Extended end-to-end repair and enlargement of the entire arch in complex coarctation

Background Treatment of hypoplasia of the entire arch in coarctation is a s urgical challenge. The current approaches have technical difficulties, high recurrence rates, and increased morbidity and mortality. Methods. Over a 14-month period, a combined extended end-to-end repair with patch enlargement of the concavity of the entire arch was performed in 6 n eonates and 1 infant; Through a midsternotomy and using cardiopulmonary byp ass and hypothermia, extended end-to-end repair was performed initially lea ving the proximal anastomosis open. The enlarging polytetrafluoroethylene p atch was then sutured starting at the incised descending aorta distal to th e extended end-to-end repair and continued retrogradely through the transve rse arch to the ascending aorta proximal to the aortic cannulation site. On e neonate had a patent ductus arteriosus and another had ventricular septal defect closure. One neonate had arterial switch and 3 had Norwood-type pro cedures performed with the enlarging patch extended to the pulmonary artery anastomosis. The remaining infant had arch enlargement performed after an arterial switch procedure and extended end-to-end repair. Results. All patients did well and showed no residual gradient up to 1 year follow-up. Two patients successfully had bidirectional Glenn shunt at 9 mo nths of age, and one had closure of residual arterial septal defect at 8 mo nths of age. Conclusion. The combined extended end-to-end repair and arch enlargement pr ocedure should minimize recurrence rates because of a tension-free enlargem ent of the entire aortic arch and elimination of the coarctation ridge and ductile tissues. Combined with the arterial switch and Norwood-type procedu res, the approach results in a large neoaorta. (C) 1999 by The Society of T horacic Surgeons.