac Cardiovasc Surg 1989;98:421–7.)
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Fig 10. . Magnetic resonance image of patient 5 nine years after her initial correction shows a very adequate-sized aortic arch after the reoperation and widening of the anastomotic obstruction.
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Results
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All 5 patients are well with no significant ascending-to-descending aortic gradient. The growth in the aortic arch has been gratifying and, as can be seen from Table 2, has varied from 62% to 106% of the descending aorta over the 8-to 19-year period. In the group with the carotid turndown, there has been differential growth between the proximal carotid artery forming the arch compared with the distal carotid artery, and the actual diameter of the new arch thus formed has increased almost threefold within 8 years.
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Comment
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The first 2 patients in this series are rather unusual in that they presented late at 5 and 9 months and it was therefore possible to use the duct in the repair. The actual growth of the duct is shown in patient 1, who had multiple postoperative studies and who currently has no gradient across the arch more than 19 years later. This method, however, is not recommended in neonates and probably not before the age of 3 months. As most patients requiring correction of interrupted arch present in the first months of life, this technique should be rarely considered; it is, however, interesting to know that duct tissue can grow in these circumstances.
Of considerable interest is the technique of the left carotid turndown. This is clearly only possible if the left carotid artery is of an adequate size. In this series the 3 patients who underwent this technique weighed between 2.9 and 3.5 kg and all 3 had a left carotid artery size estimated at 4 mm. The growth of this new arch is dependent on the flow, and the differential growth of the proximal and distal ends of the carotid artery demonstrates this. A very adequate arch has been produced by this method, although it was disappointing that a restenosis developed in 1 of our patients. This was at the anastomosis and very likely was due to some duct tissue left behind.
There can be no doubt that the best type of repair is that described by Trusler and Isukawa [3], where direct ascending-to-descending aortic anastomosis is achieved. However, this can be difficult without tension, particularly if there is an aberrant right subclavian artery coming off the descending aorta, as is the case in about one third of type B aortic interruptions. In this situation it may be difficult to mobilize the descending aorta adequately without sacrificing the right subclavian artery, and the carotid turndown therefore becomes an alternative approach. Although this rarely will be needed, it is gratifying to know that adequate growth of the new arch occurs. Our longest follow-up of this operation is now more than 15 years. Growth of the new arch may be of help also in reoperation for this condition [8].
Although achieving a satisfactory aortic arch is a prime concern in this condition, there are other problems such as aortic stenosis and subvalvular aortic stenosis that may progress, and therefore careful follow-up is important.
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Footnotes
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Address reprint requests to Mr Monro, Department of Cardiac Surgery, The General Hospital, Southampton, England, SO16 6YD.
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References
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- Collins-Nakai RL, Parisi-Buckley L, Fyler D, Castañeda AR. Interrupted aortic arch in infancy. J Pediatr 1976;88:959–62.[Medline]
- Van Praagh R, Bernhard WF, Rosenthal A, Parisi LF, Fyler DC. Interrupted aortic arch: surgical treatment. J Cardiol 1971;27:200–11.
- Trusler GA, Isukawa T. Interrupted aortic arch and ventricular septal defect: direct repair through a median sternotomy incision in a 13-day-old infant. J Thorac Cardiovasc Surg 1975;69:126–31.[Abstract]
- Monro JL, Brawn W, Conway N. Correction of type B interrupted aortic arch with ventricular septal defect in infancy. J Thorac Cardiovasc Surg 1977;74:618–23.[Abstract]
- Monro JL. Interrupted aortic arch. Techniques and results. In: Parenzan L, Crupi G, Graham G, eds. Congenital heart disease in the first 3 months of life. Bologna: Patron Editore, 1981:375–82.
- Monro JL, Bunton RW, Sutherland GR, Keeton BR. Correction of interrupted aortic arch. J Thorac Cardiovasc Surg 1989;98:421–7.[Abstract]
- Celoria GC, Patton RB. Congenital absence of the aortic arch. Am Heart J 1959;58:407–13.[Medline]
- Monro JL. Reoperations for interrupted aortic arch. In: Stark J, Pacifico AD, eds. Reoperations in cardiac surgery. London: Springer Verlag, 1989:125–41.
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Abstract
Introduction
