The causes, diagnosis and management of recoarctation of the aorta following coarctation of the aorta surgery at neonatal age
Abstract
Introduction: Symptomatic neonatal coarctation of the aorta (nCOA) is a critical heart disease requiring urgent surgery. Recoarctation of the aorta is a residual narrowing at anastomosis site with a non-invasively measured systolic gradient between upper and lower limbs higher than 20 mm Hg.
When recoarctation of the aorta is suspected based on clinical assessment (hypertension, attenuated pulses and lower pressure at lower limbs), the diagnosis is confirmed by echocar-diography, alternatively complemented with angiography, CT and magnetic resonance imaging in older children. Summary of patients and results: We analyzed data of a total of 323 patients undergoing surgery for coarctation of the aorta as neonates in the 1978-2004 period.
In 225 cases (69.6%), coarctation of the aorta was associated with another congenital intracardiac defect, most often with ventricular septal defect, transposition of the great arteries or aortic stenosis. All 281 children operated on up to 2002 were on retrospective follow-up.
The analyzed risk factors for the development of recoarctation included the age and weight at surgery, incidence of associated heart diseases, anatomy of the aortic arch and isthmus, and the technique of reconstruction of the aorta. We followed up prospectively all 42 neonates undergoing surgery for coarctation of the aorta in 2003-2004.
Additionally, we followed the growth of individual aortic segments and assessed histological findings of resected aortic preparations. Overall, the incidence of recoarctation of the aorta in children operated on for coarctation of the aorta as neonates in 1978-2004 was 18.5% (55/296).
In 296 patients surviving the early postoperative period (21 days) with the follow-up period from 6 days to 17.5 years, multivariate logistic analysis was used to test risk factors for the development of recoarctation (Table I); however, no significant independent predictor was identified. In patients operated during 2003-2004 with or without recoarctation of the aorta, no difference was seen in the histological composition of the intraoperatively resected aortic preparations or a difference in the growth of individual aortic segments.
In 30 patients, recoarctation of the aorta was managed by balloon angioplasty, while 17 had re-surgery within 1 month to 14 years of the initial procedure, of this number 4 had had angioplasty. Seven patients had recoarctation resection with direct aortic anastomosis, 4 recoarctationplasty with direct aortic Goretex patch or a homograft wall patch, 3 cases involved reverse Waldhausen plastic procedure using the left subclavian artery, and extra-anatomical bypass, resection of the recoarctation and aortic isthmus replacement with a vascular prosthesis, and resection of recoarctation and anastomosis with reverse Waldhausen plastic procedure in one case each.
Mortality of re-do surgery was 0%. The actuarial survival odds for nCOA surgery in 1978-1990 were 42.2% +- 10.7% (mean +- SEE), rising to 84.1% +- 2.5% in 1991-2004; p < 0.001.
The survival odds after nCOA surgery for recoarctation without re-intervention were 32.1% +- 6.7% over the years 1978-1990, increasing to 65.9% +- 3.6% in 1991-2004; p < 0.001. Conclusion: Surgery for symptomatic neonatal coarctation has become a routine method with very good outcomes and good prognosis.
Our preference is resection of the coarctation with direct aortic anastomosis. The incidence of recoarctation of the aorta has been decreasing over years, no independent risk factor for the development has been identified.
Our policy is primary management of recoarctation of the aorta with balloon angioplasty, in the event of failure, re-do surgery is indicated having very good outcomes with zero mortality despite its complexity and demanding nature.