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J Thorac Cardiovasc Surg 2008;136:298-306
© 2008 The American Association for Thoracic Surgery
Surgery for Congenital Heart Disease |
a Department of Pediatric Cardiac Surgery, Hôpital Necker–Enfants Malades, Paris, France
b Department of Pediatric Cardiology, Hôpital Necker–Enfants Malades, Paris, France
Received for publication June 13, 2007; revisions received February 5, 2008; accepted for publication February 26, 2008. * Address for reprints: Pascal Vouhé, MD, Department of Pediatric Cardiac Surgery, Hôpital Necker–Enfants Malades, 149 rue de Sèvres, 75015 Paris, France. (Email: pascal.vouhe{at}nck.ap-hop-paris.fr).
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Abstract |
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Methods: Data concerning all consecutive patients operated on for myocardial revascularization in our institution between 1992 and 2004 were retrospectively analyzed.
Results: Twenty-five patients (mean age, 5.3 years) underwent surgical arterioplasty of a main coronary trunk, and this was for coronary obstruction after the arterial switch operation in 19 patients. Eight patients (mean age, 8.0 years) underwent a coronary bypass, and this was for postoperative coronary obstruction in all of them. One patient died 4 days after arterioplasty because of cardiogenic shock. One patient died suddenly 3.5 months after bypass from an unknown cause. All other patients were alive after a mean follow-up of 3.4 years after arterioplasty and 4.4 years after bypass. Among the 3 patients in whom the surgical enlargement of the left main trunk was extended to the left anterior descending coronary artery, 2 presented a restenosis of this artery and necessitated a coronary bypass 2.6 and 5.7 years, respectively, after arterioplasty. Among patients who had a postoperative angiogram, 17 (89%) of 19 after arterioplasty and 3 (50%) of 6 after bypass showed a good result. A internal thoracic artery graft was occluded, another one showed a complete string sign, and, finally, a patient presented with a tight stenosis of the bypass distal anastomosis. Eighteen (72%) patients after arterioplasty and 5 (63%) after bypass remained symptom free at last follow-up.
Conclusions: Provided that the left main coronary artery bifurcation was not involved in the stenotic process, surgical arterioplasty of the main coronary trunks led to good functional and anatomic midterm results. On the other hand, variable indications and poorer preoperative cardiac conditions might have contributed to the disappointing results observed after coronary bypass.
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Introduction |
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We have therefore investigated patients on a systematic basis after ASO and operated on those with severe stenosis of a major coronary trunk and evidence of myocardial ischemia.3 This situation is challenging for several reasons. First, expertise has to be gained for reliable assessment of myocardial ischemia and viability in children. Second, when surgical intervention is indicated, one can choose between 2 revascularization techniques: surgical arterioplasty (coronary artery proximal patch arterioplasty [CAPPA],
Figure 1) or coronary artery bypass grafting (CABG), a more conventional treatment.
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The present article reports our assessment of the functional and anatomic midterm results achieved with both CAPPA and CABG in infants and children in our institution.
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Materials and Methods |
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Tables 1 and 2.
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Eight patients (mean age, 8.0 ± 4.1 years; range, 2.6–13.0 years) had a CABG, including 6 left internal thoracic artery (LITA)–LAD grafts. Indications were postoperative coronary obstruction in all patients. Patient 30 presented with an obstruction of the LAD originating from the RCA underneath a right ventricle (RV) to PA conduit inserted during the repair of a tetralogy of Fallot. Patient 32 had a modified Konno operation and right ventricular outflow tract enlargement for hypertrophic cardiomyopathy associated with the repair of an anomalous aortic origin of the RCA with intramural course. Patient 33 had a modified Bentall procedure and RV–PA conduit replacement after a neonatal repair of type I truncus arteriosus; he presented postoperatively with complete heart block and severe ischemic cardiomyopathy and underwent technically challenging CABG for LMCA occlusion 1 year later. Finally, patient 31 had a myocardial infarction at the end of a Ross procedure and required an emergency internal thoracic artery grafting to the LAD.
The coronary anatomy distribution for the patients who underwent an ASO was as follows: a usual coronary anatomy in 14 patients; coronary patterns with anterior loops, posterior loops, or both in 6 patients; and coronary arteries coursing between the great arteries in 1 patient. Four patients (nos. 5, 16, 17, and 26) had, during the ASO, a particular technique of coronary transfer in which the coronary ostia were reimplanted side-by-side in the neoaorta (single-orifice technique)7; this technique was abandoned after 1993 because of a high incidence of coronary obstruction.8 The median interval between ASO and myocardial revascularization was 6.0 years (range, 28 days to 13.5 years). It was 2.6 years (range, 1–9.4 years) for other operations.
Indication for Revascularization
Surgical intervention was indicated when a significant coronary obstruction was associated with findings suggestive of myocardial ischemia. Some patients were asymptomatic at the time of diagnosis, with no signs of ischemia either on electrocardiographic, echocardiographic, or scintigraphic analysis; coronary lesions were found incidentally during routine coronary angiography. These patients were treated medically, and revascularization was delayed until an obvious ischemia could be shown. In addition, fluorodeoxyglucose–positron emission tomography demonstrated myocardial viability in 3 patients (nos. 3, 27, and 33) in whom redistribution was incomplete at rest within the area of the perfusion defect. The mean interval between the diagnosis of coronary obstruction and myocardial revascularization was 23.4 ± 34 months (range, 8 days to 8.5 years); the median interval was 4.7 months.
Surgical Technique
Surgical arterioplasty (Figure 1)
After median resternotomy, standard cardiopulmonary bypass (CPB) was established, the aorta was crossclamped, and myocardial preservation was achieved through hot-induction blood cardioplegia, repeated cold blood cardioplegia, and warm reperfusion. In recent years, CPB was conducted on normothermia with repeated hot blood cardioplegia. For left coronary artery arterioplasty, in patients with normally related great vessels, as well as in patients with previous translocation of the great arteries, the main pulmonary trunk was transected, and both pulmonary stumps were freed from the surrounding structures to allow adequate exposure of the aortic root and left main stem. The incision was started on the anterior aspect of the aortic root and was extended toward the involved coronary ostium. In stenotic lesions the incision was extended across the stenotic area until a normal coronary artery wall was reached. In 3 patients (nos. 5, 12, and 22) the incision was extended to the LAD. In occluded lesions the left main stem beyond the obstruction was opened, and both aortic and coronary incisions were joined together across the occluded area. An onlay patch was used to enlarge not only the main coronary stem but also the adjacent 1 to 2 cm of the aortic incision to give the new coronary ostium a funnel shape. The remaining aortic incision was closed directly. A saphenous vein patch was used in 19 patients, and a fresh autologous pericardial patch was used in 3 patients; the patch was tailored in the innominate vein in 2 patients, and expanded polytetrafluoroethylene onlay patches were used in patient 19. When supravalvar aortic stenosis was associated with coronary obstruction, the sinotubular junction was enlarged between all 3 commissures by using 3 separate patches of pericardium (3-patch repair), and in the left aortic sinus the incision was extended toward the roof of the LMCA.
CABG
Standard techniques were used for internal thoracic artery dissection and anastomoses. Those anastomoses were made with 8-0 monofilament running sutures. In patient 27 the internal thoracic artery was anastomosed end-to-end to a transected LAD artery.
Adjunct surgical procedures were enlargement of pulmonary trunk stenosis in 6 patients (associated with translocation of the great arteries in 1 patient), Brom aortoplasty in 3 patients, RV–PA conduit replacement in 2 patients, repair of aortic recoarctation in 1 patient, atrial septal defect closure in 1 patient, and the Ross operation in 1 patient.
Postoperative Investigations
Patients were followed at least every year, myocardial ischemia was documented on electrocardiograms, echocardiograms, and/or myocardial perfusion images (thallium 201 scintigraphy at rest and during exercise or after injection of dipyridamole). Nineteen (76%) of 25 patients undergoing CAPPA and 6 (75%) of 8 patients undergoing CABG patients underwent selective coronary artery angiography through the femoral arterial approach after achievement of local anesthesia.
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Results |
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Hospital Events
Patient 18 had a persistent myocardial ischemia after ASO, with aortic root angiography showing equivocal results. He underwent an RCA arterioplasty 4 weeks later. He could be weaned from CPB, but both ventricles remained severely hypokinetic, and the patient died 4 days later in the intensive care unit (ICU). Autopsy demonstrated a globally ischemic myocardium with patent coronary arteries. In patient 31 the postoperative course was difficult (11 days in the ICU), with necessary mechanical assistance: 4 days of left ventricular assist device support followed by 4 more days of intra-aortic balloon pumping. Postoperative coronary angiography was not done. This patient remained in mild-to-moderate cardiac failure after hospital discharge because of ischemic cardiomyopathy. Postoperative recovery was uneventful in the other 31 patients, without any documented ischemic events during hospital stay. Mean length of stay in the ICU was 2.8 ± 1.2 days (range, 2–6 days) after CAPPA and 3.9 ± 3.4 days (range, 1–11 days) after CABG.
Follow-up
One patient (no. 20) was lost to follow-up. Patient 32 died suddenly 3.5 months after surgical intervention despite an uneventful perioperative course. This patient had a previous operation to relieve a biventricular hypertrophic cardiomyopathy; echocardiographic analysis after revascularization showed a good left ventricular function and no residual ventricular outflow tract obstruction, and an autopsy was not done. All other patients were alive after a mean follow-up of 3.4 ± 3.1 years (range, 2.4 months to 11.2 years) for CAPPA and 4.4 ± 2.8 years (range, 11.2 months to 8.7 years) for CABG. Patients 12 and 22 underwent reoperations 2.6 and 5.7 years, respectively, after arterioplasty for restenosis of the LAD, with good patency of the repaired LMCA in both cases. They underwent coronary bypass, which led to a good result for patient 12 (patient 28) and to graft occlusion, diagnosed 3 years after reoperation, for patient 22 (patient 29). In the last patient, who presented with Williams syndrome, the LAD was found to be diffusely small during the CABG.
Eighteen (72%) of 25 patients undergoing CAPPA had no symptoms and received no cardiac medication but antiplatelet therapy. Two (nos. 3 and 23) still required angiotensin-converting enzyme inhibitor therapy and presented with limited residual perfusion defects on myocardial perfusion imaging studies; echocardiographic analysis showed mild dilated cardiomyopathy in patient 3 and diastolic ventricular dysfunction with moderate mitral regurgitation in patient 23. The last patient presented with severe congestive heart failure before repair of anomalous left coronary artery originating from the PA and required 6 days of left ventricular assistance after this first operation; afterward, he had persistent left ventricular dysfunction. In a subset of 19 (76%) patients undergoing CAPPA who underwent coronary angiography, 17 (68%) presented with a good patency of the repaired main stem. Among the 4 patients who did not have postoperative angiography, 3 were symptom free.
Five (63%) of 8 patients undergoing CABG had no symptoms. Among them, 2 presented with unsatisfying angiographic results: patient 30 had a diffuse narrowing of the arterial graft (string sign) without angina or myocardial ischemia on thallium studies. Patient 29 had a graft occlusion with a residual anterior perfusion defect. The LAD distribution was well collateralized from the RCA and the circumflex artery, and the left ventricular function was relatively preserved; in view of the previous 2 surgical procedures and absence of symptoms, a new revascularization procedure was not attempted. In patient 33, despite the fact that preoperative fluorodeoxyglucose–positron emission tomographic scanning showed myocardial viability, the severe left ventricular dysfunction did not improve after the operation; angiographic analysis 3 months after revascularization revealed a tight stenosis at the distal anastomotic site, which was not accessible to a percutaneous angioplasty, and this patient was treated medically.
The last myocardial scintigram and the last coronary angiogram were obtained at an average of 3.7 ± 3.0 years (range, 2 months to 9.1 years) and 2.2 ± 1.7 years (range, 20 days to 5.1 years) after the operation, respectively.
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Discussion |
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Between 1987 and 2006, 755 neonates underwent an ASO at our institution (same surgeon). Among 713 late survivors, 290 (41%) had at least 1 selective coronary angiogram, which showed coronary obstruction in 34 patients.3 Among them, 15 patients did not have surgical revascularization either because surgical intervention was deemed impossible or hazardous (2 patients) or because there was, at that time, no evidence of myocardial ischemia (13 patients).3 A previous study, also from our institution, reported 36 coronary events in 34 patients after 432 consecutive ASOs (study period, 1987–1999). Coronary events included 16 fatal and 9 nonfatal myocardial infarctions and 12 reoperations.9 Coronary imaging after ASOs consisted of selective coronary angiography and was performed for one of the following reasons: (1) presence of electrocardiographic signs, echocardiographic signs, or both suggestive of myocardial ischemia any time after the operation; (2) presence of unusual coronary patterns (coronary arteries coursing between the great arteries) or intraoperative difficulties in coronary transfer, usually during the first postoperative year; (3) use of a single-orifice technique for coronary reimplantation; and (4) routinely in all patients before 5 years old, in the current era. Although detailed anatomy of the obstructed coronary artery and collateral vessels can be obtained by means of selective angiographic analysis, this procedure carries a certain amount of risk for the patient.10 On the other hand, multislice computed tomography is a relatively noninvasive technique that proved effective in detecting ostial and proximal coronary lesions after the ASO in a recent study.11 Thus our current policy is to perform coronary imaging by using coronary angiography, multislice computed tomographic angiography, or both in the situations listed earlier, and because the lesions are most probably progressive, those tests should be repeated at regular intervals during late follow-up after ASOs.
In many cases coronary obstruction was found in asymptomatic patients, and surgical intervention was delayed as long as there was no clear evidence of myocardial ischemia, either at rest or under stress conditions. Our study shows that coronary lesions after the ASO can be successfully enlarged by means of surgical arterioplasty with low operative mortality (there was 1 perioperative death in the CAPPA group). Thereafter, to prevent potential sudden death and to preserve ventricular function, one can speculate whether myocardial revascularization should be done as soon as coronary obstruction is diagnosed, even in the absence of obvious ischemia. However the long-term patency rate of this procedure and the fate of the patch material remain to be evaluated. The patient who died in the CAPPA group (no. 18) had previously had a neonatal ASO and remained in poor hemodynamic condition for 4 weeks after the operation because of persistent myocardial ischemia. Clinical features were misleading, and both diagnosis of coronary obstruction and revascularization came too late. The ventricles had already suffered irreversible ischemic damage at the time of reoperation, and death resulted from biventricular incompetence, despite patent coronary arteries.
Few studies have reported the use of CAPPA in pediatric patients. With 10 patients, our institution reported 8 years ago the largest series of this procedure in children.12 Since then, a few authors have reported its use in various indications. Prêtre and Turina13 operated on 3 children for coronary obstruction after the ASO, LMCA stenosis associated with supravalvar aortic stenosis, and a sequel of Kawasaki disease, with good results in each case. One author has reported a successful arterioplasty using a "pantaloon"-shaped autologous pericardial patch to enlarge a stenosis involving both the LMCA and RCA originating from a single ostium, which was obstructed after an ASO.14
In adult patients this technique is used for atherosclerotic lesions, with good results provided that some selection criteria are respected: patients with isolated noncalcified lesions confined to the proximal half of the coronary trunk are the best candidates.13,15 Meseguer and colleagues16 also reported that stenoses extending into the LMCA branches are at greater risk for thrombosis after proximal coronary arterioplasty. In our study, among the 3 patients in whom the incision was extended to the LAD coronary artery because of ostial or proximal stenosis of this artery, 2 (nos. 12 and 22) presented with a restenosis of the LAD that necessitated a coronary bypass. One hypothesis is that injury to the LAD can lead to constrictive vascular remodeling, as observed after balloon angioplasty.17 However, in patient 22 with Williams syndrome, the stenosis might be related to the progressive luminal narrowing that complicates the arteriopathy of the syndrome. Indeed, for this patient, the internal thoracic artery bypass also led to graft occlusion.
We never used, even in the less favorable cases of coronary arterioplasty, a combination of CAPPA and CABG in the same patient. Mavroudis and associates18 reported using this method in 4 patients. For 2 of them, the early postoperative angiographic studies were satisfying, whereas the repeat coronary angiograms 2 and 2
years later showed a string sign of the internal thoracic artery in both patients, with a good patency of the repaired left main trunk. The 2 other patients had a good early anatomic result but no late angiographic restudy.18 It is of course difficult to draw conclusions with only 4 patients, but it could be argued that in this setting the bypasses were probably unnecessary, at least for the 2 patients who had the string signs. They also indicate the use of the autologous aortic or PA wall because of the ease of manipulation and genetic homogeneity of this material.18 We mainly used a saphenous vein patch. Long-term follow-up should help us to determine the type of material that is best applicable for this purpose.
CABG with the ITA is technically feasible in small infants and children,5,19 with good results.18 In the patients reported on here, CABG led to unsatisfying results, with only 5 (63%) of 8 patients in good functional status, 3 (38%) of 8 patients with good angiographic results, and 1 patient with unexpected late death. Proportionately, patients in this group were in worse preoperative or perioperative states than patients in the CAPPA group. Three patients had at least 2 previous major operations, including 2 who had a failed myocardial revascularization (nos. 28 and 29) and 1 who had a very poor cardiac status before the operation (no. 33); the last patient continued to have severe heart failure after the operation. The patient who had an emergency CABG presented with a myocardial infarction with severe impairment of ventricular function during the operation, which incompletely improved afterward. Similarly, in the study by Mavroudis and associates,18 patients with severe ventricular insults during previous operations or catheterization exhibited poor improvement in ventricular function after surgical revascularization, despite patent bypass grafts. Finally, 3 patients in our study, including the one with severe cardiac failure (no. 33), exhibited unsatisfying angiographic results.
First was a graft occlusion (patient 29). The occluded LITA was grafted on a small LAD, probably related to a Williams syndrome arteriopathy. The patient was asymptomatic afterward, and collateral vessels probably had time to develop before the graft became blocked.
Second was a string sign or diffuse narrowing of the LITA, with a target LAD artery exhibiting a 75% to 90% narrowing on preoperative angiographic analysis (patient 30). This patient did not have angina or myocardial ischemia on thallium imaging after the string sign. In a multicenter randomized study 2 factors were independently associated with the emergence of a string sign on grafted radial arteries: perioperative use of 
-adrenergic agonists and target vessel stenosis of less than 90%.20
Finally, a tight anastomotic stenosis happened in a patient who had several previous operations and in whom the dissection of the LAD artery was difficult (patient 33). Furthermore, the conduit was unusual (free left subclavian artery) because both ITAs were unusable.
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Conclusions |
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TopAbstractIntroductionMaterials and MethodsResultsDiscussionConclusionsReferences |
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Internal thoracic artery bypass should be reserved for more distal lesions, long and complete occlusions of the main stem, or residual obstruction after primary surgical arterioplasty. In our series this procedure led to disappointing results, probably favored by the fact that indications in this group of patients were not as homogeneous as in the arterioplasty group.
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Footnotes |
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References |
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