Modification of the subclavian patch aortoplasty for repair of aortic coarctation in neonates and infants

Background. Coarctation repair in neonates or small infants, using a subcla vian patch, has a relatively high risk of restenosis,especially if complica ted by the presence of a short subclavian artery or long coarctation segmen t. We introduce a technical modification that facilitates the use of a subc lavian flap, and decreases the restenosis rate in this subgroup of patients . It consists of a side-to-side transverse aortic anastomosis at the level of the coarctation, which widens the coarctation segment, shortens the isth mus, and pulls the distal end of the aortotomy proximally, allowing a tensi on-free subclavian flap aortoplasty. Methods. Fifty-three consecutive neonates or infants less than 18 weeks old , with complex coarctation, underwent repair using this technique. Mean age was 26 +/- 3 days and 36 patients (68%) were less than 28 days old. Weight s ranged from 1.4 to 6.4 kg (mean 3.4 +/- 0.2 kg), and 26 patients had othe r cardiac anomalies. Preoperative gradient by Doppler measurement ranged fr om 25 to 90 mm Hg (mean 49 +/- 2 mm Hg). Results. Mean aortic cross-clamp time was 27 +/- 1 minutes (range 19 to 34 minutes). There were no deaths or surgical complications. Follow-up echocar diogram 4 to 52 months postoperatively (mean 25 +/- 2 months) demonstrated Ilo significant pressure gradient (less than 20 mm Hg) in 51 of 53 patients (96%), and a significant gradient in 2 patients (4%), which was subsequent ly corrected with balloon angioplasty. Conclusions. The technical modification described shortens the isthmus, and thus allows for a longer aortotomy distal to the area of coarctation resul ting in a tension-free repair especially in patients with a short subclavia n artery. It also widens the area of coarctation, and as a result leads to a lower early recoarctation rate in this high-risk group. With increasing e mphasis on the need for a longer aortotomy to prevent restenosis, this modi fication will have increasing application, especially in the neonatal popul ation.