Single-stage repair of aortic coarctation with ventricular septal defect using isolated cerebral and myocardial perfusion

Objective: To avoid hypothermic circulatory arrest, we have repaired aortic coarctation with ventricular septal defect (VSD) in a one-stage procedure using an isolated cerebral and myocardial perfusion technique, and retrospe ctively compared this novel approach to the conventional two-stage approach . Methods: Between October 1991 and February 1999, 14 infants, aged 4-137 d ays (median, 27 days) and weighing 1.7-4.3 kg (median, 3.0 kg), underwent t he repair of aortic coarctation with VSD either in one (group I, n = 11) or two stages (group II, n = 13). In Group I, an arterial cannula for cardiop ulmonary bypass was inserted into the ascending aorta in six patients with coarctation only, or into a polytetrafluoroethylene (PTFE) graft which was anastomosed to the innominate artery in the remaining five who had hypoplas tic arches. A cross-clamp was placed between the innominate and left caroti d arteries. The bypass flow was reduced to 30-50% of full flow at 28 degree s C, thereby maintaining a radial artery pressure of 30-45 mmHg. At this po int, the aortic coarctation was repaired by an end-to-end arch anastomosis, while maintaining brain perfusion and with the heart still beating. In fiv e patients with hypoplastic aortic arches, the innominate artery proximal t o the graft was then secured down and the arch anastomosis was extended to the distal ascending aorta, while providing isolated cerebral perfusion and cardioplegic arrest. After arch reconstruction was performed, the clamp wa s moved onto the ascending aorta, and the VSD was closed with systemic perf usion. In contrast, for group II patients, coarctation repairs were perform ed through a posterolateral approach, and existing VSDs were closed as seco ndary procedures. Results: The mean isolated cerebral and myocardial perfus ion time for group I was 13 min (range, 7-20 min). The myocardial ischemic time did not differ between groups I and II (43 +/- 4 vs. 42 +/- 5 min, not significant). There were no hospital mortalities or neurological complicat ions in either group, but one late death in each group. Conclusion: Single- stage repair of aortic coarctation with VSD does not increase myocardial is chemic time compared to the traditional two-stage approach. The isolated ce rebral and myocardial perfusion technique may offer substantial brain and m yocardial protection during aortic arch reconstruction. (C) 2000 Elsevier S cience B.V, All rights reserved.