Growth Characteristics and Reintervention Following Aortic Arch Reconstruction in Infants Undergoing Biventricular Repair
Christoph Haller1, Guillermo Larios2, Kasey Moss1, Wenli Xie1, James Meza1, Brian McCrindle1, Glen S Van Arsdell1, Luc Mertens2, Osami Honjo1
1Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada2Division of Cardiology, The Labatt Family Heart Centre, The Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
BACKGROUND - Congenital aortic arch hypoplasia necessitates extensive arch reconstruction on cardiopulmonary bypass with or without patch material. We sought to assess growth characteristics and reintervention rates of the aortic arch in infants who underwent extensive aortic arch reconstruction.
METHODS - 224 infants (median weight 3.44kg, IQR 3.00-3.97; median age 10.0days, IQR 5.0-40.8) with hypoplastic aortic arch who underwent repair on cardiopulmonary bypass via median sternotomy between 01/2005 and 12/2015 were included. Patients receiving a tubular vascular graft or with a single ventricle were excluded. Impact of primary diagnoses, type of repair, and extent of patching on aortic arch growth and reinterventions was assessed. Reconstruction type was categorized based on achieved anatomy (native vs. altered) and use of patch. Patients were grouped by arch hypoplasia (z-score≤-3 vs. >-3). Echocardiographic measurements of ascending aorta (AA), transverse arch (TA), isthmus (IA) and descending aorta (DA) were taken preoperatively, at discharge, and at latest follow-up (2.26y, IQR 0.22-5.92). Measurements were compared with paired and independent samples t-tests. Binomial logistic regression was used to identify predictors for reintervention.
RESULTS - Common associated diagnoses were VSD (69, 30.8%), IAA (56, 25.0%), TGA (26, 11.6%), and DORV (24, 10.7%). 19 patients had isolated hypoplasia. Coarctation (CoA) was present in 116 (51.8%). Absolute aortic dimensions and z-scores significantly increased postoperatively in all segments (p<.0005). Continuous growth, indicated by increasing z-scores, was observed in AA and TA (AA: p<.0005; TA: p=.028) but not in distal arch segments (IA: p=.702; DA: p=.944) at latest follow-up (Figure 1). Aortic diameters exceeded expected values at AA (p=.010), TA (p<.0005), and DA (p=.002) during follow-up. Size of IA at follow-up was comparable irrespective of preoperative CoA (p=.768). Arch reintervention was required in 12 (5.4%) patients: 7 (3.1%) for ascending aorta and 5 (2.2%) for distal aortic arch. 3 and 5-year freedom from reintervention were 93.3% and 91.0%, respectively. Reintervention rate was comparable between patients with normal vs. hypoplastic preoperative TA dimensions (z-score>-3: 82.5%, z-score≤-3: 96.0%; p=.090). The patients with preoperative CoA had a lower reintervention rate compared to those without (CoA: 96.8%, no CoA: 85.2%; p=.015). No factor was identified as a significant predictor for aortic arch reintervention in multivariable analysis.
CONCLUSIONS - Results of aortic arch reconstruction are excellent with low reintervention rate. Adequate growth was found following repair regardless of repair type. Presence or absence of CoA does not affect reintervention rate. Appropriate enlargement of the hypoplastic ascending aorta may further improve outcome.
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