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Eur J Cardiothorac Surg 1999;14:235-242
© 1999 Elsevier Science NL

Results of primary and two-stage repair of interrupted aortic arch

Tomá Tláskal, Bohumil Huín, Jaroslav Hruda, Jan Marek, Václav Chaloupeck, Martin Kostelka, Jan Janouek, Jan kovránek

Kardiocentrum, University Hospital Motol, V úvalu 84, 150 06 Prague 5, Czech Republic

Received 30 March 1998; received in revised form 10 June 1998; accepted 16 June 1998.

Corresponding author. Tel.: +420 2 24432900; fax +420 2 24432920; e-mail: tomas tlaskal@lf motol.cuni.cz

	Abstract

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Objective: Early results of primary and two-stage repair of interrupted aortic arch have improved. Experience with different surgical approaches should be analysed and compared. Methods: Forty neonates and infants with interrupted aortic arch underwent primary repair (19 patients) or palliative operation (21 patients). Twenty (50%) patients were followed-up for 5.1±4.3 years. All patients were regularly examined with the aim of determining clinical development, presence of residual lesions or complications and need for re-intervention. Aortic arch and the left ventricular outflow tract growth were assessed by echocardiographic examination. Data from hospital and outpatient department records were analysed. Results: The early mortality was 61.9% after palliative operations and 36.8% after the primary repair. Presence of complications (P<0.001), earlier year of surgery (P<0.01), bad clinical condition and acidosis (P<0.05) represented statistically significant risk factors for death in the whole series. In seven (87.5%) out of eight early survivors, after the initial palliative operation, closure of ventricular septal defect and debanding were done, and in three (37.5%) patients, re-operation for aortic arch obstruction was also required. Out of 12 patients, after the primary repair, one required early re-operation for persistent left ventricular outflow tract obstruction and two needed late re-intervention for left bronchus obstruction. In three (25%) patients, after the primary repair, left ventricular outflow tract obstruction with a maximal systolic pressure gradient higher than 30 mmHg developed. At present, all 20 early survivors are alive. Five patients, after palliative operation, are in NYHA class I, but in three patients, who are in class III or IV, the outcome is influenced by severe complications. All patients after the primary repair are in class I or II. Conclusions: Our experience confirmed better results after the primary repair of interrupted aortic arch, which was associated with lower mortality, prevalence of severe complications and need for re-intervention. Higher prevalence of subaortic stenosis after primary repair could be explained by patient selection early in our experience. We recommend the primary repair of interrupted aortic arch and associated heart lesions in neonates, however, in unfavourable conditions an individualised surgical approach with initial palliative surgery should be considered.

Key Words: Interrupted aortic arch • Heart surgery • Primary repair • Two-stage repair • Residual lesions • Mid-term results

	Introduction

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Interrupted aortic arch (IAA) represents a critical ductus dependent congenital heart disease with high mortality in the neonatal period. During the last several years, results of both the primary and two-stage repair of IAA improved, and the early mortality in some centers approached 10% [1] [2] [3]. The long-term fate of early survivors after the primary or two-stage repair of IAA and associated heart lesions remains, however, open. Some studies reported a high risk of development of re-stenosis at the site of aortic anastomosis and left ventricular outflow tract obstruction (LVOTO) [1] [2] [4] [5]. Other residual lesions and non-cardiac complications were also described [3] [5] [6]. Complications and residual lesions often require re-intervention and represent a danger of late death [3] [7] [8]. We have analysed in-hospital and follow-up data in patients after palliative or corrective operations for IAA operated on in one center.

	Materials and methods

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Patients
Between 1977 and 1997, a total of 56 neonates and infants aged from 1 day to 85 days (median 5 days) with IAA were seen in the Kardiocentrum, University Hospital Motol, Prague. Sixteen (28.6%) patients were not indicated for surgery because of very complex morphology (seven patients, 43.8%), critical clinical condition (five patients, 31.2%), severe hypoplasia or tubular stenosis of the left ventricular outflow tract and/or aorta (four patients, 25.0%). The majority of these patients were seen in our center early in our experience. Six (37.5%) non-operated patients had severe LVOTO, five had double-outlet right ventricle (DORV) and four had functionally single ventricle.

Patients indicated for palliative operation (group I)
Forty (71.4%) patients were indicated for a palliative operation or the primary repair and the basic data are summarized in Table 1. In 21 (52.5%) out of 40 operated patients, a palliative reconstruction of the aortic arch was indicated between 1978–1997. Fifteen (71.4%) patients were in critical clinical condition. IAA was of type A in two (9.5%), and type B in 19 patients (90.5%). In five patients with type B IAA, an aberrant right subclavian artery was present. Right-sided distal part of the aortic arch and descending aorta was observed in two patients. Ventricular septal defect (VSD) was present in all patients, LVOTO in two (9.5%), transposition of the great arteries (TGA), DORV and left pulmonary branch stenosis in one (4.8%) patient each (Table 2). Signs of DiGeorge syndrome were found in 13 (61.9%) patients, gastrooesophageal reflux was present in one and fracture of parietal bone in another neonate.

Surgical methods
Palliative operations (group I)
Palliative reconstruction of the aortic arch without extracorporeal circulation was indicated in 21 patients. Only two palliative operations were performed after 1993 when the protocol of a routine primary repair of IAA was introduced. In 19 (90.5%) patients with the left, and in two patients (9.5%) with the right aortic arch, the right lateral thoracotomy was performed. Palliative procedures usually consisted of reconstruction of the aortic arch and pulmonary artery banding (Table 3). In 10 (47.6%) patients with type B and a longer distance between the ends of aorta, a vascular prosthesis (5–8 mm Dacron or Gore-Tex) was used ( Fig. 1 ). The prosthesis was sutured between the base of the left carotid artery and the descending aorta. In five (23.8%) patients, direct anastomosis between the left carotid artery and the descending aorta was performed ( Fig. 2 ). In two (9.5%) patients with type A direct aortic anastomosis was possible. In one (4.8%) patient the arch was reconstructed using the left subclavian artery (Park procedure). In one patient with right-sided descending aorta a direct end-to-end anastomosis between the right subclavian and the right carotid artery was successful ( Fig. 3 ). In one patient, not more than pulmonary artery banding was done and, in the last patient, explorative thoracotomy was performed because of severe hypoplasia of the ascending aorta.

View larger version (15K): [in this window] [in a new window]   Fig. 1. Scheme of reconstruction of interrupted aortic arch using a Gore-Tex prosthesis between the left carotid artery and descending aorta.

View larger version (15K): [in this window] [in a new window]   Fig. 2. Scheme of reconstruction of interrupted aortic arch using a direct anastomosis between the left carotid artery and the descending aorta.

View larger version (16K): [in this window] [in a new window]   Fig. 3. Scheme of reconstruction of interrupted aortic arch with the right descending aorta by a direct end-to-end anastomosis between the right carotid artery and the right subclavian artery.

View larger version (16K): [in this window] [in a new window]   Fig. 4. Scheme of the primary repair of interrupted aortic arch with ventricular septal defect consisting of reconstruction of the aortic arch by a direct anastomosis between the descending and the ascending aorta and closure of the atrial and ventricular septal defect with patches.

View larger version (18K): [in this window] [in a new window]   Fig. 5. Scheme of the primary repair of interrupted aortic arch with persistent truncus arteriosus consisting of reconstruction of the aortic arch by a direct anastomosis between the descending and the ascending aorta, closure of ventricular septal defect with a patch and reconstruction of the right ventricular-to-pulmonary artery continuity with a pulmonary homograft.

View larger version (16K): [in this window] [in a new window]   Fig. 6. Scheme of the primary repair of interrupted aortic arch with transposistion of the great arteries consisting of reconstruction of the aortic arch by a direct anastomosis between the descending and the ascending aorta and arterial switch operation.

Post-operative follow-up
Twenty early survivors were followed up and examined clinically with determination of growth, pressure measurements on arms and legs and ECHO examination of the heart and the aorta. The complete ECHO study by two-dimensional, M-mode, Doppler and color flow mapping was concentrated to determine the left ventricular size, left ventricular posterior wall thickness, and diameters of the left ventricular outflow tract, aortic anulus, ascending aorta, aortic arch and the site of aortic anastomosis. Special attention was paid to measurements of pressure gradients at the level of the left ventricular outflow tract and the aortic arch, and detection of residual lesions.

	Results

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Early mortality
Twenty (50.0%) out of 40 operated patients died in the course of 30 days after surgery. Out of 21 palliated patients (group I) 13 (61.9%) patients died, and out of 19 corrected patients (group II), seven (36.8%) died (Table 2Table 3). Early results depended on experience: out of 29 patients operated on between 1978–1993, nineteen (65.5%) patients died, and out of 11 patients operated on between 1994–1997, one (9.1%) patient died. By both univariate and multivariate statistical methods, presence of pre-operative complications (P<0.001), earlier year of surgery (P<0.01), bad clinical condition (P<0.05) and acidosis (P<0.05) represented main risk factors of death in the whole series. The difference between mortality in groups I and II was not statistically significant. The presence of DiGeorge syndrome did not have any influence on mortality in either group.

Out of 13 patients who died after palliative surgery (group I), six patients died from low cardiac output syndrome (LCO), two from sepsis and one from multiple organ failure, ventricular fibrillation, hypoxia, consequences of trauma and aspiration, respectively. Out of the seven patients who died after the primary repair (group II), four died from LCO and three died from sepsis.

Eight (38.1%) early survivors after initial palliative operation, and 12 (63.2%) patients after the primary repair of IAA were followed up for 0.5–15.1 years (mean 5.1±4.3 years, median 3.5 years) after the first surgery. During the follow-up no patient died.

Re-interventions
Re-interventions after palliative operation (group I)
One patient required re-operation several hours after surgery for obstructed aortic anastomosis between the left carotid and the descending aorta, and seven (87.5%) out of eight survivors of palliative operation required a total of 12 late re-interventions. Seven late re-operations were done for VSD closure and debanding. In two patients reconstruction of pulmonary branch stenosis was also required. Aortic valvotomy and patch enlargement of the ascending aorta were necessary in another patient. In three patients a second re-intervention was indicated for obstruction at the aortic arch. In one of them, anastomotic stricture could be resected. In two patients, after previous graft interposition procedure, re-operation required use of an extra-anatomic by-pass between the ascending and the descending aorta (16 mm Dacron or Gore-Tex prosthesis). Two patients needed balloon dilatation of stenotic aortic anastomosis.

Re-interventions after the primary repair (group II)
Four patients after the primary repair necessitated re-operation in the course of 30 days after surgery (two for bleeding, one for a residual LVOTO and one for a phrenic paralysis). Two (16.7%) late re-operations were required for left bronchus obstruction 215 and 187 days, respectively, after the repair. In one of them, the bronchial obstruction was caused by aneurysmatically dilated aortic root due to severe aortic regurgitation seven months after repair of truncus arteriosus with IAA. In the second patient, the bronchial obstruction was caused by a dilated pulmonary trunk and the neoaortic arch. Extensive surgical procedure with resection of the aortic aneurysm, replacement of the ascending aorta with a 14 mm Dacron conduit, replacement of the aortic valve with a mechanical prosthesis, plastic reconstruction of right pulmonary artery and exchange of the homograft pulmonary artery were performed in the first patient [10]. In the second patient, plication of a dilated pulmonary trunk and angiopexy of the pulmonary trunk and the aortic arch were necessary.

Post-operative development
The follow-up of patients after initial palliative operation (group I) was characterized by development of an important systolic pressure gradient at the aortic arch in five patients. Balloon angioplasty was performed in two patients and re-operation in three patients. In two patients, after palliative operation, severe neurological complications developed. In the first patient, it occurred after balloon angioplasty for aortic arch stenosis two months after original surgery. In this patient dysfunction of the left ventricle also occurred. In the second patient, a prolonged cardiopulmonary resuscitation following VSD closure and debanding resulted in severe brain damage. In two patients, stenosis of one pulmonary branch developed after pulmonary artery banding and prompted the second stage surgery.

In patients after the primary repair (group II), clinical development was more favourable but this group was followed-up for a shorter period of time (0.5–4.6 years, median 2.7 years) in comparison with the two-stage group followed for 0.6–15.1 years (median 9.4 years). In only one patient, after the primary repair of IAA an important systolic pressure gradient at the site of the aortic anastomosis developed which was successfully relieved by angioplasty. In this patient, however, LVOTO with a maximal Doppler pressure gradient of 90 mmHg also developed. The patient remains in a very good clinical condition but she will soon be considered for re-operation. LVOTO also developed in two other patients after the primary repair, with gradients of 66 and 46 mmHg, respectively. These children were not indicated for re-operation. In two of the three patients who have LVOTO today, subaortic stenosis was present at the time of repair, and in both of them myectomy was performed with good early result. Early and mid-term results in either group were not influenced by DiGeorge syndrome. Late complications and outcome of patients after initial palliative operation and the primary repair are summarized in Table 4Table 5.

Doppler echocardiographic examination showed a maximal systolic pressure gradient on the aortic arch between 20–54 mmHg in four patients after initial palliative operation, and between 15–47 mmHg in three patients after the primary repair. Maximal systolic pressure gradient at the left ventricular outflow tract was 18 and 20 mmHg, respectively, in two patients originally palliated, and between 14 and 90 mm Hg in six patients after the primary repair. In three of them it was higher than 30 mmHg (46, 66, and 90 mmHg, respectively).

	Discussion

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Early and mid-term results
Certainly, it is very difficult to compare results of two approaches in severely ill neonates operated on under incomparable conditions in two different eras. This fact will surely limit the validity of findings in this study. In the series of patients after palliative operations, the surgical mortality was higher in comparison with the group of patients who underwent the primary repair, but the difference was not statistically significant. The higher mortality was influenced by less experience, worse pre-operative clinical condition and presence of other era-related risk factors as proved by statistical analysis. In all patients but one, after a palliative procedure, the second stage procedure in extracorporeal circulation was already done without mortality. Two patients required angioplasty for restenosis at the site of aortic anastomosis. In two out of five patients in whom the aortic arch was reconstructed using a prosthetic graft, second re-operation with construction of an extra-anatomic by-pass was required. At present, five patients are in NYHA class I, but in three patients, who are in class III and IV, respectively, severe neurological or lung complications are present.

In the group of patients after the primary repair, the early post-operative course often required secondary chest closure, inotopic support and prolonged ventilation. In two patients, re-operation for the left bronchus obstruction was necessary but, in only one patient, signs of stenosis at the aortic arch developed. More important, however, was the finding of a progressive subaortic stenosis with a systolic pressure gradient of more than 30 mmHg which was found in three (25%) patients after the primary repair. Two of these patients had LVOTO at the time of the first surgery. The unusual higher occurrence of LVOTO after the primary repair in comparison with a staged approach was probably caused by patient selection early in our experience when patients with severe LVOTO and/or aortic hypoplasia were not indicated for surgery. During the follow-up no patient died and all survivors are in NYHA class I or II.

Stenosis at the aortic arch
Karl reported a 20% prevalence of aortic arch obstruction [1]. In a 10-year follow-up study after the repair of IAA from Paris, 27.2% prevalence of aortic arch gradient higher than 30 mmHg was reported [3]. In the Sell's series aortic arch obstruction developed in 15 (47%) out of 32 early survivors and, opposite to our experience, it was more common in patients with a direct aortic anastomosis than in patients in whom an interposition graft had been used [4]. Sell indicated direct aortic anastomosis and earlier date of surgery to be incremental risk factors for recurrent or persistent aortic arch stenosis.

Most often in our experience, the development of a systolic pressure gradient across the aortic arch was caused by a small vascular prosthesis used for arch reconstruction in the neonatal period. In these patients, an extra-anatomic bypass between the ascending and the descending aorta is usually required. On the other hand, a real stricture of the aortic anastomosis may develop when anastomosis remains under tension due to inadequate mobilisation of the aorta, after the use of a biological glue or inadequate excision of the ductal tissue.

Balloon angioplasty represents the method of choice in recurrent aortic arch stenosis [1] [3] [4]. If angioplasty is not successful, different surgical methods may be used as described by Monroe [5]. Resection of a stenotic segment with end-to-end anastomosis represents the preferred procedure which is, however, seldom possible. Construction of an extra-anatomic bypass between the ascending and the descending aorta using a Gore-Tex or a Dacron graft represents the most widely used method, but, subclavian or carotid turn-down procedure or patch enlargement of the stenotic area might be also considered [5].

Left ventricular outflow tract obstruction
Serraf recently reported a surprisingly low prevalence (3.6%) of LVOTO during a 10-year follow-up of 55 survivors after primary or two-stage repair of IAA [3]. Sell, in contrast, reported a 42% incidence of development of this complication in course of the first 3 years after both the primary and the two-stage repair of IAA [4]. The difference between the two studies could be partially explained by a different surgical strategy in Boston and Paris. The Boston series, however, also comprises patients operated on more than 20 years ago under incomparable conditions.

The danger of the development of LVOTO in IAA is based on the primary morphological changes of the left ventricular outflow tract and the aortic valve which are often narrow in IAA [11] [12] [13]. The prevalence of LVOTO is higher in type B associated with aberrant right subclavian artery [12] [13]. Geva recently reported the possibility of an echocardiographic prediction of the risk of development of this complication by exact measurement of the left ventricular outflow tract dimensions in different projections, which could help during the surgical treatment and the post-operative management of patients with IAA [14].

Basically, however, there is no general agreement as far as the need for primary intervention on a narrow left ventricular outflow tract is concerned. Jonas does not recommend any intervention unless the subaortic stenosis is extreme, which means the diameter of the left ventricular outflow tract is less than about 3.5 mm in a neonate [2] [13]. A relatively simple method of prevention of the LVOTO development based on placement of a patch for VSD closure to the left side of the conal septum without myectomy was recommended by Starnes's group [15]. Good experience with myectomy of the conal septum from the right atrial or ventricular approach was reported by Ilbawi and Bove [16] [17].

Left bronchus compression
The development of left bronchus compression after correction of IAA was described by several authors [1] [3] [5] [6]. Usually, it develops soon after the primary repair as a result of inadequate mobilisation of the aorta and construction of a direct aortic anastomosis low and under tension. The second possible cause is represented by the presence of residual heart lesions leading to cardiomegaly, dilatation of the left atrium, pulmonary trunk or even the aortic root, as we have recently described [10]. The most commonly used method to treat this dangerous complication is aortopexy and/or use of a vascular graft to release aortic arch tension [1] [3] [5] [6].

Residual heart lesions
Residual VSD requiring re-operation was described by several authors [3] [18] [19]. Usually, however, small VSD may close spontaneously as we have observed in two patients. Valvar aortic stenosis may develop after operation in patients with a bicuspid aortic valve and in patients who have narrow ascending aorta and/or subaortic region [13]. Some degree of aortic regurgitation was present in all patients with persistent truncus arteriosus before surgery and it persisted during the follow-up. In all three patients who survived correction of PTA with IAA, right pulmonary branch stenosis also developed. Only in one patient, however, was plastic repair needed. A mild valvar and supravalvar pulmonary stenosis was found in the child after the primary repair of IAA and arterial switch operation for TGA [20].

Mid- and long-term clinical condition
In their multi-institutional study, Jonas and co-workers found 63% survival at four years after repair of IAA and VSD in a group of 174 patients [2] but, in more recent studies, actuarial survival probabilities of between 70 and 75% at 5 years [1] [3] have been reported. In our experience comprising patients with IAA with different associated heart lesions, 50% of operated patients are alive at 0.5–15.1 years (median 3.5 years) after the first operation. In the group of patients after the primary repair, 63.2% are alive at 0.5–4.6 years (median 2.7 years) following surgery.

It seems that the long-term outcome of patients after both the primary and two-stage repair of IAA will be influenced especially by the development of LVOTO, which will probably require additional surgical interventions in 20–40% of early survivors. The clinical development may be affected also by the pre-operative clinical condition and presence of co-existent non-cardiac diseases [1] [3] [8] [19] [21]. The long-term influence of deep hypothermic circulatory arrest on neurological and psychomotor development will require additional studies, as signs of chorea and other CNS functional lesions may occur relatively late after surgery with a hypothermic low flow bypass or circulatory arrest [21] [22]. Patients with DiGeorge syndrome and other associated non-cardiac malformations will need detailed genetic, immunological, endocrinological and metabolic studies with an individualised medical treatment and follow-up [8] [21].

	Conclusions

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Our experience has confirmed better results with the primary repair of IAA, which had lower mortality, lower prevalence of severe late complications and need for re-intervention. In the future, re-interventions for LVOTO will be certainly required. Neurological and psychomotor development of patients after repair of IAA necessitates further studies. The long-term fate of patients after the repair of IAA depends on many factors but, more than 50% of these patients can be expected to maintain normal lives without handicaps and significant limitations. Based on our recent experience, we prefer the primary repair of IAA but in premature neonates weighting less than 1500g, in the presence of severe infection, intracranial hemorrhage, multiple organ failure and very unfavourable heart and/or aortic morphology, we would consider a two-stage repair.

	Acknowledgments

 
The study was supported by grants Nos. 2905-3, 2045-3 and 3919-3 IGA MZ R (Intern Grant Agency of the Ministry of Health of the Czech Republic).

	References

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