REPAIR OF COARCTATION OF THE AORTA IN NEONATES AND INFANTS - A 30-YEAR EXPERIENCE

Between January 1962 and December 1991, 179 children less than 1 year of age underwent repair of coarctation of the aorta. Group I (1962 to 1971) consisted of 19 patients, group II (1972 to 1981) of 57 patients , group III (1982 to 1991) of 103 patients. Neonates (<30 days old) ma de up 60% of group I, 57% of group II, and 70% of group III. The propo rtion of infants with associated complex cardiac abnormalities was 7% in group I, 25% in group II, and 39% in group III. Techniques of repai r included resection with end-to-end anastomosis (n = 65), subclavian nap repair (n = 85), patch aortoplasty (n = 18), and other procedures (n = 11). The early mortality (<30 days) was lowest in group III (grou p I, 21%; group II, 21%; and group III, 7%; p < 0.05), but the late mo rtality was similar in all groups (group I, 11%; group II, 13%; and gr oup III, 15%). The overall actuarial survival was 57.7% +/- 0.15% at 2 7.1 years in group I, 65.7% +/- 0.07% at 19.7 years in group II, and 7 7.5% +/- 0.04% at 9.3 years in group III (p = not significant). Twenty -five restenoses requiring intervention occurred in 23 patients, for a n overall restenosis rate of 16.4%. The incidence of restenosis was 23 % for the patients who underwent end-to-end anastomosis, 11% for those who underwent subclavian nap repair (p < 0.1), and 27% for those who underwent patch aortoplasty (p < 0.01). Balloon angioplasty was succes sful in relieving 11 of the 12 restenoses in groups II and III. The me an interval (+/- the standard deviation) between repair of coarctation of the aorta and definitive intracardiac repair decreased from 61.5 /- 43.5 months in group I to 41.8 +/- 45.5 months in group II and 10.3 +/- 13.7 months in group III (p < 0.001). Twenty-eight variables (var ious patient characteristics, presenting signs and symptoms, managemen t and operative variables, and severity of disease) were subjected to a Cox proportional hazards multivariate regression analysis to determi ne predictors of restenosis and mortality. Only patch aortoplasty was significantly associated with restenosis (p < 0.01). Increasing age at operation and the use of monofilament nonabsorbable suture were signi ficantly associated with freedom from restenosis (p < 0.02). Younger a ge at operation, the need for concomitant pulmonary artery banding, an d the existence of associated cardiac abnormalities were significantly associated with early mortality (p < 0.01). This retrospective review revealed that (1) subclavian nap aortoplasty is associated with the l owest rate of restenosis after repair of coarctation during infancy, a nd, conversely, patch aortoplasty is significantly associated with res tenosis; (2) the restenosis rate is significantly lower in association with the use of monofilament nonabsorbable suture than with the use o f other suture material; (3) the early mortality after coarctation rep air has decreased significantly in the current era, despite a higher p roportion of infants with complex cardiac malformations; and (4) late mortality is associated with younger age at operation and the presence of severe associated cardiac anomalies, and this has remained constan t during the three decades covered by this study.