Ann Thorac Surg 2004;78:1993
© 2004 The Society of Thoracic Surgeons
INVITED COMMENTARY
Ralph S. Mosca, MD
Department of Surgery, Children's Hospital of New York, Columbia Presbyterian Medical Center, 3959 Broadway, CHN #274, New York, NY 10032, USA
rm891{at}columbia.edu
The surgical treatment of patients with aortic arch obstruction (AAO) and ventricular septal defect (VSD) has mirrored the development of the field of pediatric cardiac surgery. Early surgical attempts were approached as a two-stage undertaking. Aortic arch repair with pulmonary artery banding, performed through a left thoracotomy, was followed by subsequent repair of intracardiac defects and de-banding. The mid-1970s saw the introduction of prostaglandin E1, and with it, improved preoperative status of the patients. Median sternotomy and single-stage repair was advocated and gradually supplanted the two-stage approach. Cardiopulmonary bypass (CPB) techniques have varied, ranging from deep hypothermic circulatory arrest to regional perfusion and continuous myocardial perfusion, as surgeons attempt to avoid potential complications of cerebral, systemic and myocardial ischemia.
Considerable controversy persists surrounding issues including the best technique of arch reconstruction, the importance and optimal timing of surgical therapy for left ventricular outflow tract obstruction, and therapy of associated cardiac conditions. The best perfusion method, deep hypothermic circulatory arrest, low-flow continuous cerebral ± myocardial perfusion, and low-flow cardiopulmonary bypass with short periods of hypothermic circulatory arrest all have their advocates and critics.
The current report describes one strategy of low-flow hypothermic cardiopulmonary bypass, arch reconstruction with a beating heart, followed by predominately transatrial VSD closure, postoperative inotropic support, inhaled nitric-oxide, and delayed chest closure. The authors should be commended for their excellent results. At a mean follow-up of 2.3 years, all patients were well and without overt neurological symptomatology. However, there is no data concerning neurological examinations provided. Of concern, 1 of 6 patients required reintervention for recurrent or residual arch stenosis.
As with many lesions, it appears that with AAO and VSD we have nearly conquered the hurdle of postoperative mortality. Our efforts must turn to perioperative morbidity. To decipher this we need more exacting data. Today, the absence of overt neurological symptoms is insufficient to promote a strategy. As a detailed look into the Boston Circulatory Arrest Study has shown, many patients exposed to cardiopulmonary bypass may have some neurological impairment. Thankfully, because most children studied at 8 years following surgery overall functioned within normal limits, delineating particular deficiencies involved detailed cognitive and psychomotor testing. The neurological response to CPB is most certainly multifactorial and related to preoperative state (underlying disease, cyanosis, genetics [APOE genotype], etc.) as well as postoperative hemodynamics. The continuous perfusion technique the authors promote can be cumbersome and restrict arch reconstruction, which may relate to the number of patients requiring additional arch interventions. Certainly, we need more data before the authors can promulgate their technique as the "standard approach" for all corrections requiring aortic arch reconstruction.
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Primary Repair for Aortic Arch Obstruction Associated With Ventricular Septal Defect
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Ann. Thorac. Surg. 2004 78: 1989-1993.
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