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J Thorac Cardiovasc Surg 2005;130:61-65
© 2005 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Interdigitating arch reconstruction eliminates recurrent coarctation after the Norwood procedure

Harold M. Burkhart, MD a , * , David A. Ashburn, MD c , Igor E. Konstantinov, MD, PhD c , Nilto C. De Oliviera, MD c , Lee Benson, MD b , William G. Williams, MD c , Glen S. Van Arsdell, MD c

a Department of Cardiothoracic Surgery, University of Iowa Hospital and Clinics, Iowa City, Iowa
b Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
c Section of Pediatric Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada

Received for publication June 15, 2004; revisions received November 15, 2004; accepted for publication February 22, 2005.

* Address for reprints: Harold M. Burkhart, MD, University of Iowa, Department of Cardiothoracic Surgery, 200 Hawkins Dr, 1603 JCP, Iowa City, IA 52242 (Email: harold-burkhart{at}uiowa.edu).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
BACKGROUND: We sought to determine whether evolving techniques of aortic arch reconstruction used during the Norwood procedure decreased the incidence of postoperative aortic arch obstruction.

METHODS: Our technique for aortic arch reconstruction in patients undergoing the Norwood procedure has evolved from using an allograft patch (classic group, n = 26) to primary connection of the pulmonary artery and arch (autologous group, n = 20). More recently, we have used a novel technique involving coarctation excision, an extended end-to-end anastomosis on the back of the arch, and a counterincision on the anterior descending aorta to sew in an allograft patch for total arch reconstruction (interdigitating group, n = 33). Cardiac catheterizations performed before stage II palliation were reviewed for aortic diameters at multiple levels in 79 infants (median age, 4.2 months). Aortic arch obstruction was defined as a ratio between the diameters of the arch anastomosis and the descending aorta (coarctation index) of less than 0.7.

RESULTS: Overall, 15 (19%) children had aortic arch obstruction. All 15 required aortic intervention (balloon angioplasty, n = 12; surgical patch angioplasty, n = 2; both, n = 1). Aortic arch obstruction rates for the classic, autologous, and interdigitating groups were 46% (n = 12), 15% (n = 3), and 0%, respectively (P > .001).

CONCLUSION: Reconstruction of the aortic arch with excision of ductal and coarctation tissue is associated with lower aortic arch obstruction rates in patients undergoing the Norwood procedure. Arch reconstruction with a novel interdigitating technique decreases the incidence of aortic arch obstruction.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
Aortic arch obstruction (AAO) after the Norwood procedure has been reported to be as high as 20% to 36% 1–5 Go and is a significant cause of morbidity and mortality. From a clinical standpoint, postoperative neoaortic obstruction causing increased afterload can result in ventricular dysfunction, poor systemic output, and tricuspid regurgitation. Prior reports suggest that 7% to 8% of deaths after the Norwood procedure might be attributable to AAO. 6,7 Go Since the Norwood procedure’s original description, 8 Go several modifications of arch reconstruction have been described. The purpose of this study was to determine whether there were AAO differences among 3 distinct arch reconstruction techniques used at the Hospital for Sick Children, Toronto, Ontario, Canada.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
We reviewed infants who underwent the Norwood procedure and survived to stage II palliation at the Hospital for Sick Children, Toronto, between February 1991 and December 2002. During this period, our technique for aortic arch reconstruction in patients undergoing the Norwood procedure has evolved. Early in our experience, we incised across the coarctation and used a homograft patch to reconstruct the coarctation site, as well as the hypoplastic arch (classic group, n = 26; Figure 1). Beginning in 1998, we opted to excise the coarctation and ductal tissue before reconstruction. The arch was reconstructed by anastomosing the distal aorta, aortic arch, and main pulmonary artery together, as described by Fraser and Mee 9 Go (autologous group, n = 20; Figure 2). More recently, we have used a novel technique involving complete coarctation excision with an extended end-to-end anastomosis on the back of the arch. A 1- to 2-cm counterincision is made on the anterolateral aspect of the descending aorta. A homograft patch is sutured from the descending aorta along the underside of the arch to the ascending aorta for total arch reconstruction (interdigitating group, n = 33; Figure 2).


Figure 1
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  		Figure 1. Classic technique. The arch anatomy is examined (A), the patent ductus arteriosus is ligated, and an incision is made across the coarctation (B). The aortic arch is reconstructed with a homograft patch (C). Ao, Aorta; LCA, left carotid artery; LSA, left subclavian artery; PA, pulmonary artery; PDA, patent ductus arteriosus; RCA, right carotid artery; RSA, right subclavian artery; SVC, superior vena cava.

 

Figure 2
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  		Figure 2. Autologous and interdigitating techniques. An incision is made across the coarctation (A), and the periductal area is completely excised. In the autologous technique (B and C) the arch is reconstructed by anastomosing the aortic arch, distal aorta, and main pulmonary artery together. In the interdigitating technique (B1 and C1) 2 longitudinal incisions are made in the anterior and posterior walls of the descending aorta (B1.a), and an extended end-to-end anastomosis is constructed between the distal aortic arch and the posterior descending aorta (B1). A homograft patch is then used to reconstruct the remainder of the arch (C1). Ao, Aorta; LCA, left carotid artery; LSA, left subclavian artery; PA, pulmonary artery; RCA, right carotid artery; RSA, right subclavian artery; SVC, superior vena cava.

 
Primary diagnoses for the overall cohort are shown in Table 1, with a majority having hypoplastic left heart syndrome. Of the 50 patients with hypoplastic left heart syndrome, 12 had aortic atresia. Demographic characteristics for each of the 3 surgical technique groups are shown in Table 2.


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  		TABLE 1. Diagnoses of 79 patients undergoing the Norwood procedure
 

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  		TABLE 2. Demographic comparison of 79 patients who had 3 types of aortic arch reconstruction in the Norwood procedure
 
Cardiac catheterizations performed before stage II palliation were reviewed to obtain aortic diameter in 5 locations. The following angiographic measurements were taken: aorta at the level of the ascending aorta, transverse arch, left subclavian artery, distal neoaortic anastomosis, and descending aorta. Coarctation index (CI) was calculated as the ratio of the distal neoaortic anastomosis to the descending aorta. 10,11 Go AAO was defined as a CI of less than 0.7. 11 Go Patient records, subsequent angiograms, and operative reports were reviewed for AAO intervention.

Data are described as frequencies, medians with ranges, or means with SDs as appropriate. Intergroup comparisons were made by using {chi}2 or Fisher exact tests for categoric variables and t tests or analysis of variance for continuous variables. General linear regression was used to define associations between continuous variables and CI, and multiple linear regression allowed comparison of CI after accounting for baseline differences among groups. All statistical analyses were performed with SAS Version 8 statistical software (SAS Institute, Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
Aortic angiographic measurements are shown in Table 3. The aorta at the level of the transverse arch and the left subclavian artery was significantly larger in the interdigitating group compared with in the classic group. However, the size of the aorta at the distal neoaortic anastomosis was similar in all 3 groups.


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  		TABLE 3. Mean aortic angiographic measurements after the Norwood procedure
 
CIs for the classic, autologous, and interdigitating groups were 0.68 ± 0.21, 0.91 ± 0.16, and 1.1 ± 0.16, respectively (P > .001). After accounting for age at the time of the Norwood procedure, weight, and sex, the autologous group had a higher CI than the classic group (P > .001), and the interdigitating group had a significantly higher CI than both the classic (P > .001) and autologous (P = .002) groups.

Overall, 15 (19%) children had AAO requiring intervention. The mean gradient for the AAO at cardiac catheterization was 21.3 ± 13.3 mm Hg. Diagnoses of the patients requiring intervention were hypoplastic left heart syndrome in 12 patients (1 with aortic atresia), transposition of the great arteries in 1 patient, mitral stenosis in 1 patient, and univentricular heart in 1 patient. AAO rates for the classic, autologous, and interdigitating groups were 46% (n = 12), 15% (n = 3), and 0%, respectively (P > .001). Thirteen of the 15 children with AAO were treated with percutaneous balloon angioplasty. Three of these children required repeat balloon dilation. Three children (1 after balloon angioplasty and 2 as primary treatment) were treated surgically with a patch angioplasty at the time of stage II palliation. Table 4 demonstrates the variables associated with postoperative AAO. Arch reconstruction technique, as well as distal neoaortic anastomosis size, descending aorta size, and CI, were all significantly associated with postoperative AAO.


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  		TABLE 4. Association of variables with postoperative aortic arch obstruction and their univariable significance
 

   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
AAO of the distal neoaortic anastomosis after the Norwood procedure is a frequently reported complication. Starnes and colleagues 4 Go and Zellers 5 Go have reported AAO rates of 33% and 36%, respectively. Because most children undergoing the Norwood procedure already have decreased ventricular function, it is understandable that AAO is not well tolerated. By increasing afterload, ventricular function and tricuspid regurgitation worsen, whereas systemic blood flow decreases. Coronary flow is compromised after an increase in systole time. Increased stress on a single right ventricle with shunt-dependant physiology is poorly tolerated. Fraisse and associates 2 Go reported a higher risk of death in Norwood survivors who had AAO compared with those who did not (relative risk, 5.9). In addition, treatment of AAO with balloon dilation has inherent risk. Tworetzky and coworkers 1 Go reported 2 (25%) of 8 patients requiring cardiopulmonary resuscitation and inotropic support after cardiac decompensation during balloon angioplasty.

Several theories exist as to the cause of AAO after the Norwood procedure. Contributing factors include residual ductal tissue and surgical technique. Machii and Becker 12 Go examined the histology of 5 hypoplastic left heart specimens. In 4 specimens they found ductal tissue extending into the aorta both proximally and distally from the ductal orifice. They concluded that coarctation was due to this extension and emphasized the importance of aortic augmentation beyond the site of coarctation. In children in whom we did not excise the coarctation tissue (classic group), the AAO rate was significantly higher (46%) than in the groups in which ductal tissue was excised (autologous [15%] and interdigitating [0%] groups). We strongly believe that complete coarctation excision is one of the keys to avoiding postoperative AAO.

Even if the ductal tissue is grossly resected, AAO can occur. The interdigitating technique herein described provides a tapering distal anastomosis, with any potential residual ductal tissue being split longitudinally in an anterior and posterior position. The longitudinal incisions are augmented with autologous tissue posteriorly and pulmonary homograft anteriorly, hence the interdigitating designation.

The limitations of this study should be addressed. As Table 2 demonstrates, the time from the Norwood procedure to cardiac catheterization was least in the interdigitating group. Whether this earlier catheterization time could have influenced the recoarctation rate cannot be said for certain. Table 2 shows that the descending aorta in the classic group was significantly larger than in the interdigitating group. This could possibly be due to poststenotic dilation. This increased number would decrease the CI. Of note is that the decision to intervene was based not just on the CI but also on angiographic appearance, as well as hemodynamics. Another limitation is the lack of complete hemodynamic data on the patients without AAO. However, Lemler and colleagues 11 Go demonstrated that the CI correctly predicted a nonobstructed aortic arch in all of their patients without AAO. Furthermore, their CI correlated with their catheter-measured gradients (r = –0.78, P > .001). Nonetheless, having the complete hemodynamic data might have provided more insight.

In conclusion, excision of the ductal and coarctation tissue and the use of an interdigitating repair during Norwood arch reconstruction are associated with decreased AAO rates. Our novel technique of reconstruction with an interdigitating anastomosis decreases postoperative AAO.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

  1. Tworetzky W, McElhinney DB, Burch GH, Teitel DF, Moore P. Balloon arterioplasty of recurrent coarctation after the modified Norwood procedure in infants. Catheter Cardiovasc Interv. 2000;50:54-58.[Medline]
  2. Fraisse A, Colan SD, Jonas RA, Gauvreau K, Geva T. Accuracy of echocardiography for detection of aortic arch obstruction after stage I Norwood procedure. Am Heart J. 1998;135:230-236.[Medline]
  3. Ishino K, Stumper O, De Giovanni JJV, et al. The modified Norwood procedure for hypoplastic left heart syndrome. early to intermediate results of 120 patients with particular reference to aortic arch repair. J Thorac Cardiovasc Surg. 1999;117:920-930.[Abstract/Free Full Text]
  4. Starnes VA, Griffin ML, Pitlick PT, et al. Current approach to hypoplastic left heart syndrome. palliation, transplantation, or both?. J Thorac Cardiovasc Surg. 1992;104:189-195.[Abstract]
  5. Zellers TM. Balloon angioplasty for recurrent coarctation of the aorta in patients following staged palliation for hypoplastic left heart syndrome. Am J Cardiol. 1999;84:231-233.[Medline]
  6. Bartram U, Grunenfelder J, Van Praagh R. Causes of death after the modified Norwood procedure. a study of 122 postmortem cases. Ann Thorac Surg. 1997;64:1795-1802.[Abstract/Free Full Text]
  7. Weinberg PM, Chin AJ, Murphy JD, Pigott JD, Norwood WI. Postmortem echocardiography and tomographic anatomy of hypoplastic left heart syndrome after palliative surgery. Am J Cardiol. 1986;58:1228-1232.[Medline]
  8. Norwood WI, Lang P, Hansen DD. Physiologic repair of aortic atresia-hypoplastic left heart syndrome. N Engl J Med. 1983;308:23-25.[Medline]
  9. Fraser CD, Mee RBB. Modified Norwood procedure for hypoplastic left heart syndrome. Ann Thorac Surg. 1995;60(suppl):S546-S549.[Medline]
  10. Ramaciotti C, Chin AJ. Noninvasive diagnosis of coarctation of the aorta in the presence of a ductus arteriosus. Am Heart J. 1993;125:179-185.[Medline]
  11. Lemler MS, Zellers TM, Harris KA, Ramaciotti C. Coarctation index. identification of recurrent coarctation in infants with hypoplastic left heart syndrome after the Norwood procedure. Am J Cardiol. 2000;86:697-699.[Medline]
  12. Machii M, Becker AE. Nature of coarctation in hypoplastic left heart syndrome. Ann Thorac Surg. 1995;59:1491-1494.[Abstract/Free Full Text]



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This Article
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