1. One-Stage Repair of Aortic Coarctation & Intracardiac Defects
SNU Children’s Hospital
One-Stage Repair of Aortic Coarctation & Intracardiac Defects
Yong Jin Kim, M.D.
Department of Thoracic & Cardiovascular Surgery
Seoul National University Hospital
Seoul, Korea
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2. Morphology of Coarctation
SNU Children’s Hospital
Morphology of Coarctation
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3. Repair of CoA with Intracardiac Defects
SNU Children’s Hospital
Repair of CoA with Intracardiac Defects
Controversies still exist
about optimal surgical treatment
Methods of repair
Coarctation repair alone
Coarctation repair with PA banding
One-stage repair of associated defects
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4. Advantages of One-stage Repair
SNU Children’s Hospital
Advantages of One-stage Repair
Avoid complications of longstanding disease
Benefits in the perioperative period
Ease of repair in arch hypoplasia
Lower recurrence rate
Benefits for complete anatomic repair
Overall wellbeing in the future development
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5. One-Stage Repair of CoA with Associated Defects
SNU Children’s Hospital
One-Stage Repair of CoA with Associated Defects
The time of CPB, TCA, ACC
Relief of LVOT obstruction
Residual diseases
Residual coarctation
Residual subaortic stenosis
Residual intracardiac defects
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6. Subaortic Stenosis in Coarctation
SNU Children’s Hospital
Subaortic Stenosis in Coarctation
Reasons of underestimation
Presence of nonrestrictive VSD
Aortic arch obstruction
Hemodynamic status
Criteria by anatomic measurement
Diastolic ratio of descending aorta to LVOT
below 1.0 is indicative , severe below 0.6
LVOT value less than 4-5 mm in neonate
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7. Surgical Technique of Aortic Arch Reconstruction
SNU Children’s Hospital
Surgical Technique of Aortic Arch Reconstruction
Wide mobilization of aorta & arch vessels
Careful trimming of all the ductal tissue
Elimination of anastomosis to the isthmus
beyond the left subclavian artery
Extended end-to-end or side anastomosis
proximal to arch hypoplasia
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8. SNU Children’s Hospital
Operative Procedure
Extended end-to-end anastomosis
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9. SNU Children’s Hospital
Operative Procedure
Extended end-to-side anastomosis
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10. Experience of One-stage Repair
SNU Children’s Hospital
Experience of One-stage Repair
Seoul National University Children’s Hospital
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11. SNU Children’s Hospital
Purpose
To evaluate the effectiveness of surgical treatment
mortality, morbidity and outcome
66 patients who underwent one-stage transsternal repair of coarctation and associated defects.
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12. SNU Children’s Hospital
Patient Profiles
Duration : Sept Dec. 1999
Number : 66 patients
Sex : 40 male, 26 female
Age : 67 ± 82 d ( 5 d d )
Bwt (kg) : 4.1 ± 0.2 Kg ( Kg)
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13. SNU Children’s Hospital
Distribution
Type of lesion No. of No. of
patient tubular hypoplasia
Group 1
CoA, minor defects ( 12.1%) (12 %)
Group 2
CoA, VSD* ( 69.7%) (72 %)
Group 3
CoA, complicated defects 12 ( 18.2%) (50 %)
Total (100 %) (61 %)
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14. SNU Children’s Hospital
Associated Anomalies
in CoA with minor defects (n=8)
ASD + PDA
Anomalous origin of RPA + PDA
ASD + AS (bicuspid AV) 1
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15. SNU Children’s Hospital
Associated Anomalies
in CoA with VSD (n=46)
PDA
ASD
Aortic stenosis 2
Coronary artery anomaly 1
Tricuspid valve straddling 1
Congenital tracheal stenosis 1
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16. SNU Children’s Hospital
Types of Isolated VSD
n=46
Type of VSD No. of patients
Perimembranous
with extension 14
with posterior malalignment 14 (6)*
Subarterial
with subaortic stenosis (3)*
Multiple
* Enlargement of VSD, resection of conal septum was done
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17. Associated Anomalies in CoA with complicated defects (n=12)
SNU Children’s Hospital
Associated Anomalies in CoA with complicated defects (n=12)
TOF
Shone’s syndrome
Parachute MV + SAS + supravalvular AS
MSR + AS(bicuspid)
TGA with VSD
DORV with subaortic VSD
Single atrium, VSD, systemic venous anomaly 1
Lt SVC with unroofed CS, AS, VSD 2
HLHS
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18. SNU Children’s Hospital
Surgical Methods (1)
Operative technique : simultaneous repair of CoA & associated defects through the transsternal approach
Conduction of CPB
Intermittent cold crystalloid or blood cardioplegia
Deep hypothermic circulatory arrest
CPB time (min) : 131 ± 38 ( )
ACC time (min) : 60 ± 16 ( )
TCA time (min) : 37 ± 14 ( )
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19. SNU Children’s Hospital
Surgical Methods (2)
Type of operation No. of patient
Patch angioplasty ( 7.6%)
R & A* (18.2%)
ERAA** (74.2%)
Total
* R & A = resection & anastomosis
** ERAA = extended end-to-end anastomosis
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20. SNU Children’s Hospital
Mortality
Group early death late death
Gr 1 (n= 8)
Gr 2 (n=46) ( 10.8 %)
Gr 3 (n=12) ( 16.7 %)
Total (n=66) ( 10.6 %)
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21. SNU Children’s Hospital
Causes of Early Death
Pneumonia, sepsis, multiorgan failure (POD #20)
Remaining AS & AR, LCO (POD # 8)
Residual SAS, myocardial failure (POD # 1)
Myocardial failure, Pulm. HT (POD # 1)
Myocardial failure, residual SAS (POD # 1)
Afterload mismatch, LV failure, Pulm. HT (POD # 0)
Mediastinitis, sepsis (POD #11)
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22. Actuarial Survival Rate
SNU Children’s Hospital
Actuarial Survival Rate
96.6%
94.7%
92.9%
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23. SNU Children’s Hospital
Complications
n= 66
Complication No.of patient
Diaphragmatic palsy
Hypoxic encephalopathy 3
Pneumonia 3
Transient seizure 2
Arrhythmia 3
Mediastinitis 2
Chylothorax 2
Pericardial effusion 2
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24. Risk Factors for Hospital Mortality
SNU Children’s Hospital
Risk Factors for Hospital Mortality
Variables Group Mean or Mortality p-Value
Age at Op survivor ± 88d± 88d mortality ± 19d
ACC survivor ± 17min mortality ± 22min
SAS (+) / %
(-) / %
Complicated defects (+) / %
(-) / %
Arch hypoplasia (+) / %
(-) / %

25. SNU Children’s Hospital
Follow-up Results (1)
Follow-up
Total 59 patients
Duration (mo) : ± 33.5 ( )
Late death (4 / 59 survivors, 6.8%)
Asphyxia during seizure, respiratory failure
CHF, febrile seizure, respiratory failure
Intestinal strangulation (malrotation)
Pneumonia
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26. SNU Children’s Hospital
Follow-up Results (2)
Residual coarctation (2/55, 3%)
Color Doppler (> v = 2.25m/s), Pr gradient (>20mmHg)
Two, borderline degree (interval 12, 32mo)
No additional procedure
Reoperation (2/55, 3%)
Konno operation due to recurrent subaortic stenosis (interval 44mo)
Permanent pacemaker insertion due to heart block (interval 7 years)
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27. SNU Children’s Hospital
Conclusions
One-stage transsternal repair of aortic coarctation & cardiac
defects is a good surgical option in selected cases.
This approach may be applicable to following conditions ;
Patients with little benefits from relief of CoA alone.
Size & type of VSD, unlikely to close spontaneously.
CoA with minor, major associated defects repaired.
CoA with severe hypoplasia of aortic arch.
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