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Eur J Cardiothorac Surg 2006;29:635-636
© 2006 Elsevier Science NL
Letter to the Editor |
Division of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ont., Canada M5G 1X8
Received 16 November 2005; accepted 6 January 2006.
* Tel.: +1 416 813 6204; fax: +1 416 813 7984. (Email: igorkonst{at}hotmail.com).
Key Words: Truncus arteriosus • Interrupted aortic arch • Surgery • Congenital
I read with interest the recent article by Tlaskal et al. [1] that described their experience with eight consecutive children with truncus arteriosus (TA) and interrupted aortic arch (IAA) operated on between 1993 and 2004. Operative mortality was 12.5%. Seven survivors were followed up for 2.0–11.7 years (median 2.6 years). Subsequently, two patients were reoperated for aortic regurgitation and one had balloon angioplasty for aortic arch obstruction. I congratulate Tlaskal et al. [1] on achieving low mortality and very good mid-term result in this challenging group of patients.
A few comments seem appropriate.
We have recently reported a study of 472 neonates with IAA enrolled prospectively from 33 institutions between 1987 and 1997 [2]. Of 453 patients who had IAA repair, after 16 years 33% had died and 28% had undergone an aortic arch reintervention. TA was a risk factor for death, and reintervention was more likely for those who had TA repair or IAA repair by a method other than direct anastomosis with patch augmentation, including the use of a polytetrafluoroethylene as either an interposition graft or a patch [2].
Our study performed on behalf of the Congenital Heart Surgeons’ Society members that included 50 neonates who underwent TA and IAA repair indicated poor prognosis with survival of 39% at 1 year and 30% at 15 years [3]. In contrast, neonates with aortopulmonary window (APW) associated with IAA had good survival. In our recent study of 20 neonates with APW and associated IAA, overall survival since admission was 91%, 86% and 84% at 1, 5 and 10 years, respectively [4].
One cannot help but wonder why children with combination of TA and IAA do so much worse as compared to TA alone or combination of APW and IAA operated during the same time and at the same institutions? The residual aortic anastomotic obstruction following IAA repair seems to have a greater importance in children with abnormal truncal valve, while most children with APW have a normal aortic valve and tolerate residual aortic obstruction much better. Thus, in addition to the methods of truncal valve repair, one should search for the ways to prevent residual obstruction of the aortic anastomosis.
My colleagues and I have recently described the interdigitating arch reconstruction that eliminates recurrent coarctation after reconstruction of severely hypoplastic aorta [5]. The interdigitating technique with generous patch augmentation of the aortic anastomosis may be very useful in the prevention of recurrent coarctation or residual aortic anastomotic obstruction, as any degree of arch obstruction is tolerated extremely poorly following truncal valve repair.
Various current techniques for repairing truncal valve have been described and may be of great help to ensure the competence of the truncal valve. However, as rightly pointed out by Tlaskal et al. [1], often the truncal valve dysplastic with combination of regurgitation and stenosis, which makes the plasty very difficult. Providing an unobstructed aortic outflow is of extreme importance in these patients to ensure good long-term results.
In summary, achieving both truncal valve competence and unobstructed aortic anastomosis appears to be crucial for successful outcome in patients with TA associated with IAA.
References
This article has been cited by other articles:
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  T. Tlaskal Reply to konstantinov. Eur. J. Cardiothorac. Surg., April 1, 2006; 29(4): 636 - 637. [Full Text] [PDF]
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