DECISION-MAKING FOR THE SURGICAL-MANAGEMENT OF AORTIC COARCTATION ASSOCIATED WITH VENTRICULAR SEPTAL-DEFECT

Coarctation of the aorta and associated ventricular septal defect may be repaired simultaneously or by initial coarctation repair with or wi thout banding of the pulmonary artery. The question is whether specifi c preoperative criteria can enable the surgeon to choose the optimal s urgical management. Between 1980 and 1993, 80 infants younger than 3 m onths with coarctation and ventricular septal defect were treated surg ically, In 64 infants (multistage group), simple coarctation repair wa s performed through a posterolateral approach, with concomitant bandin g of the pulmonary artery in 10 infants, Twenty ventricular septal def ects were closed as a secondary procedure and four were closed as a te rtiary procedure, Sixteen infants (single-stage group) underwent one-s tage repair through an anterior midline approach. The total in-hospita l mortality rate was 7.5%. Freedom from recoarctation after 5 Sears wa s 91.3% in the multistage group versus 60.0% in the single-stage group (p = 0.018). Freedom from secondary ventricular septal defect treatme nt in the multistage group after 5 years was 40.7%, versus 100% in the single-stage group (p = 0.016). Thirty-seven ventricular septal defec ts (47.8%) closed spontaneously, In particular, the preoperative left- to-right shunt and extension of the perimembranous VSD into the inlet or outlet were risk factors for the need for eventual surgical ventric ular septal defect closure after initial coarctation repair. On the ba sis of these two risk factors, the probability of the need for eventua l surgical treatment of ventricular septal defect after initial coarct ation repair can be calculated. This policy offers a well-considered c hoice between single-stage and multistage repair, weighing the risk of secondary ventricular septal defect treatment versus the risk of reco arctation. Finally, the number of surgical procedures per infant will be as low as possible.