Eur J Cardiothorac Surg 2001;20:1202-1206
© 2001 Elsevier Science NL
Surgery for aortic coarctation: a 30 years experience
Antonio F. Corno,
Umberto Botta,
Michel Hurni,
Maurice Payot,
Nicole Sekarski,
Piergiorgio Tozzi,
Ludwig K. von Segesser
Centre Hospitalier Universitaire Vaudois (CHUV), 46 rue du Bugnon, CH-1011 Lausanne, Switzerland
Received 6 July 2001;
received in revised form 3 September 2001;
accepted 3 September 2001.
Corresponding author. Tel.: +41-21-314-2280; fax: +41-21-314-2278
e-mail: antonio.corno{at}chuv.hospvd.ch
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Abstract
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Objective: A retrospective study to review the experience of a single center with surgery for aortic coarctation over a period of 30 years (1970–1999). Methods: Criteria for inclusion: (a) aortic coarctation, isolated or associated with congenital heart defect; (b) surgery between 1970 and 1999. Data recorded: (1) date of surgery; (2) age at surgery; (3) associated lesions; (4) surgical technique; (5) simultaneous surgical procedures; (6) early and late surgical results in term of: (a) deaths; (b) need for reoperation because of re-coarctation or other cardiac lesion; (c) residual/recurrent pressure gradient, evaluated at cuff/Doppler at rest; (d) systemic hypertension, requiring medical treatment. Results: One hundred and forty-one patients underwent surgery for aortic coarctation: 30 neonates, 29 infants, 45 children and 37 adults. Associated lesions were found in 8/37 (=21.6%) adults and in 73/104 (=70.1%) pediatric patients. There were no hospital deaths. During the follow-up there were one late death in the adults group (1/37=2.7%) and three late deaths in the pediatric group (3/104=2.9%), all unrelated with aortic coarctation. Re-operation because of re-coarctation occurred only in ten late survivors of the pediatric group (10/101=9.9%), 9/10 operated on before 1980 (P<0.00001). End-to-end anastomosis, enlarged to the aortic arch in neonates, was associated with the lowest incidence of re-coarctation (P<0.005). A significant (>20 mmHg at rest) pressure gradient was found in none of the adults, and in seven of the 91 pediatric patients (7/91=7.7%) late survivors. Three adults (3/36=8.3%) late survivors are on medical treatment to control systemic hypertension. Conclusions: The long-term results of our retrospective study confirm that surgery has to be considered the gold standard for the treatment of aortic coarctation. The interventional angioplasty techniques have to provide long-term outcome at least similar to the results obtained with surgery.
Key Words: Aortic coarctation • Balloon dilatation • Cardiac surgery • Congenital heart defects • Re-coarctation • Re-operation
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1. Introduction
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As interventional angioplasty techniques have been refined, a non-surgical approach to both the unoperated aortic coarctation [1–4] and the post-surgical re-coarctation [5–8] have been proposed and utilized, in children and in adults [1–8]. Several reports have documented both the efficacy and the safety of the procedure of interventional cardiology [1–8]. However, there are very little data available on the long-term follow-up of patients treated with angioplasty techniques [5,8]. Before the introduction of interventional angioplasty, in our as well as in other units, surgery was the treatment of choice for native aortic coarctation as well as for re-coarctation in both children and adults [9–16]. We therefore decided to perform a retrospective study in order to review the single center experience with surgery for aortic coarctation over a period of 30 years.
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2. Materials and methods
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Criteria for inclusion in the study were: (a) the presence of aortic coarctation, either isolated or associated with other congenital heart defect; (b) surgery performed between 1970 and 1999, in patients of any age. The sources of clinical data were: (a) hospital documents; (b) direct contact with the patients or their families in case of children; (c) direct contact with the referring cardiologist or pediatric cardiologist; (d) direct contact with the family physician or pediatrician; (e) deaths registry.
For each patient the following data were recorded: (1) date of surgery; (2) age at surgery; (3) associated lesions; (4) type of surgical technique; (5) simultaneous surgical procedures; (6) early and late surgical results in terms of: (a) deaths; (b) need for re-operation because of development of re-coarctation or other cardiac lesion; (c) residual/recurrent pressure gradient, evaluated at cuff/Doppler at rest: a pressure gradient >20 mmHg was considered significant; (d) systemic hypertension, requiring medical treatment. Because of the hospital rules, the patients were divided into pediatric (<15 years of age) and adults (>15 years of age), according to the age at hospital admission for surgery.
From 1970 to 1999 104 pediatric patients and 37 adult patients underwent surgery for aortic coarctation. The demographic data were the following: 30 neonates (<1 month of age), 29 infants (1 month–1 year), 45 children (1–15 years), and 37 adults (mean age=27 years, range 16–51 years). The date of surgery for both pediatric and adult patients is reported in Fig. 1
, where we arbitrarily divided the entire experience in three periods of 10 years: 1970–1979, 1980–1989, and 1990–1999. Associated lesions were found in 8/37 (=21.6%) adults and in 73/104 (=70.1%) pediatric patients (Tables 1 and 2). The end point of the study was that in all the patients either death of last clinical observation with blood pressure cuff and/or Doppler measurement within the last 6 months of year 2000 was observed.
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Fig. 1. Distribution of the number of operation for aortic coarctation over three different periods of 10 years.
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3. Results
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Different types of surgical techniques were utilized (Fig. 2
), and their distribution is listed in Tables 3 and 4.
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Fig. 2. (A) Subclavian flap. (B) Resection and end-to-end anastomosis enlarged to the aortic arch. (C) Resection and end-to-end anastomosis. (D) Pyloroplasty type. (E) Patch aortoplasty. (F) End-to-end conduit interposition. (G) Left subclavian artery to descending thoracic aorta conduit interposition.
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Simultaneous surgical procedures were associated only in pediatric patients: through left thoracotomy, closure of patent ductus arteriosus in 36 patients and pulmonary artery banding in six; through median sternotomy, aortic valvotomy in two, Senning operation in one and closure of ventricular septal defect in one neonate of 6 days of age, 1.6 kg of body weight.
During the follow-up 15 children underwent another surgical procedure to treat the associated congenital heart defect, and a patient of 19 years of age underwent aortic valve replacement 1 year after aortic coarctectomy.
There were no hospital deaths. During the entire follow-up there were one late death in the adults group (1/37=2.7%), 25 years after the operation for aortic coarctation and unrelated to the previous operation, and three late deaths in the pediatric group (3/104=2.9%), all within 1 year after aortic coarctectomy (2, 5, and 7 months after surgery), and all related to the associated heart defect: transposition of the great arteries, Shone complex, and Eisenmenger.
Re-operation because of development of a re-coarctation did not occur in the adult group, while it occurred in ten late survivors of the pediatric group (10/101=9.9%). We therefore analyzed the incidence of re-operation because of re-coarctation in the pediatric group with regard to: (a) date of operation, (b) age at operation, (c) surgical technique (Table 5).
With regard to the residual/recurrent pressure gradient at the isthmus level, a significant (>20 mmHg at rest) pressure gradient was found in none of the adults, while it was found in seven of the 91 pediatric patients (7/91=7.7%) late survivors, not yet treated with re-operation or balloon dilatation. Three adults (3/36=8.3%) late survivors are on medical treatment to control systemic hypertension, respectively 32 years after resection and end-to-end anastomosis, 15 years after pyloroplasty type and 11 years after conduit interposition between the left subclavian artery and the descending thoracic aorta.
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4. Discussion
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Surgery has long been considered the treatment of choice for aortic coarctation in children and adults [9–16]. Within the last decade good results have been reported with the interventional angioplasty techniques, for the native aortic coarctation and the re-coarctation as well, in children and in adults [1–8]. Since there are very little data available on the long-term outcome of the angioplasty techniques [5,8], we reviewed the long-term surgical results of our center over a period of 30 years.
Our retrospective study has been focused on the main problems generally reported in the literature after surgery for aortic coarctation: mortality, residual/recurrent coarctation requiring for further treatment, residual/recurrent systemic hypertension [9–23].
4.1. Mortality
In our review there was no hospital mortality in both groups, pediatric and adult patients. The late mortality was 2.7% (=1/37) in the adults, and 2.9% (=3/104) in children, and in both groups the late mortality was unrelated to the aortic coarctation. By considering the mean age in the adult group, the incidence and type of associated lesions in the pediatric group, and the length of the observation period (30 years), the observed total (hospital+late) mortality can stand against any comparison with the reported surgical and interventional approaches.
4.2. Residual/recurrent coarctation
This complication, generally absent in adults, as in our experience, is disturbingly frequent in pediatric patients, particularly in two categories: neonates and patients with associated hypoplasia of the aortic arch [9,11–13,16]. By analyzing our experience, we found that 9/10 children requiring re-operation because of development of re-coarctation had undergone surgery within the first 10 years of the experience. We have to recognize that during the 1970s the technique of resection and end-to-end anastomosis enlarged to the aortic arch, as well as the suturing materials currently utilized, were not yet available. During the last 20 years there has been only one case of re-coarctation requiring re-operation, independently from the utilized surgical technique.
4.3. Residual/recurrent systemic hypertension
While it is quite frequent, in our experience as well as in the literature [4,10,11,14,17,18], to observe paradoxic systemic hypertension shortly after surgery particularly in older patients, we found a relatively low incidence (8.3%) of adults requiring medical treatment to control systemic hypertension. In children the persistent systemic hypertension was always accompanied by re-coarctation.
4.4. Surgical techniques
The classical technique of resection and end-to-end anastomosis (Fig. 2B) has been proved to be feasible in almost all cases, with the evident advantage of avoiding foreign material other than sutures. In the small child, particularly in the presence of hypoplastic aortic arch, our current policy is to consider as the first choice the technique of resection and end-to-end anastomosis enlarged to the aortic arch (Fig. 2C). The subclavian flap (Fig. 2A) is taken into consideration only in the presence of hypoplasia of the distal aortic arch. Recently, after the period observed in this study, we performed a reverse subclavian flap in the presence of severe hypoplasia of the transverse aortic arch [13].
The technique of patch aortoplasty (Fig. 2E), utilized in the first period, has been completely abandoned, because of the known problems associated with the presence of a synthetic patch [23]. In order to detect the occurrence of aneurysm early, the patients considered at risk are followed at regular intervals by magnetic resonance imaging (MRI) or computerized tomography (CT) angiography [11,20–22]. Prosthetic conduit interposition, as end-to-end (Fig. 2F) as well as bypass (Fig. 2G) has nowadays a very limited application.
Quite interesting are the results obtained with the technique of pyloroplasty type (Fig. 2D), utilized in adults as well as children, with only one case of re-coarctation, despite it being used within the first period of the study. To our knowledge, this type of technique has not been frequently reported in the surgical literature, and it has the advantage of using only the native material in order to obtain aortic enlargement.
4.5. Limits of the study
Our study was evidently the retrospective evaluation of the experience developed in 30 years by different surgeons. Therefore we did not have any control on the timing of surgical indication and surgical approach, as well as on the type of surgical technique and suture materials utilized. Furthermore, since in each period of the experience and in each age group various surgical techniques have been utilized, the numbers were not large enough to justify any uni- or multivariate analysis of the different variables: suture materials used in pediatric patients, incidence of re-coarctation, blood pressure at the last follow-up.
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5. Conclusions
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The long-term results of our retrospective study, not different from other favorable surgical reports [9–16], confirm that surgery has to be considered the gold standard for the treatment of aortic coarctation. The interventional angioplasty techniques, apparently so appealing because they avoid an operation, have to provide long-term outcome at least similar to the results obtained with surgery.
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Acknowledgments
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We would like to thank Gianmarco Codeluppi M.D. who helped us for the data collection, and Philippe Clavel for the technical assistance with the surgical drawings.
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Abstract
1. Introduction
