SURGICAL-MANAGEMENT OF NEONATAL COARCTATION

Between 1983 and 1994, 307 consecutive neonates underwent coarctation repair by a single surgical technique: extended end-to-end anastomosis , Mean age at operation was 13 +/- 8 days, Isolated coarctation was pr esent in 95 patients (group 1), 102 patients had associated ventricula r septal defect (group 2), and 110 patients had associated complex int racardiac lesions (group 3), Aortic arch hypoplasia was present in 81% of the patients (62% in group 1 versus 85% in group 2 and 93% in grou p 3: p < 0.001), In 271 patients, the aortic arch reconstruction was p erformed via a left thoracotomy with normothermia (100% of group 1, 95 % of group 3 and 72% of group 3); in the other 36 patients, undergoing one-stage repair or palliation of the associated lesion, it was perfo rmed via a midline sternotomy during a short period of deep hypothermi a and circulatory arrest (5% of group 2 and 28% of group 3), Pulmonary artery banding was performed in 94 patients, Spontaneous ventricular septal defect closure was observed in 39% of the patients of group 2 o perated on via thoracotomy, Early mortality rates in groups 1 (2%) and 2 (2%) were significantly lower than in group 3 (17%) (p < 0.001). Th ere were 29 late deaths, all related to associated cardiac lesions or their subsequent repair. The overall total mortality was 16.9%. In gro up 3 this rate was significantly higher in patients undergoing two-sta ge procedures (47%) than in those undergoing one-stage repair (23%) (p < 0.05). All but 14 survivors were followed up for a mean of 61 +/- 3 6 months, Actuarial survivals at 10 years were 98% in group 1, 94% in group 2, and 60% in group 3, The recoarctation rate was 9.8%, leading to 21 reoperations and three angioplasties without mortality, Patients with a more extended or severe form of aortic arch hypoplasia had a s ignificantly higher risk of recoarctation (p < 0.001), Actuarial freed om from reoperation for recoarctation at 10 years was 93%. The finding s of this study suggest that extended end-to end anastomosis provides an adequate and safe repair of neonatal coarctation, Law recoarctation rate, owing to effective relief of the obstruction created by aortic arch hypoplasia and to complete resection of ductal tissue, freedom fr om major morbidity, and feasibility via both lateral and anterior appr oaches are the main advantages of the extended end-to-end anastomosis, Mortality is mainly dependent on the complexity of the cardiac associ ations, Successful management of the majority of the neonates with coa rctation and associated ventricular septal defect is possible with rep air of coarctation alone, One-stage repair of neonatal coarctation and associated complex heart defects (with indication for two-ventricle r epair) by means of an anterior approach provides a better outcome than a two-stage repair.