End-to-side anastomosis and autologous pulmonary artery patch for aortic coarctation and hypoplastic aortic arch

Introduction

Aortic coarctation (CoA) is a complicated congenital abnormality that accounts for 6–8% of congenital heart diseases (CHDs) (1). CoA can appear alone or in combination with other CHD, including ventricular septal defect (VSD), patent ductus arteriosus (PDA), bicuspid aortic valve (BAV), double outlet of the right ventricle (DORV), and transposition of the great arteries (TGA) (2,3). Some studies have suggested that the hypoplastic aortic arch (HAA) should be considered when the coarctation segment involves the aortic arch (4,5). CoA often combines different degrees of HAA with a proportion of as high as 81% (6,7). Recently, surgery is the main treatment (8). If HAA is not treated properly, it may increase the risk of aortic recoarctation (reCoA). Currently, end-to-side anastomosis (ESA) and autologous pulmonary artery patch (APAP) are mainstream surgeries. ESA requires fewer surgical steps and less time, but the rebuilt aortic arch geometry is closer to Gothic (G-AAg), which increases the risk of reCoA, elevated blood pressure (EBp), and even hypertension. Although better aortic geometry can be achieved with APAP, aneurysm development is always a cause of concern. Limited clinical data currently exist that compare the outcomes of the both surgeries. The goal of this study was to analyze the available data and summarize the experience of ESA and APAP in CoA and HAA to enrich the clinical experience. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1635/rc).

Methods

Study population

First, this was a single-center retrospective study. The target population was patients with CoA and HAA who underwent surgery between 2015 and 2021. The cases are consecutive, and no cases were excluded due to missing data, lack of consent, or other reasons. Gender, age, and weight at the time of surgery were collected, as well as the coarctation segment and pressure gradient measured by echocardiography. The aorta was measured by computed tomography (CT) and its related Z-score, including aortic arch height (A) and width (T). Arm-leg systolic blood pressure gradient (cuff), time of operation, cardiopulmonary bypass (CBP), aortic cross-clamp (AAC), intensive care unit (ICU) hospitalization, complications, and follow-up data (mortality, re-intervention) were recorded. All the data come from the hospital medical record system. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board, Children’s Hospital of Chongqing Medical University (No. 258-1) and individual consent for this retrospective analysis was waived.

ReCoA was defined as a pressure gradient at the repair site reported by transthoracic echocardiography greater than 20 mmHg and the systolic blood pressure gradient of the arm-leg was greater than 20 mmHg, or needed to be re-intervened (balloon angioplasty, stent implantation, or surgery). Hypertension was defined as a systolic and/or diastolic blood pressure above the 95th percentile of age and height. Newborns were defined as within 30 days after birth, and early death was defined as death before discharge or within 30 days after the operation.

Statistical analysis

The Kolmogorov-Smirnov test was used to examine the normality of the continuous variables. Values were presented as mean ± standard deviation (SD) or median (P25, P75). Student’s t-test, analysis of variance (ANOVA), or Wilcoxon signed-rank test was performed depending on the type of distribution. The Chi-squared test was used to compare the rates or ratios. The cumulative survival rates of avoiding G-AAg, EBp, and ReCoA were calculated using the Kaplan-Meier (K-M) curve and log-rank test. Cox regression analysis was used to analyze the influence of variables on the different outcomes. All statistical analyses were performed using SPSS (version 26.0) and GraphPad Prism software (version 9.0), and statistical significance was defined as P<0.05.

Results

Table 1 presents the baseline patient characteristics. The study included 96 patients (67 male and 29 female). They were divided into two groups based on surgery: 59 ESA (G1) and 37 APAP (G2). The surgical age in the G2 group was lower. No significant difference was observed in weight.

There were 14 newborns, and the PDA was not statistically significant. Two of them received prostaglandin E1 perioperatively (both in G2).

Approximately 4/5 patients had VSD (80/96), particularly in G2 (P=0.004). Similarly, the G2 group had a higher incidence of ASD (P=0.003). The incidences of airway stenosis and other CHD did not differ significantly between the groups.

The aortic arch in G2 was slightly smaller than that in G1, but no significant difference was observed in any segment, according to our analysis of the Z-score.

CBP and deep hypothermic circulatory arrest (DHCA) are two important surgical procedures. We performed the procedure on 85 patients who underwent median sternotomy and employed selective antegrade cerebral perfusion (SACP) to protect brain function because of possible risks. The operation time was longer in G1 (P<0.001), AAC (P<0.001), and SACP (P<0.001) because of the need to trim the pulmonary artery patch and repair the pulmonary artery defect (Table 2).

Three patients died of low cardiac output syndrome and hemorrhagic shock (two in G1 and one in G2). None of the 93 patients who survived had neurological events or renal failure, and no significant difference was observed in the time of mechanical ventilation, ICU admission, or postoperative hospitalization (Table 3).

Figure 1 shows the changes in the systolic blood pressure gradient of the arm-leg. We found that the preoperative gradient was similar and decreased significantly postoperatively (G1, P<0.001; G2, P<0.001). On the first postoperative day, there was no significant difference in the invasive blood pressure gradient, but the gradient of G2 was significantly lower than that of G1 on the third postoperative day and at discharge (the third postoperative day, P=0.03; at discharge, P<0.001). The G1 gradient gradually increased during hospitalization, reaching 13.00 (8.00, 14.00) mmHg at discharge, while it steadily decreased in G2, and finally reached 2.89±0.78 mmHg at discharge.

Figure 1 The average systolic blood pressure gradient from preoperative to discharge. APAP, autologous pulmonary artery patch; ESA, end-to-side anastomosis.

Ultimately, 93 patients (57 in G1 and 36 in G2) were successfully followed, with a period of 46.20 (34.40, 54.70) months. The results are presented in Table 3. All incidences of G-AAg, EBp, and reCoA happened within 2 years of the surgery. There were 21 patients had G-AAg and no late death. ReCoA affected 13 patients (12 in G1 and one in G2, P=0.04), and a CT scan showed that the aortic arch geometry of 12 in G1 was closer to Gothic than normal (Figure 2), whereas that of one in G2 was not. Of the 13 patients, two had aortic balloon dilatation (one in G1 and one in G2), and both recovered well. Two intended to have balloon dilatation (all in G1), while the close regular follow-up of the remaining nine patients continued. Fourteen patients had EBp (13 in G1 and one in G2, P=0.04), 2 of whom had hypertension. They underwent balloon dilation due to reCoA, and their blood pressure returned to normal. The remaining 12 patients underwent regular follow-up. Additionally, we discovered that two (all in G1) had no airway compression or stenosis on preoperative CT 3D-reconstruction, but exhibited it in follow-up without corresponding clinical symptoms. They did not pick the fiberoptic bronchoscope for further evaluation and decided to maintain close follow-up and no such situation was observed in G2. Meanwhile, we found no signs of aneurysm, aortic valve dysfunction, or permanent left laryngeal nerve injury during the follow-up. In G2, no evidence of pulmonary valve dysfunction was found.

Figure 2 CT, the aortic arch geometry is closer to Gothic. CT, computed tomography.

Cox regression analysis showed that ESA was a risk factor for G-AAg, EBp, and reCoA (Table 4). The K-M curve showed that the survival rate without G-AAg was 77.4% and G2 was 91.7%, significantly higher than that in G1 (Figure 3A, multivariate Cox regression, P=0.03). Regarding EBp (84.9%), G2 was 97.2%, significantly higher than G1 (Figure 3B, multivariate Cox regression, P=0.04). Analysis of reCoA showed that G2 was 97.2%, which was also significantly higher than that in G1 (Figure 3C, multivariate Cox regression, P=0.04).

Figure 3 Freedom after discharge. (A) G-AAg. (B) EBp. (C) reCoA. APAP, autologous pulmonary artery patch; ESA, end-to-side anastomosis; HR, hazard ratio; CI, confidence interval; G-AAg, aortic arch geometry is closer to Gothic; EBp, elevated blood pressure; reCoA, aortic recoarctation.

Discussion

CoA often combines HAA and other CHD. The situation is intricate, and mortality is high (9), and the risk of postoperative hypertension and aortic arch re-intervention is also significantly increased (10,11). If the diagnosis is clear, immediate treatment should be carried out (12). The typical surgical indication in clinical practice is a gradient above 20 mmHg at the coarctation segment or a 50% reduction in the diameter of the restricted segment (13). Additional indications include evidence of obvious coarctation and identification of collateral circulation through imaging examinations (3). However, there are currently no clear diagnostic criteria for HAA. This study referred to the criteria of the CHD database. Specifically, the diameter of the aorta between the innominate artery and left common carotid artery was less than 60% of that of the ascending aorta, the diameter of the aorta between the left common carotid artery and left subclavian artery was less than 50%, and the diameter of the aortic isthmus was less than 40% (14). Other criteria include that the diameter of the transverse aortic arch (mm) is smaller than the patient’s weight (kg) +1 (15), the diameter of the transverse aortic arch is less than 50% of that of the diaphragm descending aorta (16), and the Z-score of the diameter of the proximal aortic arch is less than −2 (17).

Several studies propose “blood flow theory” to explain relationship between CHD and CoA and HAA (18,19). Specifically, fetal hemodynamics are believed to have a significant impact on the formation and remodeling of the aortic arch. When CHD results in a left-to-right shunt, it reduces the blood flow through the left ventricle and aorta, weakening the stimulating growth effect on the aorta, which may eventually result in aberrant aortic development, CoA, and HAA. Approximately 80% of the patients in this study had VSD, whereas 70% had ASD. There is still no consensus on the optimal choice of surgical strategy for this type of patients right now (20). When making a plan, it is imperative to consider age, anatomical configuration of the aortic arch, and other CHD that may require simultaneous repair, which will affect the decision between median sternotomy and lateral thoracotomy as well as the need for CBP, DHCA, and SACP. Some studies have reported that a one-stage approach using median sternotomy can achieve good results (3,21). Nearly 90% had this strategy in this study, two died of low cardiac output syndrome and hemorrhagic shock (the other one underwent lateral thoracotomy), and few serious complications. Meanwhile, analysis of follow-up also supported these findings, indicating that the surgical approach of one-stage repair via median sternotomy is both safe and effective.

DHCA is a crucial technique in aortic arch surgery; however, it cannot stop brain metabolic activity. Over time, the physiological metabolic activity of the body becomes abnormal, and the risk of neurological complications and death increases (22). With the development of surgical technology, SACP can offer continuous support for cerebral blood flow, reduce the possibility of brain injury, and provide beneficial outcomes (23,24). We performed SACP, and no neurological events were detected during follow-up. These results were acceptable.

ESA can be performed by connecting the descending aorta to the distal end of the ascending aorta or the proximal aortic arch. However, in certain patients, the distance between the two ends of the anastomosis is excessively long, and the G-AAg postoperatively, and associated abnormal arch hemodynamics, which is one of the important reasons for reCoA (25,26). Simultaneously, the area beneath the reconstructed aortic arch diminishes, leading to compression of the bronchi. Over time, complications, such as bronchial stenosis and even left atelectasis may occur (27).

In contrast, patch aortoplasty can be performed without altering the geometric configuration of the aortic arch, which may be beneficial. Various types of patch materials are available, including artificial materials, autologous pericardium, and APAP (28). Some researchers have chosen polyester or polytetrafluoroethylene patches to repair the aortic arch. However, related research indicates that these artificial materials lack the physiological elasticity of normal blood vessels, and the tension and pressure at the repair site are uneven, making aneurysms and reCoA more likely (29,30). A study by Walhout et al. reported 118 patients who underwent repair with an artificial patch; the aneurysm rate was 7% over the follow-up (31). Later, researchers began to focus on autologous pericardial patches. Although it has the advantages of good hemostasis, strong flexibility, and low immunogenicity, it has been reported that the treated pericardial patch is an independent risk factor for reCoA, which may be because pericardial patch contracture offsets the growth potential of autologous tissue to some extent (32).

Notably, the pulmonary artery and aorta develop from the truncus arteriosus, which has superb homology, good histocompatibility, good elasticity, and potential for growth with age, making it a relatively ideal material (33,34). According to previous reports, the results of the APAP therapy are acceptable. Wen et al. revealed that throughout a median follow-up of 24 months, no aneurysm or reCoA was discovered (28). Twenty-three patients with APAP were described by Roussin et al. (35), the results of early and mid-term follow-up were favorable in comparison to the pericardial patch, and no patients experienced reCoA or aneurysm. A study by Xu et al. reported that the mid-term follow-up of APAP was also good; the rates of avoiding reCoA were 95.5% and 72.1% at 1 year and 3 years after discharge, respectively (36).

Blood pressure plays a critical role in long-term prognosis (37,38). Lee et al. reported the repair of HAA with ESA through median sternotomy (39). During the 18-year follow-up period, the survival rate was 93%, and 87% of the patients did not require reoperation. However, 10% of the patients were diagnosed with hypertension and 17% had prehypertension. This may be due to the geometry of the aortic arch after surgery. The Gothic aortic arch is characterized by an acute angle formed by the ascending and descending aorta as well as a shortened or absent horizontal part of the arch (40). The proportion of hypertension in patients with Gothic arch structure obviously increased, even if the gradient across the repaired area measured by echocardiography or the arm-leg gradient measured by the cuff was normal following surgery. The incidence of exercise-induced hypertension 15 years after surgery was 83%, whereas that in patients with a normal arch structure was 21% (41). However, postoperative hypertension is uncommon in patients receiving APAP therapy. Wen et al. did not observe any obvious gradient, and the aortic arch blood flow was unobstructed during follow-up (28).

Notably, the patch is constrained by the size of the pulmonary artery. The requirements for arch expansion cannot be satisfied if the amount of material is small. Thankfully, pulmonary hypertension is typically present in CoA and HAA, and even pulmonary artery dilatation, which somewhat reduces the difficulty of acquiring a patch. In addition, surgeons should take care to keep the incision away from the sinus and pulmonary artery branches to prevent pulmonary valve regurgitation and pulmonary artery stenosis caused by surgical injury. Finally, the pulmonary artery sampling defect was filled with the pericardium. In this study, the outcome was acceptable and no signs of pulmonary valve dysfunction were observed.

All patients in this study had CoA and HAA. We found that G2 had more VSD and ASD, a smaller aortic arch, and younger age. It is possible that G2 was more serious, and surgery needed to be completed as soon as possible to improve hemodynamics. The analysis showed that G2 required a longer operation time and AAC time. Thus, the duration of SACP was also increased to protect the brain function. Fortunately, neither during hospitalization nor during follow-up, G2 did not have serious complications under the influence of these factors. Meanwhile, there was no significant increase in the duration of mechanical ventilation, ICU stay, or hospitalization. Thus, we speculate that with the proper use of SACP, APAP can improve management of the aortic arch, prevent excessive anastomotic tensione, and G-AAg without raising the associated risks and benefit patients for a long time. Finally, treatment does not terminate when surgery is performed. They require routine follow-up, especially long-term follow-up, by professionals to identify any possible risks early and take appropriate action.

There are several limitations on this study. First of all, this is a retrospective study, which has its limits. At the same time, our follow-up time is relatively short, so patients with possible reCoA and EBp had not been identified. However, since all cases of reCoA and EBp in the study happened within 2 years after surgery, we do not think that this limitation would have an impact on the research. Meanwhile, the suspected airway stenosis had not been validated using fiberoptic bronchoscopy, so it is impossible to comprehensively evaluate the impact of surgery on postoperative airway stenosis. In the future, a longer follow-up term and prospective cohort study may increase understanding and assist surgeons in developing more optimized strategies.

Conclusions

In summary, one-stage repair through median sternotomy is safe and effective for CoA and HAA, and other CHD. Compared with ESA, APAP may lower the risks of G-AAg, EBp, and reCoA, providing more benefits. When circumstances allow, we recommend expanding the application of APAP to reconstruct the aortic arch. Even if it takes longer operation time, the related risks can be greatly reduced by the proper use of SACP.

Acknowledgments

We would like to appreciate all people who contributed to this study.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1635/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1635/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1635/prf

Funding: This work was supported by the Chongqing Science and Technology Bureau (No. CSTC2021jscx-gksb-N0018).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1635/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board, Children’s Hospital of Chongqing Medical University (No. 258-1) and individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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