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One-Stage Repair of Aortic Coarctation & Intracardiac Defects

One-Stage Repair of Aortic Coarctation & Intracardiac Defects. Yong Jin Kim, M.D. Department of Thoracic & Cardiovascular Surgery Seoul National University Hospital Seoul, Korea. Morphology of Coarctation. Repair of CoA with Intracardiac Defects. Controversies still exist

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One-Stage Repair of Aortic Coarctation & Intracardiac Defects

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  1. 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

  2. SNU Children’s Hospital Morphology of Coarctation

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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

  8. SNU Children’s Hospital Operative Procedure Extended end-to-end anastomosis

  9. SNU Children’s Hospital Operative Procedure Extended end-to-side anastomosis

  10. SNU Children’s Hospital Experience of One-stage Repair Seoul National University Children’s Hospital

  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.

  12. SNU Children’s Hospital Patient Profiles • Duration : Sept. 1989 - Dec. 1999 • Number : 66 patients • Sex : 40 male, 26 female • Age : 67 ± 82 d ( 5 d - 530 d ) • Bwt (kg) : 4.1 ± 0.2 Kg (1.8 - 9.8 Kg)

  13. SNU Children’s Hospital Distribution Type of lesion No. of No. of patient tubular hypoplasia Group 1 CoA, minor defects 8 ( 12.1%) 1 (12 %) Group 2 CoA, VSD* 46 ( 69.7%) 33 (72 %) Group 3 CoA, complicated defects 12 ( 18.2%) 6 (50 %) Total 66 (100 %) 40 (61 %)

  14. SNU Children’s Hospital Associated Anomalies in CoA with minor defects (n=8) • ASD + PDA 5 • Anomalous origin of RPA + PDA 2 • ASD + AS (bicuspid AV) 1

  15. SNU Children’s Hospital Associated Anomalies in CoA with VSD (n=46) • PDA 42 • ASD 18 • Aortic stenosis 2 • Coronary artery anomaly 1 • Tricuspid valve straddling 1 • Congenital tracheal stenosis 1

  16. SNU Children’s Hospital Types of Isolated VSD n=46 • Type of VSD No. of patients • Perimembranous 28 • with extension 14 • with posterior malalignment 14 (6)* • Subarterial 17 • with subaortic stenosis 3 (3)* • Multiple 1 * Enlargement of VSD, resection of conal septum was done

  17. SNU Children’s Hospital Associated Anomaliesin CoA with complicated defects (n=12) • TOF 2 • Shone’s syndrome 2 • Parachute MV + SAS + supravalvular AS 1 • MSR + AS(bicuspid) 1 • TGA with VSD 2 • DORV with subaortic VSD 1 • Single atrium, VSD, systemic venous anomaly 1 • Lt SVC with unroofed CS, AS, VSD 2 • HLHS 2

  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 (86 - 335) • ACC time (min) : 60 ± 16 (21 - 117) • TCA time (min) : 37 ± 14 (20 - 72)

  19. SNU Children’s Hospital Surgical Methods (2) Type of operation No. of patient Patch angioplasty 5 ( 7.6%) R & A* 12 (18.2%) ERAA** 49 (74.2%) Total 66 * R & A = resection & anastomosis ** ERAA = extended end-to-end anastomosis

  20. SNU Children’s Hospital Mortality Group early death late death Gr 1 (n= 8) 0 1 Gr 2 (n=46) 5 ( 10.8 %) 1 Gr 3 (n=12) 2 ( 16.7 %) 2 Total (n=66) 7 ( 10.6 %) 4

  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)

  22. SNU Children’s Hospital Actuarial Survival Rate 96.6% 94.7% 92.9%

  23. SNU Children’s Hospital Complications n= 66 Complication No.of patient Diaphragmatic palsy 4 Hypoxic encephalopathy 3 Pneumonia 3 Transient seizure 2 Arrhythmia 3 Mediastinitis 2 Chylothorax 2 Pericardial effusion 2

  24. SNU Children’s Hospital Risk Factors for Hospital Mortality Variables Group Mean or Mortality p-Value Age at Op. survivor 76 ± 88d± 88d 0.055 mortality 28 ± 19d ACC survivor 59 ± 17min 0.390 mortality 67 ± 22min SAS (+) 2/ 8 25.0% 0.877 (-) 9/58 15.5% Complicated defects (+) 4/14 28.6% 0.552 (-) 7/52 13.5% Arch hypoplasia (+) 7/40 17.5% 0.496 (-) 4/26 15.4%

  25. SNU Children’s Hospital Follow-up Results (1) • Follow-up • Total 59 patients • Duration (mo) : 30.4 ± 33.5 ( 8 - 127 ) • Late death (4 / 59 survivors, 6.8%) • Asphyxia during seizure, respiratory failure • CHF, febrile seizure, respiratory failure • Intestinal strangulation (malrotation) • Pneumonia

  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)

  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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