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.