Management of arch hypoplasia after successful coarctation repair

Background. Pronounced arch obstruction can be seen after a well-repaired coarctation, and this probably results from the failure of a somewhat hypoplastic arch to grow or from clamp injury at the time of the initial repair, or from both causes. Because of mediastinal adhesions and minimal collateral circulation, use of extraanatomic bypass grafts appears to be the preferred approach. Methods. Six children or young adults presented with arch obstruction over a 3-year period. Their mean age was 13.5 ± 4 years, and the mean interval from the time of the initial repair was 10 ± 4 years. The mean age of the patients at the time of the initial repair was 3.2 ± 5 years. Symptoms included exertional headache and chest pain. The mean systolic gradients, as shown by echocardiography and cardiac catheterization, were 34 ± 7 mm Hg and 33 ± 6 mm Hg, respectively. Repair was accomplished through a midsternotomy using a polytetrafluoroethylene patch placed in the concavity of the arch, which extended from the ascending to the descending aorta. Dissection was kept close to the aorta and arch to minimize injury to the phrenic and recurrent laryngeal nerves. Cardiopulmonary bypass and moderate hypothermia (25°to 27°C bladder temperature) without circulatory arrest were used. Results. All patients were discharged home 4 to 20 days postoperatively (mean, 7 ± 6 days). All patients were found to be normotensive at a mean follow-up of 1.3 ± 1 years. Postoperative echocardiograms, which were obtained in all patients, revealed no residual gradients. Exercise blood pressure was evaluated in 2 patients and found to be normal. Conclusions. Transsternal arch enlargement using cardiopulmonary bypass and moderate hypothermia without circulatory arrest is an attractive and safe approach for the treatment of arch obstruction after coarctation repair. Unlike the use of extraanatomic bypass grafts, it allows complete relief of the obstruction, unhampered aortic growth, the minimal use of foreign material, and a repair that is protected deep within the mediastinal space.