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J Thorac Cardiovasc Surg 2003;125:S87-S89
© 2003 The American Association for Thoracic Surgery

Editorials

Management strategies for infants with coarctation and an associated ventricular septal defect

From the Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pa.

Received for publication April 19, 2001. Accepted for publication April 24, 2001. Address for reprints: J. William Gaynor, MD, Pediatric Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 34th St & Civic Center Blvd, Philadelphia, PA 19104.

The first 300 words of the full text of this article appear below.

The optimal management strategy for patients with aortic coarctation and an associated ventricular septal defect (VSD) remains controversial. The patients are heterogeneous, with considerable variation in the morphology of the aortic arch, as well as variation in the characteristics of the VSD. Additional levels of left ventricular outflow tract obstruction are often present. Systemic perfusion may be dependent on ductal patency, and surgical repair is usually necessary in the neonatal period or early infancy. A variety of therapeutic strategies have been proposed, including coarctation repair alone with later VSD closure, if necessary; coarctation repair with pulmonary artery banding followed by delayed VSD closure and debanding; and single-stage repair of both defects. Multiple techniques have also been used for arch reconstruction in these patients, including subclavian flap aortoplasty, patch aortoplasty, and resection with end-to-end anastomosis. Not surprisingly, there is an ongoing debate over the best technique for arch reconstruction and the timing of VSD closure. Most reports contain relatively small numbers of patients and focus on the short-term outcome of a specific strategy, usually in terms of operative mortality and early recoarctation. Little data exist concerning the long-term outcome of these patients, specifically persistent hypertension, ventricular function, adverse neurodevelopmental sequelae, and the incidence of reintervention other than for recoarctation.

In 1994, the Congenital Heart Surgeons Society reported results of a multi-institutional study evaluating 326 symptomatic neonates with coarctation either with or without an associated VSD. ¹ A VSD was present in 155 of these infants, and 153 underwent surgical repair. This report provided an important snapshot of management strategies and outcomes at the participating institutions but did not resolve questions concerning the optimal management strategy. For neonates having a moderate or large VSD, repair of the coarctation plus pulmonary artery banding was associated with both the highest non-risk-adjusted and risk-adjusted survival. Single-stage . . . [Full Text of this Article]