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J Thorac Cardiovasc Surg 2007;133:1544-1546
© 2007 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Discussion

Dr James S. Tweddell (Milwaukee, Wis). Interstage survival, as well as improved candidacy for stage II palliation, depends on limiting the development of recurrent or residual lesions addressed in the initial stage I operation, including the prevention of coronary insufficiency, the development of a restricted atrial septal defect, the development of restriction of pulmonary blood flow, and, the subject of this presentation, prevention of aortic arch obstruction.

The authors have reviewed a 5-year experience with 210 patients with HLHS, with special attention to the issue of arch obstruction. The authors identified a posterior shelf in 47% of these 210 patients, and this was taken as evidence of coarctation.

One theory of coarctation suggests there is migration of ductal smooth muscle cells into the periductal aorta, with subsequent constriction and narrowing of the aortic lumen. Alternatively, in the case of infantile coarctation, we postulate that the hemodynamic lesion itself results in an imbalance between the larger ductus and the smaller adjacent aorta, such that a larger portion of the junction of these 2 structures is comprised of the ductal tissue, and the subsequent ductal involution results in coarctation.

Coarctation can therefore be thought of as one end of the spectrum of HLHS, and we could postulate an even greater imbalance in the proportion of ductus and the adjacent aorta, making coarctation a uniform part of this anomaly. Indeed, as pointed out in the discussion in your article, it is thought to occur in at least 80% of patients with HLHS. Prosthetic material that crosses this area of ductal tissue, which ultimately necroses and fibroses, will result in a circumferential ring of nonviable tissue that does not grow and is probably the substrate of recurrent coarctation.

The principal finding of this study was a decrease in the incidence of recoarctation . . . [Full Text of this Article]

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J. Thorac. Cardiovasc. Surg. 2007 133: 1540-1546. [Abstract] [Full Text] [PDF]