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J Thorac Cardiovasc Surg 2001;122:883-890
© 2001 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease (CHD)

Recurrent arch obstruction after repair of isolated coarctation of the aorta in neonates and young infants: Is low weight a risk factor?

From the Divisions of Pediatric Cardiothoracic Surgery^a and Pediatric Cardiology,^b The Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pa.

This study was supported in part by grants from The Daniel M. Tabas Endowed Chair in Cardiothoracic Surgery and The Ethel Brown Foerderer Fund for Excellence.

Presented in part at the 2000 Annual Meeting of the American Academy of Pediatrics, Chicago, Ill, October 28, 2000.

Received for publication Sept 22, 2000. Revisions requested Dec 19, 2000; revisions received April 4, 2001. Accepted for publication April 6, 2001. Address for reprints: J. William Gaynor, MD, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104 (E-mail: gaynor{at}email.chop.edu).

Abstract

Background: Repair of aortic coarctation is often delayed in small infants because of the belief that such patients are at risk of recurrent arch obstruction and that growth will decrease this risk. To determine whether low weight was a risk factor for recurrent arch obstruction, we reviewed our experience with coarctation repair via left thoracotomy in infants less than 3 months of age.
Methods: From 1990 to 1999, 103 patients less than 3 months of age underwent repair of aortic coarctation through a left thoracotomy. Median age was 18 days (1-90 days), with 45 patients less than 2 weeks. Median weight was 3.3 kg (1.0-6.4 kg) and 14 patients were less than 2 kg. The method of repair was resection and end-to-end anastomosis in 64 patients, subclavian flap angioplasty in 34, and patch augmentation of the arch in 5. Demographic, echocardiographic, and operative variables were analyzed for correlation with recurrent arch obstruction.
Results: One early and 1 late death occurred, both in patients who had complications but no evidence of recoarctation. At median follow-up of 24 months, reinterventions for recurrent arch obstruction were performed in 15 patients. The median time to reintervention was 5 months and was less than 1 year in 12 patients. Kaplan-Meier freedom from arch reintervention was 88% at 1 year (95% confidence intervals: 82%-94%) and 82% at 5 years (95% confidence intervals: 72%-92%). Factors associated with shorter duration to arch reintervention by univariable Cox regression included younger age (continuous, P = .01; <2 weeks, P = .005), smaller transverse arch (absolute diameter, P < .001; indexed to weight, P = .03; indexed to ascending aortic diameter, P = .02), and smaller ascending aorta (absolute diameter, P = .02). Smaller absolute transverse arch diameter and younger age were the only independent predictors of shorter time to arch reintervention by multivariable Cox regression analysis. Weight and type of repair did not correlate with risk of recoarctation.
Conclusions: Low weight is not a risk factor for recurrent obstruction after repair of coarctation of the aorta in infants less than 3 months of age. Rather, risk of recoarctation is more a function of the anatomy of the arch. Thus, it is not indicated to delay repair in low weight infants with the goal of achieving growth.

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