Approach Of The Strategic Decision Of The Treatment Of Aoctic Coarctation In Infant And Children

BackgroundCoarctation of the aorta(CoA) is a stenosis which involved the region of the ligamentum arteriosum. CoA always associated with other congenital cardiac defects in infant, and has a high mortality, if not treated. As the development of the deep hypothermic circulatory arrest(DHCA) and the deep hypothermic with low flow rate(DHLF) in cardiopulmonary bypass(CPB), and the conjunctive use of angioplasty and surgery, the viability of the infant with CoA ascend. However, the problem of recoarctation which acurred after the therapy still puzzled the cardiothoracic surgeon. The surgical technical modification is always performed for the lower morbidity of the recoarctation, and endovascular management of the CoA has evolved over the past two decades, though these provide the possibility for the successful treatment of CoA, the optimal management is still controversial.ObjectiveIn this project,the outcome of the management were compaired in all kinds of surgery techniques,especially between the surgical and endovascular management and between different age groups patients.And then to find the factors that affect the recurrent coarctation after the treatment,to discuss the prospect of application and extension of the conjunctive use of angioplasty and surgery.SubjectsSurgery Group(43 patients):Male 27,Femal 16.The range of age was from 9 days to 9 years and 3 months,with the mean age 15.9±27.2months.And the range of weight was from 3kg—21kg,with the mean weight 4.5±1.4kg.There were 16 cases of Simple CoA,27 cases were suffered from CoA with other heart malformation.Resection and end to end anastmosis in 8 patients,Radically extended end to end anastomosis in 11 patients,Left subclacian patch aortoplasty in 10 patients,Pulmonary autograft patch aortoplasty in 10 patients,Pericardium autograft patch aortoplasty in 2 patients,Gortex patch aortoplasty in 2 patients.Median sternotomy for one stage repair in 20 patients,Through left posterolateral thoracotomy repair in 24 patients.Balloon angioplasty Group(22 patients): Male 12,Femal 10.The range of age was from 7 months to 13 years,with the mean age 69.3+49. 1 months,and the range of weight was from 8kg—37kg,with the mean weight in 23±19.8kg.Simple CoA in 14 patients(with PDA in 5 patients),CoA with VSD in 3 patients,CoA with AS in 3 patients,recoarctation in 2 patients.MethodsRecoarctation is defined as peak-to-peak systolic pressure between arms and legs gradient ≥20 mmHg,and with the same time the Echocardiographic Doppler gradient is higher than 20 mmHg.The peak-to-peak systolic pressure between arms and legs gradient and the Echocardiographic Doppler gradient was determined at preoperative,one-day,three-months,six-months,one-year after the operative.The recoarctation patients and calculation the recoarctation morbidity was recorded.The outcome of all kinds of surgery techniques was compaired, the recoarctation morbidity was compaired between the surgical and endovascular management and between the younger-than-2-years-old patients and older-than-2-years-old patients with statistical analysis. Results1. The recoarctation morbidity of Surgery treatment Group was 5.7%,and that in endovascular management Group was 16.7%. The difference between the surgical and endovascular management Group was not significant.( 0.25 < P < 0.5)2. The recoarctation morbidity of younger-than-2-years-old patients is 5.6%, and that in older-than-2-years-old patients is 17.6%. And the difference between the surgical and endovascular management was not significant.( 0.25 < P < 0.5)3. Radically extended end to end anastomosis and left subclacian patch aortoplasty were the better techniques.Conclusion1. The presence of symptoms is absolute indication for surgery for infant CoA as soon as possible.2. It regards that the optimal approach is to repair the coarctation associated with a VSD as soon as possible.3. Radically extended end to end anastomosis is the better technigue for treatment infant CoA.4. The conjunctive use of angioplasty and surgery has certain advantage for the treatment of the infant CoA.