MANAGEMENT OF ARCH HYPOPLASIA AFTER SUCCESSFUL COARCTATION REPAIR

Background. Pronounced arch obstruction can be seen after a well-repai red coarctation, and this probably results from the failure of a somew hat hypoplastic arch to grow or from clamp injury at the time of the i nitial repair, or from both causes. Because of mediastinal adhesions a nd minimal collateral circulation, use of extraanatomic bypass grafts appears to be the preferred approach. Methods. Six children or young a dults presented with arch obstruction over a 3-year period. Their mean age was 13.5 +/- 4 years, and the mean interval from the time of the initial repair was 10 +/- 4 years. The mean age of the patients at the time of the initial repair was 3.2 +/- 5 years. Symptoms included exe rtional headache and chest pain. The mean systolic gradients, as shown by echocardiography and cardiac catheterization, were 34 +/- 7 mm Hg and 33 +/- 6 mm Hg, respectively. Repair was accomplished through a mi dsternotomy using a polytetrafluoroethylene patch placed in the concav ity of the arch, which extended from the ascending to the descending a orta. Dissection was kept close to the aorta and arch to minimize inju ry to the phrenic and recurrent laryngeal nerves. Cardiopulmonary bypa ss and moderate hypothermia (25 degrees to 27 degrees C bladder temper ature) without circulatory arrest were used. Results. All patients wer e discharged home 4 to 20 days postoperatively (mean, 7 +/- 6 days). A ll patients were found to be normotensive at a mean follow-up of 1.3 /- 1 years. Postoperative echocardiograms, which were obtained in all patients, revealed no residual gradients. Exercise blood pressure was evaluated in 2 patients and found to be normal. Conclusions. Transster nal arch enlargement using cardiopulmonary bypass and moderate hypothe rmia without circulatory arrest is an attractive and safe approach for the treatment of arch obstruction after coarctation repair. Unlike th e use of extraanatomic bypass grafts, it allows complete relief of the obstruction, unhampered aortic growth, the minimal use of foreign mat erial, and a repair that is protected deep within the mediastinal spac e. (C) 1997 by The Society of Thoracic Surgeons.