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Letters to the Editor |
a Pediatric Cardiac Surgery Department, ‘Policlinico-Giovanni XXIII’ Hospital, University of Bari, Piazza Giulio Cesare 11, Bari 70100, Italy
b Department of Biomedicine of Evolutive Age, Neonatal Intensive Care Unit, Section of Neonatal Cardiology, University of Bari, Piazza Giulio Cesare 11, Bari 70100, Italy
Received 27 June 2007; accepted 14 August 2007.
* Corresponding author. Address: Via Lorenzo D’Agostino 1/a, ZC 70124, Bari, Italy. Tel.: +39 0805461499; fax: +39 02700411718. (Email: detroise{at}libero.it).
Key Words: Aortic coarctation • Congenital heart disease • Subclavian artery
We read with great interest the article by Barreiro et al. [1] regarding the current role of subclavian flap aortoplasty (SFA) in the surgical treatment of coarctation in infancy.
We are in complete agreement with the authors that the SFA still has a role in isolated isthmic coarctation repair, in infancy as well as in the most difficult subgroups of patients operated in neonatal age. In fact, the technique itself allows excellent aortic continuity with naturally harmonious restoration of the aortic arch–isthmus tract. These goals are not foreseen either with patch aortoplasty or with end-to-end (ETE) anastomosis, both of which, respectively, distort and eliminate the stenotic thoracic aorta. If the hypoplasia of the aortic arch is mild-to-nil, the physiological antegrade flow through the arch and the absence of gradient at the end of the procedure will guarantee adequate long-term repair, in most cases.
In our institute, 178 patients presenting with neonatal coarctation were operated. In the search for the (perhaps utopic) ideal surgical management, we have changed our surgical strategy over the years in our institute. In the early-to-mid phase of our activity we proposed a patch aortoplasty for all neonates that has the advantage of always relieving the gradient at the level of the isthmus by means of a technique which is both time- and hemorrhage-controlled. The incidence of aneurysm formation in the long term (2/178 in our experience at a follow-up of 10 years, but frequently reported in the literature [2] to longer follow-up) and the high rate of recoarctation (26%) discouraged us from electively employing the patch.
After a period of non-randomized surgical strategy of SFA, extended ETE (EETE) anastomosis and ETE anastomosis technique, in our institute we currently adopt the following strategies:
Even though early results were encouraging, it is not possible to make statistical comparisons between the different strategies on account of the small numbers of subgroups of patients in which alternative strategies to patch aortoplasty were performed.
We strongly recommend close follow-up with frequent outpatient controls, especially in the case of arch reconstruction by autologous tissues associated to pulmonary artery banding [4], since, as highlighted in the literature [5], the risk of recoarctation in these surgical strategies is always present in the first year of life and, often, in the first months postoperatively, even in the case of a trivial residual gradient.
References
This article has been cited by other articles:
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  L. A. Vricella and D. E. Cameron Reply to Troise et al.: Subclavian flap aortoplasty in neonates and infants Eur. J. Cardiothorac. Surg., November 1, 2007; 32(5): 824 - 825. [Full Text] [PDF]
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