Outcomes of different surgical strategies in the treatment of neonates with aortic coarctation and associated ventricular septal defects.

BACKGROUND: We reviewed surgical results after treatment of aortic coarctation (CoA) associated with ventricular septal defect (VSD) in neonates. We examined morbidity associated with the two different therapeutic strategies of combined repair versus initial coarctation repair alone and attempted to identify preoperative predictors to guide optimal surgical management.

METHODS: Between 1990 and 2006, 141 neonates with CoA and VSDs underwent operation using two management strategies. In group A (n = 89), initial simple CoA repair was done through posterolateral thoracotomy, plus concomitant pulmonary artery banding (n = 54), followed by VSD closure. In group B (n = 52), both defects were repaired simultaneously through a sternotomy.

RESULTS: Overall 10-year survival was 90.8%, with no difference between groups. The 5-year freedom from arch reoperation was 93.5%, with no difference between groups. The 10-year freedom from reoperation for subaortic obstruction was 95% for group A and 75% for group B (p = 0.016). In group A, 41 patients required secondary VSD closure at a median interval of 48 days after CoA repair. Freedom from reoperation at 1 month and 5 years was 78.5% and 45.8% in group A versus 97.8% for both in group B. Preoperative predictors for requirement for later VSD closure in group A were VSD type other than muscular (p = 0.0009) and larger VSD identified by higher VSD diameter/aortic valve annulus ratio (p < 0.0001).

CONCLUSIONS: Results of both treatment strategies are good. Neonates with larger VSDs, especially outlet, malalignment, and perimembranous types, are likely to require VSD closure. Although midline sternotomy and combined treatment strategy may be necessary in neonates with proximal arch hypoplasia, initial coarctation repair alone is valid option at the possible expense of additional operation.