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Ann Thorac Surg 2000;69:881
© 2000 The Society of Thoracic Surgeons
a Thorax Center, University Hospital Groningen, Hanzeplein, 1, 9700RB Groningen, The Netherlands
e-mail: t.ebels{at}thorax.azg.nl
Invited commentary
Doctor Allen and coworkers describe an interesting variation of the subclavian flap repair of aortic coarctation. Their short-term results are excellent, which warrants placing their technique in the context of contemporary coarctation repair. With a mean follow-up of 25 months in infants less than 18 weeks, these results are short-term, compared to the childrens life expectancy. Although recoarctation is often, but not always, described early after primary correction, other sequelae, particularly aneurysm formation can occur late. The unusual inclusion age limit of 18 weeks, is unexplained in the current paper, and one wonders what happened to older patients. As a variation of the subclavian flap technique, the coarctation tissue is left in place (which can create intraluminal unevenness) by scar formation and thus possibly turbulence–the long term effects of which remain to be seen. The authors do not report Doppler investigation of flow patterns at the site of repair. Long term results of patch angioplasty for coarctation revealed a disturbingly high incidence of late aneurysms, which led to its subsequent fall into oblivion. Patch angioplasty has a fundamental similarity with subclavian flap angioplasty, in leaving coarctation tissue in place, while widening the site of the coarctation.
The notion that an underdeveloped aortic arch usually grows after repair of the coarctation is endorsed by several studies. Growth to normal size then appears to be the consequence of increased flow after coarctation repair and ductal closure. Extended aortic arch repair is only indicated for severely hypoplastic arches, usually in children in severe cardiac failure. Since extended repair also is associated with an increased risk, I wholeheartedly support the authors policy in this respect.
I was somewhat surprised, however, by the authors assertion that resection and end-to-end anastomosis of aortic coarctation is characterized by a "complex circumferential suture line, more extensive mobilization and longer cross clamp time." On the contrary, my experience is that mobilization of the vessels at this age is relatively straightforward and easy. Resection removes all coarctation tissue, so that a smooth anastomosis can be made with normal vascular tissue. The isthmus is usually resected along with the coarctation, so that the anastomosis is then located at the end of the aortic arch. The circumferential suture is easily done with a monofilament suture in a cross clamp time closer to 10 than to 15 minutes. Therefore, my personal preference remains with resection of all coarctation tissue and end-to-end anastomosis, not only because it is easy, but above all because of its proven long-term result. Nonetheless, I compliment the authors on the publication of an imaginative technique and excellent results.
Related Article
Ann. Thorac. Surg. 2000 69: 877-880.
This article has been cited by other articles:
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  R. J. Walhout, J. C. Lekkerkerker, G. H. Oron, G. B.W.E. Bennink, and E. J. Meijboom Comparison of surgical repair with balloon angioplasty for native coarctation in patients from 3 months to 16 years of age Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 722 - 727. [Abstract] [Full Text] [PDF]
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