Ann Thorac Surg 1997;64:1785-1786
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
James L. Monro, FRCS
Department of Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton General Hospital, Southampton S016 6YD, England
See also page 1782.
This report of a large series of infants with type B interrupted aortic arch undergoing a two-stage repair between 1980 and 1995 underlines several points in the approach to this difficult condition. A survival of 85% at 1 year is better than some reports of one-stage repair. These are good results and demonstrate considerable surgical expertise, as often the ascending aorta in these patients is only 5 or 6 mm in diameter and anastomosing a graft to such a small ascending aorta without bypass is difficult. It would be interesting to know if other types of interrupted arch were treated during the same time period and what the results were. The incidence of aberrant right subclavian artery (63%), bicuspid aortic valve (85%), and DiGeorge syndrome (78%) are rather higher than previously reported. However, the incidence of the development of subaortic stenosis in survivors (18%) is somewhat lower than after correction in some series. Certainly subaortic stenosis is one of the most difficult problems encountered in patients with interrupted arch, and if the incidence is really less after a two-stage repair this might support the two-stage repair approach.
As Mainwaring and associates mention, inserting a graft that will not grow is one of the major drawbacks to this approach, and all patients will require at least a third operation for graft replacement. Satisfactory results have been achieved by others with turning down the left carotid artery or turning up the left subclavian artery, thus forming a new arch with growth potential. Surely if a two-stage approach had to be used (as with an associated univentricular heart) it is better to avoid synthetic tubes. However, I find it most surprising that Mainwaring and associates have only changed their policy to a one-stage repair as recently as 1995. Trusler showed us how to do this operation in 1975 with an approach from the front using bypass, with closure of the ventricular septal defect and end-to-side anastomosis of the descending to ascending aorta. The one-stage repair cannot therefore be considered a "recent" development as suggested by Mainwaring and associates; I and many other surgeons have been using a one-stage approach with good results for more than 20 years.
Related Article
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Mid- to Long-Term Results of the Two-Stage Approach for Type B Interrupted Aortic Arch and Ventricular Septal Defect
- Richard D. Mainwaring and John J. Lamberti
Ann. Thorac. Surg. 1997 64: 1782-1785.
[Abstract]
[Full Text]
