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Ann Thorac Surg 2006;82:158-163
© 2006 The Society of Thoracic Surgeons

Original article: Cardiovascular

Repair of Coarctation of the Aorta in Infants Weighing Less Than 2 Kilograms

Catherine D. Sudarshan, MD, FRCS, Andrew D. Cochrane, FRACS, FRCS (CTh) * , Zhang H. Jun, MD, Rodrigo Soto, MD, Christian P. Brizard, MD

Cardiac Surgery Unit, Royal Children's Hospital, Parkville, Victoria, Australia

Accepted for publication March 3, 2006.

* Address correspondence to Dr Cochrane, Cardiac Surgery Unit, Royal Children's Hospital, Flemington Rd, Parkville, Victoria 3052, Australia (Email: andrew.cochrane{at}rch.org.au).


   Abstract
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BACKGROUND: We retrospectively reviewed our experience in aortic coarctation repair on infants weighing less than 2 kg to evaluate the results and assess the rate of recoarctation in this group of patients.

METHODS: Twenty-four consecutive babies weighing 2 kg or less were operated on over a period of 15 years. Median gestational age was 33 weeks (range, 30 to 36), and median weight was 1.6 kg (range, 1.0 to 2.0). Seventeen of them had associated cardiac anomalies. The methods of repair undertaken were resection with extended end-to-end anastomosis (n = 13), subclavian flap angioplasty (n = 9), carotid flap angioplasty (n = 1), and patch repair using pulmonary homograft tissue (n = 1).

RESULTS: Mean follow-up was 52.5 months (range, 0.5 to 151). There were 3 in-hospital deaths and 2 late deaths. Recoarctation developed in 7 babies. Four underwent balloon dilatation; 1 of them required further surgery; 3 others have mild recoarctation, but have not required further intervention. Risk factor analyses revealed that the presence of preoperative congestive cardiac failure, and coexisting noncardiac lesions as well as the duration of descending aortic cross-clamp and postoperative ventilation had a significant influence on mortality after repair.

CONCLUSIONS: Coarctation repair in infants less than 2 kg can be performed safely. The incidence of recoarctation is acceptable and comparable with that of other pediatric cohorts that have been reported. Preoperative cardiac function and associated noncardiac lesions may influence the incidence of mortality after repair. Delaying the timing of surgical repair to achieve growth is not necessary.


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Satisfactory results have been achieved after early repair of congenital heart anomalies in low birth weight infants [1–3]. With regard to coarctation of the aorta (CoA), two broad policies have been adopted worldwide in the management of low birth weight infants and neonates. Whereas some advocate delaying the timing of surgery until the baby grows up and gains weight, others, like ourselves, favor early intervention [4]. Despite recent advances and several reports of successful early balloon dilatation, surgery remains the choice of treatment for CoA in most patients [5], especially neonates [6, 7]. Many centers have reported low and acceptable surgical mortality rates [8, 9], even in small infants [10]. However, most debate continues to focus on the question of optimal timing for surgery and the incidence of recoarctation of the aorta (Re-CoA) in the latter group.

The purpose of this paper is to review our surgical experience with CoA in low birth weight—less than 2 kg—infants (small infants) as well as to identify the risk factors for mortality and early Re-CoA.


   Patients and Methods
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Consent to conduct this retrospective analysis was obtained from the Ethical Committee of the hospital before collection of data. The Committee waived the obtainment of individual consent.

Between January 1988 and December 2002, 24 consecutive small infants underwent surgical repair of CoA. There were 16 males and 8 females (M:F = 2:1). Age and weight at the time of surgery ranged from 6 to 58 days (median, 17) and 1.0 to 2.0 kg (median, 1.6), respectively. The gestational age varied from 30 to 36 weeks (median, 33). Sixteen of them had associated major cardiac anomalies (66.7%). These included ventricular septal defects (n = 15), hypoplastic left ventricle or aortic arch (n = 6), double outlet right ventricles (n = 3), and atrial septal defects (n = 2). In addition, other significant noncardiac abnormalities were present in 6 (25%). The details are summarized in Table 1.


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  		Table 1. Associated Cardiac and Noncardiac Anomalies
 
All patients had the diagnosis confirmed by two-dimensional echocardiography before surgery, and prostaglandin infusion was commenced immediately after the diagnosis was made. The diameter of the ascending aorta ranged between 4.5 and 7.4 mm (median, 6 mm), and the diameter of the isthmus was between 2 and 4 mm (median, 3). The mean transverse aortic arch diameter was 3.1 mm (range, 2.5 to 4). The maximum measured velocity across the area of CoA (Vmax) ranged between 2.7 and 7.4 m/s (median, 3.6 m/s). Fourteen infants required preoperative ventilatory or inotropic support, or both (58.3%).

Seven patients had repair of an intracardiac defect 0.5 to 17 months (median, 6) after the initial CoA repair. The procedures included closure of ventricular septal defects (n = 6), Damus-Kaye-Stansel connections (n = 2), and bandings of the pulmonary artery (n = 3).

Surgical Procedure
For the purpose of analysis, patients were further subdivided according to the type of surgical procedure performed. There were two major surgical procedures used in this group. Nine patients underwent subclavian flap angioplasty (SFA [37.5%]). One baby had a carotid flap angioplasty, and another had a patch repair using pulmonary homograft. The remaining 13 patients in the group underwent resections with extended end-to-end anastomoses (ETE [54.2%]).

The surgical technique carried out in our unit has evolved over time. Subclavian flap angioplasty was performed in all patients before 1996 in this series, but the ETE technique has been the standard and preferred method of repair since then.

For the SFA method, it is important that a long aortotomy is carried out distally to acquire sufficient length well beyond the ductal tissue [11]. Tacking sutures are placed on either side of the isthmus using an interrupted 6-0 monofilament suture (Prolene; Ethicon, Somerville, New Jersey) to optimize the diameter of the aortic wall. At the same time, it must be ensured that the anastomosis of the subclavian flap is tension free.

The technique of ETE performed is similar to that reported elsewhere [12]. A left posterolateral thoracotomy through the fourth intercostal space is carried out. Two major points have to be emphasized here that we believe require careful attention to prevent Re-CoA. First, all ductal tissue must be completely excised [13]. Second, the incision must be extended onto the undersurface of the aortic arch as proximal as possible after resecting the coarcted segment.

All anastomoses were performed with either a 7-0 or 8-0 monofilament running suture (Prolene; Ethicon). The aortic clamp time varied between 10 and 35 minutes (median, 17.5).

Follow-Up
Follow-up was carried out by direct communication with the patient's family or by the local cardiologist. All surviving patients have therefore been followed up between 0.5 and 151 months (mean, 52.5). All those who were seen have had echocardiograms as part of their review.

Statistical Analysis
The patients who had the carotid flap angioplasty and the patch repair have not been included in the analysis. It would not be appropriate nor feasible to do so as the operative procedures are entirely different with only 1 patient in each of these categories.

All data are presented as median values with respective ranges. Univariate analysis was performed with the aid of the Student t test for continuous variables and the Fisher exact test for dichotomous variables if appropriate. Multivariate risk factor analysis was carried out with the use of multiple logistic regression estimating 95% confidence intervals. The statistical program used is SPSS v11.5 for Windows 2002 (SPSS, Chicago, Illinois).


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In-Hospital Deaths
Three patients died in hospital. The causes of death are listed in Table 2. A baby who had a severely hypoplastic left ventricle, multiple ventricular septal defects, and congestive cardiac failure preoperatively died 64 days after the repair as a result of worsening cardiac failure and long-term ventilatory support, despite successful balloon dilatation of the Re-CoA. Another patient who had multiple malformations including ventricular septal defect, hyaline membrane disease, and bronchopulmonary dysplasia had repair of CoA and banding of the pulmonary artery at the age of 2 weeks. He remained ventilator dependent after the repair and died 109 days later after the second stage operation when he underwent closure of the ventricular septal defect and debanding of the pulmonary artery. A third baby who had associated complex cardiac and noncardiac defects with severe preoperative cardiac failure died from worsening cardiac dysfunction on the night of the repair.


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  		Table 2. Analysis of Mortality
 
Late Mortality
There were 2 late deaths during the follow-up period. One patient who had severe congestive cardiac failure and poor left ventricular function before surgery required balloon dilatation for Re-CoA, which was successful. He unfortunately died as a result of cardiac arrest after the second stage correction of his perineal hypospadias nine months later. Another patient died 3 months after his CoA repair. He had severe congestive cardiac failure and multiple cardiac and noncardiac anomalies. He died of staphylococcal sepsis, worsening respiratory failure, and persistent cardiac failure.

Complications
No severe neurologic complications were recognized. Four infants had postoperative left phrenic nerve paralysis and underwent plication of the left hemidiaphragm. One baby had obstruction of the superior vena cava as a result of septic thrombosis, for which he underwent thrombectomy. Two patients had chylothoraces that required intercostal drainage for prolonged periods.

Recoarctation
Residual CoA was considered to be present if (a) the baby required further interventions or treatment for symptoms of CoA, (b) the blood pressure gradient across the arch was more than 25 mm Hg, or (c) the estimated Vmax across the arch on two-dimensional echocardiography was more than 2.5 m/s with diastolic run-off. All patients had regular postoperative echocardiograms. None had residual CoA early after repair. The mean Vmax in the early postoperative period was 1.5 m/s. That had decreased significantly after the operation (p < 0.01).

In 7 patients (29.2%), Re-CoA developed. Three of these cases were mild—peak velocity of less than 3 m/s on two-dimensional echocardiography—and free of clinical symptoms and have not required any further intervention so far. Four patients (16.7%) underwent balloon dilatation of their Re-CoA. One of them has subsequently required surgical reconstruction of the persistent hypoplastic aortic arch (see Table 3).


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  		Table 3. Patients with Recoarctation of the Aorta (CoA)
 
It is important to emphasise that there were no late Re-CoAs (later than 1 year) in either surgical group. That enabled us to statistically analyze and compare the two groups albeit small numbers.

In multivariate analysis of factors associated with mortality, the presence of preoperative congestive cardiac failure (defined in this series as the requirement for ventilatory or inotropic support), coexisting noncardiac defects, the duration of descending thoracic aortic cross-clamp, and the duration of postoperative ventilation reached statistical significance (see Table 4). The latter factor could be an indirect index of poor cardiac function. None of the independent variables analyzed revealed an association with the incidence of Re-CoA. There were no significant differences between the SFA and ETE groups in terms of mortality (p = 0.14) nor Re-CoA (p = 0.09; Table 5). We do recognize and acknowledge that the number of patients in each group is small.


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  		Table 4. Analysis of Risk Factors for Mortality and Recoarctation of the Aorta (Re-CoA)
 

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  		Table 5. Results of Surgical Procedures
 
We have performed a brief analysis of the outcome of all neonates and infants who have had a repair of CoA at the Royal Children's Hospital. It is important to point out that weight at the time of surgery is not a significant risk factor for morbidity and mortality in the entire group.


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It is generally perceived that low birth weight is not a contraindication for early repair of congenital cardiac anomalies [1, 2, 12, 14]. High mortality rates have been reported in small infants with uncorrected CoA [15]. In recent years, great advancements have been made in the surgical management of neonates, and results have constantly improved. Despite the increasing number of cardiac centers reporting better results over the last decade on small infants who have undergone operations, low birth weight is perceived to be a major and important risk factor for morbidity and mortality after cardiac surgery. Whether this is also the case with mortality after CoA repair is yet to be proven. We attempted to answer this question from our experience on repair of CoA in small infants in our center.

Recent studies have reported the mortality of CoA repair in small infants to range from 12% to 25% [8, 14]. It is certainly lower in isolated CoA in full-term neonates and young infants, in whom fewer than 2% of the patients have died in the early postoperative period [4]. Bacha and associates [10] analyzed the outcome of 18 patients less than 2 kg in weight undergoing repair of critical CoA; only 1 patient died in the immediate postoperative period (5.5%).

Only a few risk factors for death after CoA repair in small infants have been recognized so far. Critical preoperative clinical status and associated complex cardiac lesions have been documented to be the most common and important risk factors to influence mortality after surgery [3, 8–10, 12, 13]. Little is known about factors such as the type of repair performed and the weight at operation and the influence they have on mortality.

Although the mortality in our group of patients is toward the high end of the spectrum (20.1%), each of the babies who died had significant preoperative risk factors, and the analysis covers a 15-year period. It is important to emphasize at this juncture that none of them died directly as a result of the surgical repair.

Statistical analysis reveals that preoperative congestive cardiac failure and coexisting noncardiac defects, as well as the duration of aortic cross-clamp and long-term postoperative ventilatory support, play a significant role in influencing mortality in this group of patients.

The incidence of Re-CoA is reported to range between 10% and 20% [3, 4, 8, 12]. The presence of Re-CoA can be defined by several criteria. Our definition of Re-CoA is as described before, which is similar to that documented by other centers [4, 10].

Weight at Operation
Bacha and associates [10] found that low birth weight (less than 1.5 kg) infants had a significantly higher chance of having residual CoA or developing Re-CoA. However, McElhinney and colleagues [4] concluded that low weight was not a risk factor for recurrent stenosis after repair of CoA in small infants. Our results also suggest that there is no statistically significant difference between patients weighting less than 1.5 kg and those between 1.51 kg and 2 kg in terms of risks of Re-CoA.

Surgical Technique
No technique of repair is completely free of the risk of Re-CoA. It has been documented that there is a higher incidence of Re-CoA in simple prosthetic patch aortoplasty and simple resection with ETE anastomosis, both of which are almost never used in neonates today. Residual ductal tissue in the aortic wall certainly plays a role in promoting Re-CoA [13]. Allen and colleagues [16] suggest that if the aortotomy is not carried out far enough distally to extend beyond ductal tissue when performing a SFA, the potential for restenosis exists. In recent years, the ETE anastomosis has been widely considered to be the ideal procedure for repair of CoA, as it can provide a wide anastomosis and enables full excision of ductal tissue. It combines the advantages of both the SFA and the simple end-to-end procedures.

We could not elicit any statistical differences between the SFA and the ETE procedures in our group of patients, echoing the view of other centers [17]. We are aware that two techniques performed during different eras are being compared here. As mentioned before, all patients operated on since 1996 have had the ETE repair.

Most neonatal Re-CoA that has been reported occurred during the first year after repair. Balloon dilatation is considered to be the treatment of choice for treating this complication. Bacha and associates [10] have reported that in 7 of 8 babies, residual or Re-CoA had been detected within the first year after repair; 5 of these patients underwent balloon dilatation. McElhinney and colleagues [4] report that 80% of the Re-CoA required further interventions within a year of the initial repair. Pfammatter and coworkers [18] report that in all 6 cases of Re-CoA in their series, symptoms and signs of Re-CoA developed within the first few months after the initial repair.

There have been 7 Re-CoAs (29.2%) in the first year after repair in our series. We have had 4 balloon dilatations in this group so far. Three were successful: 1 patient required further surgery for continuing arch hypoplasia 7 months after the reintervention.

In conclusion, CoA repair in infants weighing less than 2 kg can be performed safely with reasonable outcomes. The preoperative cardiac function, associated noncardiac lesions, the duration of aortic cross-clamp, and postoperative ventilatory support are the possible risk factors influencing mortality.

The rate of Re-CoA is acceptable and comparable with that reported in the literature. These patients have been mostly managed successfully by balloon dilatation alone. There is no difference between the two techniques of ETE and SFA.

We therefore advocate commencement of prostaglandin infusion immediately after establishment of the diagnosis and early surgical intervention in this group of patients. Delaying the timing of surgery is not necessary, whereas it may worsen the clinical state of the patient.


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   References
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  1. Rossi AF, Sciden HS, Sadeghi AM, et al. The outcome of cardiac operations in infants weighing two kilograms or less J Thorac Cardiovasc Surg 1998;116:28-35.[Abstract/Free Full Text]
  2. Reddy VM, McElhinney DB, Sagrado T, Parry AJ, Teitel DF, Hanley FL. Results of 102 cases of complete repair of congenital heart defects in patients weighing 700 to 2500 grams J Thorac Cardiovasc Surg 1999;117:324-331.[Abstract/Free Full Text]
  3. Zehr KJ, Gillinov AM, Redmond JM, et al. Repair of coarctation of the aorta in neonates and infantsa thirty-year experience. Ann Thorac Surg 1995;59:33-41.[Abstract/Free Full Text]
  4. McElhinney DB, Yang SG, Hogarth AN, et al. Recurrent arch obstruction after repair of isolated coarctation of the aorta in neonates and young infantsis low weight a risk factor?. J Thorac Cardiovasc Surg 2001;122:883-890.[Abstract/Free Full Text]
  5. Corno AF, Botta U, Hurni M, et al. Surgery for aortic coarctationa 30 years experience. Eur J Cardiothorac Surg 2001;20:202-206.
  6. Kothari SS, Juneja R, Saxena A, Reddy SCB, Sharma S. Balloon dilatation of simple aortic coarctation in neonates and infants Indian Heart J 1998;50:187-192.[Medline]
  7. Fletcher SE, Nihill MR, Grifka R, O'Laughlin MP, Mullins CE. Balloon angioplasty of native coarctation of the aortamidterm follow up and prognostic factors. J Am Coll Cardiol 1995;25:730-734.[Abstract]
  8. Conte S, Lacour-Gayet F, Serraf A, et al. Surgical management of neonatal coarctation J Thorac Cardiovasc Surg 1995;109:663-675.[Abstract/Free Full Text]
  9. Backer CL, Mavoroudis C, Zias EA, Amin Z, Weigel TJ. Repair of coarctation with resection and extended end-to-end anastomosis Ann Thorac Surg 1998;66:1365-1371.[Abstract/Free Full Text]
  10. Bacha EA, Almondovar M, Wessel DL, et al. Surgery for coarctation of the aorta in infants weighing less than 2 kg Ann Thorac Surg 2001;71:1260-1264.[Abstract/Free Full Text]
  11. Stark J. Coarctation of the aortaIn: Stark J, de Leval M, editors. Surgery for congenital heart defects. 2nd ed.. Philadelphia: WB Saunders; 1994. pp. 290.
  12. Van Heurn LWE, Wong CM, Spiegelhalter DJ, et al. Surgical treatment of aortic coarctation in infants younger than three months1985 to 1990. J Thorac Cardiac Surg 1994;107:74-86.[Abstract/Free Full Text]
  13. Russell GA, Berry PJ, Watterson K, Dhasmana JP, Wisheart JD. Patterns of ductal tissue in coarctation of the aorta in the first three months of life J Thorac Cardiovasc Surg 1991;102:596-601.[Abstract]
  14. Chang AC, Hanley FL, Lock JE, Castaneda AR, Wessel DL. Management and outcome of low birth weight neonates with congenital heart disease J Pediatr 1994;124:461-466.[Medline]
  15. Kecskes Z, Cartwright DW. Poor outcome of very low birthweight babies with serious congenital heart disease Arch Dis Child Fetal Neonatal Ed 2002;87:F31-F33.[Abstract/Free Full Text]
  16. Allen BS, Halldorsson AO, Barth MJ, Iibawi MN. Modification of the subclavian patch aortoplasty for repair of aortic coarctation in neonates and infants Ann Thorac Surg 2000;69:877-881.[Abstract/Free Full Text]
  17. Trinquet F, Vouhe PR, Vernant F, et al. Coarctation of the aorta in infantswhich operation?. Ann Thorac Surg 1988;45:186-191.[Abstract]
  18. Pfammatter JP, Ziemer G, Kaulitz R, Heinemann MK, Luhmer I, Kallfelz HC. Isolated aortic coarctation in neonates and infantsresults of resection and end-to-end anastomosis. Ann Thorac Surg 1996;62:778-782.[Abstract/Free Full Text]



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