Ann Thorac Surg 2008;85:1753-1758. doi:10.1016/j.athoracsur.2008.01.059
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Perioperative Evaluation of Airways in Patients With Arch Obstruction and Intracardiac Defects
Won Kyoung Jhang, MDa,
Jeong-Jun Park, MD, PhDa,
Dong-Man Seo, MD, PhDa,*,
Hyun Woo Goo, MD, PhDb,
MiJeung Gwak, MD, PhDc
a Division of Pediatric Cardiac Surgery, College of Medicine, University of Ulsan, Seoul, Korea
b Department of Radiology, College of Medicine, University of Ulsan, Seoul, Korea
c Department of Anesthesiology and Pain Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea
Accepted for publication January 18, 2008.
* Address correspondence to Dr Seo, Division of Pediatric Cardiac Surgery, Asan Medical Center, 388-1 Poongnap-Dong, Songpa-Ku, Seoul, 138-736, Republic of Korea (Email: dmseo{at}amc.seoul.kr).
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Abstract
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Background: Patients with arch obstruction and intracardiac defects have a high probability of abnormal aortopulmonary space geometry, which provides airway compression. The tissue-to-tissue technique arch repair could result in real airway problems. This report describes our experience with the perioperative evaluation and management of airway problems.
Methods: We retrospectively reviewed the medical records of 90 patients with arch obstruction and intracardiac defects who underwent computed tomography (CT) and corrective surgery in our institution between January 2000 and January 2007.
Results: Of the 77 patients who underwent preoperative CT (group 1), 21 were found to have airway compression (27.2%).Of those 21 patients, 5 underwent concomitant airway relieving procedures. In group 1, 2 patients required subsequent secondary surgery for airway problems after the initial arch repair. Of the 13 patients who underwent postoperative CT only (group 2), 6 underwent subsequent secondary surgery for airway relief. For airway relief, several procedures were additionally performed (eg, right pulmonary artery translocation anterior to the aorta, aortopexy, peribronchial dissection, and tissue augmentation). In terms of the type of arch repair, 48 patients underwent end-to-side anastomosis, 39 underwent extended end-to-end anastomosis, and 3 underwent end-to-end anastomosis. End-to-side was the repair type most commonly associated with airway compression requiring additional procedure (10 of 15, 66.6%).
Conclusions: Patients with arch obstruction and intracardiac defects had a rather high incidence of airway compression preoperatively and postoperatively. Preoperative CT and intraoperative complementary bronchoscopy were useful for identifying and fixing the airway problems. Additional procedures for relieving airway compression were required more frequently after end-to-side type arch repair than after extended end-to-end anastomosis. More meticulous intraoperative evaluation and management are recommended in this type of repair.
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Introduction
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Patients with aortic arch obstructions have a high probability of a complex relationship between the arch vessels and the tracheobronchial tree that can result in abnormal geometry of the aortopulmonary space and airway compression [1–3]. Arch reconstruction can cause further narrowing of the aortopulmonary space, especially when tissue-to-tissue techniques are used extensively (Fig 1). Such airway compression frequently leads to long-term ventilator dependency or recurrent respiratory problems. Early detection and prompt management of airway problems improves prognosis.
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Fig 1. A 2-month-old girl with coarctation of aorta with ventricular septal defect and double-outlet right ventricle. (A) The oblique sagital computed tomography image of aorta before arch repair. The arrow represents the distance between ascending and descending aorta. (B) The postoperative oblique sagittal computed tomography image of aorta after end-to-side anastomosis arch repair. The arrow shows shortened distance between ascending and descending aorta.
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Heart computed tomography (CT) for preoperative evaluation is increasingly playing an important role in evaluation of cardiac anomalies, particularly those involving extracardiac vascular structures, and improves the likelihood of detecting potential airway problems preoperatively [4, 5].
The present study of patients with arch obstruction and intracardiac defects describes the usefulness of preoperative heart CT or postoperative CT and complementary intraoperative flexible bronchoscopy for airway evaluation and management.
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Patients and Methods
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Patients
Between January 2000 and January 2007, 202 consecutive infants with or without intracardiac defects underwent arch repair. The present study excluded patients with hypoplastic left heart syndrome, truncus arteriosus, arch anomalies without intracardiac defects such as double aortic arch, vascular ring, right pulmonary artery from the ascending aorta, simple coarctation of the aorta, and patients who had not undergone cardiac imaging studies. The medical records of the remaining 90 patients with arch obstruction and intracardiac defects who underwent CT were retrospectively reviewed for the study. The Institutional Review Board at Asan Medical Center, Seoul, Korea, approved this retrospective study and granted a waiver of informed consent.
Seventy-seven patients underwent preoperative CT (group 1). Thirteen patients underwent only postoperative (ie, after arch repair) CT (group 2). The group 2 patients did not undergo preoperative CT owing to poor general preoperative conditions such as high-level ventilator care, need for emergency surgery, incubator care, and unstable hemodynamics. Collated patient data included sex, age and weight at the arch repair operation and subsequent operations, duration of postoperative ventilatory support, intensive care unit stay, hospital stay, CT findings, flexible bronchoscopy examination findings if performed, and hospital and follow-up courses.
The preoperative arch anomaly diagnoses were aortic coarctation (n = 66) and interrupted aortic arches (n = 24). Combined intracardiac anomalies comprised ventricular septal defects (n = 59), double-outlet right ventricles (n = 9), atrial septal defects (n = 6), functional single ventricles (n = 6), complete atrioventricular septal defects (n = 4), aortic stenosis (n = 3), and transposition of great arteries (n = 3). There were 56 males and 34 females. Except for 3 patients, all patients were younger than 1 year old. The median age at the arch repair operation was 15 days (range, 3 to 315), and the median weight was 3.3 kg (range, 1.58 to 6.7 kg). Four patients had deletion 22q11.2 syndrome. One patient had cleft palate and another patient had multiple combined anomalies of duodenal web, ureterovesicojunctional obstruction, and polydactyly.
Surgical Procedure
The initial operation was arch repair with or without intracardiac defect correction. The type of arch repair depended on the type of arch anomaly, with 48 patients undergoing end-to-side anastomosis (ESA), 39 patients undergoing extended end-to-end anastomosis (EEEA), and 3 patients undergoing end-to-end anastomosis (EEA). One-stage total correction was performed in 57 patients, whereas 33 patients underwent staged operations for complex intracardiac anatomy.
For relieving airway compression, additional procedures were performed such as right pulmonary artery translocation anterior to the ascending aorta, aortopexy, extensive peribronchial dissection, Lecompte maneuver with ascending aorta augmentation with pulmonary autograft, and ascending aorta augmentation with a pulmonic autograft interposition.
Computed Tomography Protocol
All CT examinations were performed using a multislice (4- or 16-slice) spiral CT scanner. Four-slice CT data were obtained using the following parameters: 1.25-mm collimation, 3.75-m/s table feed, and 0.5-mm reconstruction interval. A weight-based, low-dose CT protocol (120 kVp, 30 to 80 mA) was used. Sixteen-slice CT data were obtained using a 0.75-mm detector collimation, 0.75-mm section thickness, 0.5-mm reconstruction interval, and 12-mm table feed; or using a 1.5-mm detector collimation, 2-mm section thickness, 0.7-mm reconstruction interval, and 24-mm table feed, as required for anatomic coverage, usually from the thoracic inlet level to the L 1-2 level. A weight-based, low-dose CT protocol (80 kVp and 40 to 170 effective mA) was used with automatic tube current modulation.
Flexible Fiberoptic Bronchoscopy
Once an airway problem was suspected after arch repair, flexible bronchoscopy, whenever possible, was performed in the operating theater by an anesthesiologist using a flexible fiberoptic bronchoscope (LF-DP; Olympus, Tokyo, Japan). Each procedure was recorded with a video camera (Sony DXC-C1; Tokyo, Japan). It was performed through an endotracheal tube just before separation from cardiopulmonary bypass. Once significant airway compression was detected, the traction of ascending aorta anteriorly was first used to relieve airway compression, and more extensive peribronchial dissection or mobilization was employed as the next step. If it was not effective, we considered individualized additional procedures for relieving airway compression. After additional procedure, confirmative flexible bronchoscopy is our routine nowadays.
Statistical Analysis
Statistical analysis was performed using SPSS version 12.0 (SPSS, Chicago, Illinois). All results were expressed as median and range or mean ± SD. One-way analysis of variance (ANOVA) was used to compare differences among the three groups. Unpaired Student's t tests and Mann-Whitney U tests were used for comparisons between two groups. The 
2 test was used to assess categorical variables. Logistic regression analysis was used to assess the impact of each potential risk factors. A p value less than 0.05 was considered to indicate a significant difference.
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Results
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A total of 157 CT examinations were performed in 90 patients with arch obstruction. Heart CT identified 44 of 90 patients (48.8%) with airway compression, 32 of 77 (41.5%) in group 1 and 12 of 13 (92.3%) in group 2 (Table 1). There were 21 cases (21 of 77, 27.2%) preoperatively detected in group 1, and 23 cases were newly detected after arch reconstruction (11 in group 1 and 12 in group 2). In group 1, 16 of 59 patients with aortic coarctation showed airway compression (27.1%) whereas 5 of 18 with interrupted aortic arches showed airway compression (27.7%). The interaction between type of arch obstruction and preoperative airway compression, however, was not significant.
The mean duration of ventilator support was 7.71 ± 16.61 days, of intensive care unit stay, 11.71 ± 18.72 days, and of hospital stay, 25.10 ± 23.04 days. These durations were similar for both group 1 and group 2 (Table 1).
Compression lesions were most commonly observed in the left main bronchus (n = 41), followed by the left lower lobe bronchus (n = 2) and the trachea (n = 1). Preoperatively, compressed lesions were observed between the right pulmonary artery and descending aorta in 4 cases, the left pulmonary artery and descending aorta in 4 cases, and the left pulmonary artery and heart in 2 cases; and other compression cases were by the enlarged left atrium or several vascular structures such as innominate artery, vertical vein, and left upper pulmonary vein. Postoperative detection identified compression in the shortened aortic arch (n = 8), between the right pulmonary artery and descending aorta (n = 3), the descending aorta and heart (n = 3), the left pulmonary artery and descending aorta (n = 1), and also nonvascular compression (n = 3).
Three types of arch reconstruction were performed, ESA (n = 48), EEEA (n = 39), and EEA (n = 3). After arch reconstruction, 16 after ESA type repair (16 of 48, 33.3%), 7 after EEEA (7 of 39, 17.9%), and none after EEA showed airway compression.
Fifteen patients (15 of 90, 16.6%) underwent additional procedures for relieving the compressed airway. In group 1, 7 patients underwent concomitant airway relieving procedures. Five of those patients were identified using preoperative CT, with 3 of those also identified using intraoperative flexible bronchoscopy. The remaining 2 patients were identified through intraoperative inspections after arch repair. The other 8 patients (2 in group 1 and 6 in group 2) who underwent additional procedures for relieving the compressed airway were identified using postoperative CT, which was performed because of recurrent failure of extubation (n = 3) or respiratory symptoms that required admission treatment (n = 5; Fig 2).
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Fig 2. This diagram summarizes the present study. Each path shows how preoperative (preop) and postoperative computed tomography (CT) evaluation, airway compression detection, and additional procedures were performed for each patient. (op = operation; pts = patients.)
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Unpaired Student's t tests showed significant differences between two groups (patient group needing additional airway relieving procedures versus patient group not needing additional procedures) in terms of duration of postoperative ventilatory support intensive care unit stay and hospital stay (Table 3).
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Table 3 Comparisons Between Patients Who Needed Additional Procedures for Airway Compression (n = 15) and Those Who Did Not (n = 75)
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The additional airway relieving procedures performed were right pulmonary artery translocation anterior to the ascending aorta (n = 9; Fig 3), aortopexy (n = 2), and extensive peribronchial dissection (n = 2). Tissue augmentation was needed in 2 cases of Lecompte maneuver with ascending aorta augmentation with pulmonary autograft (n = 1) and ascending aorta augmentation with a pulmonic autograft interposition (n = 1). All compressed lesions that needed additional procedures were left main bronchus. In terms of type of arch repair, additional procedures for relieving airway compression were performed for 10 patients (10 of 15, 66.6%) with ESA and 5 (5 of 15, 33.3%) with EEEA. For 7 patients with ESA and 4 with EEEA type arch repair, a left main bronchus compression was observed in the middle of the right pulmonary artery and the descending aorta. For 2 patients with ESA, it was relieved by aortopexy, and the other 9 patients needed right pulmonary artery translocation. In 2 patients with interrupted aortic arches, markedly shortened arch space and left main bronchus compression developed after ESA type arch repair. To augment length of ascending aorta or arch space, pulmonic autograft as tube graft was used to relieve airway compression. In 1 patient with ESA and 1 with EEEA, bronchus mobilization by extensive dissection relieved airway compression.
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Fig 3. A 3-day-old female baby with coarctation of aorta and ventricular septal defect. Preoperative computed tomography (CT) images: (A) airway volume-rendered image. Complete luminal compression appears in the left main bronchus (arrow); (B) axial CT image shows that left main bronchus is compressed by right pulmonary artery (circle). Postoperative CT images: (C) image of relieved airway compression (arrow); (D) axial image shows anteriorly translocated right pulmonary artery and relieved left main bronchus compression (circle).
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The mortality rate was 8.8% (8 of 90), with no deaths being related to airway problems.
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Comment
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Congenital cardiac and aortic arch anomalies often result in pediatric airway compression [6]. The normal aortic arch produces a wide and harmonious curve that encircles the origin of the right pulmonary artery and the left main bronchus [1]. Arch obstructions have a high probability of causing abnormal geometry of the aortopulmonary space and airway compression [1–3]. Arch repair involving complex reconstruction of the aorta can cause relative shortening of the space between ascending and descending aorta or decrease the aortopulmonary space, resulting in airway compression.
The present study found that preoperative CT, examining 77 patients with arch obstruction and intracardiac defects, identified airway compression in 21 of the 77 (27.2%), and postoperative CT newly identified airway compression in 23 of 69 patients (33.3%), which is a rather high incidence. Moreover, early detection and management of airway compression appeared to decrease morbidity related to airway problems. Among many ways of evaluating airway problems, CT is a safe, fast, effective, and noninvasive first-line diagnostic tool for airway evaluation, and plays an important supplementary role in evaluation of patients with congenital heart disease [4–8]. Computed tomography is superior to bronchoscopy as it shows specific anatomic relationships with excellent image quality. Accurate preoperative evaluation appears to be useful for prompt detection and planning of airway management. Concomitant surgical intervention for airway compression can also reduce the number of operations. In the present series, 7 group 1 patients underwent concomitant additional surgical procedures for airway compression, and required no subsequent surgery. In contrast, 2 of the group 2 patients required further surgery only owing to significant respiratory symptoms related to airway compression. It may be that such additional surgery could have been avoided had preoperative heart CT been performed in those patients.
Postoperative respiratory problems can be difficult to assess and can be confused with secondary bronchomalacia, which is very similar to airway compression in clinical presentation. Such confusion can increase morbidity and hence the need for measures such as prolonged ventilator support and prolonged intensive care unit or hospital stay [9]. As shown in Table 3, the patients who needed additional procedures for airway problems required longer duration of ventilator support, intensive care unit stay, and hospital stay. Although uncommon, extrinsic airway compression must be considered in children with congenital heart disease as it is an important cause of respiratory insufficiency [3, 10]. Upon suspicion of airway problems, prompt evaluation and correction are necessary to decrease morbidity.
In this study, although airway compression was mostly detected using CT, intraoperative flexible bronchoscopy was helpful in 10 cases. Flexible bronchoscopy plays a complementary role to radiologic images [10, 11], and is very useful when applied in the operating room for confirmation of airway compression after arch repair before weaning from cardiopulmonary bypass.
In terms of arch repair type, although several reports, including the Congenital Heart Surgeons Society (CHSS) study [12–14], were devoted to a direct anastomosis with patch augmentation for arch reconstruction, a recent report from Texas Children's Hospital showed good results without patch augmentation [15]. We also could manage all the patients with direct tissue-to-tissue techniques.
For 15 patients who had needed additional procedures (15 of 90, 16.6%), ESA type arch repair was observed more frequently than EEEA (10 of 15 [66.6%] versus 5 of 15 [33.3%]), although the difference was not statistically significant.
Several surgical interventions can be used to prevent or relieve airway compression, including anterior translocation of the right pulmonary artery over the aorta [16–19], aortopexy [20], and graft interposition [21] between the ascending and descending aorta. All such procedures are considered in our institution depending on the nature of the compression. In 2 patients with interrupted aortic arches, pulmonic autograft was used as tube graft to augment length of ascending aorta or the space between ascending and descending aorta for relieving compressed airway. Except for these 2 patients, a direct tissue-to-tissue anastomosis technique was maintained, and other additional procedures could relieve the airway compression. All of them required no further airway management and had no airway-related problems. Choosing the appropriate management according to the type of airway problem is important for effective treatment.
In conclusion, airway problems can occur in patients with arch obstruction and intracardiac defects. Preoperative CT and intraoperative complementary bronchoscopy were very useful for identifying and fixing the airway problems. Additional procedures for relieving airway compression were more frequently needed in ESA type arch repair. Therefore, more meticulous intraoperative evaluation and management are recommended in this type of repair. If airway compression is detected, aggressive management is required to decrease postoperative morbidity and mortality related to airway problems. (Table 2).
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Table 2 Comparisons Among Three Groups of Patients Who Underwent Arch Repair by Extended End-to-End Anastomosis (EEEA), End-to-Side Anastomosis (ESA), and End-to-End Anastomosis (EEA)
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Abstract
Introduction
