Surgical treatment indication and approach
All surgical practitioners in our center followed the same protocol for
aortic arch surgery. We have a firm preference for performing one-step
complete arch reconstruction in neonates with CoA with VSD. Within the
Society of Thoracic Surgeons (STS) Congenital Heart Surgery database,
Ross and colleagues (5) identified 840 patients treated for CoA with
VSD, 211 (25%) of whom underwent VSD closure and 89 (11%) pulmonary
artery banding, whereas 540 (64%) did not undergo VSD closure. In this
study, in-hospital mortality proved low, without significant
between-strategy differences. In our center, HAA or CoA without VSD are
treated differently, depending on the lesion extent. Arch enlargement
plasty via median sternotomy is our preferred approach for severe
proximal HAA cases. This also applies to any aortic Segment I hypoplasia
with a Z-score <-3 and diameter inferior to body weight (Kg)
+1mm. Similarly, we prefer this approach for managing supra-aortic
artery abnormalities like bovine arch. Complete reconstruction via
median sternotomy and CPB enables good arch reconstruction without
requiring aortic clamping at the BCA’s origin. Of note, median
sternotomy enables us to simultaneously close any associated atrial
septal defect, thereby improving left ventricular preload. Optimizing
this preload further improves left ventricular development, and that of
the aorta downstream, potentially reducing reoperation rates (6). The
Sakurai and colleagues’ study involved 288 patients treated for CoA and
HAA without VSD over two decades. Their analysis revealed a trend
towards a higher number of sternotomies during the second decade (36%
vs. 6%), along with a significantly low reoperation rate (5% vs. 16%,
p=0.02) (7).Complete reconstruction via lateral thoracotomy, using the
extended Crafoord technique (8) without CPB, is the approach we prefer
in case of isolated isthmic CoA, either small in size or extending as
far as Segment II .Over a 10-year period (2008–2019), we performed 180
lateral thoracotomies versus 31 median sternotomies, all age groups
taken together.