Challenges In Surgical Treatment Following Bail-out Stenting For High-risk Patients With Critical Neonatal Coarctation Of The Aorta
Philippe Grieshaber, MD1, Moritz Merbecks, MD1, Christoph Jaschinski, MD1, Elizabeth Fonseca, MD1, Stojan Lazarov, MD2, Matthias Gorenflo1, Tsvetomir Loukanov, MD1.
1University Heidelberg, Heidelberg, Germany, 2National Heart Hospital, Sofia, Bulgaria.
Objectives:Coarctation of the aorta (CoA) in infants is usually treated by surgical repair. However, under certain high-risk constellations, primary bail-out stenting may be considered followed by surgical repair during the first months of life. We report our experience with this staged approach in 26 patients.Methods:All patients who underwent surgical CoA repair after primary stenting at our institution between 2011 and 2019 were included in this retrospective analysis. Patient characteristics and outcomes were analyzed. Results:Twenty-six neonates received stent implantation (median length 12mm) at a median age of 21days (IQR 9-30days). Subsequent surgical repair was conducted at an age of 3.0months (IQR 2.5-4.0months) with a median body weight of 5.6kg (IQR 4.5-6.5kg). Cardiopulmonary bypass was applied in 96% of cases. Median bypass time was 99min. (IQR 86-112min.). Extended end-to-end anastomosis was possible in 11 patients. Extended reconstruction with xenopericardial (n=4) or autologous (n=2) patch or homograft material (n=9) was necessary in the remaining patients. In four patients, stent remnants needed to remain in situ. Postoperative ventilation duration was 1.0day (IQR 0.3 to 2.3days) with an intensive care unit stay of 4.8days (IQR 3.9-6.8days). The aortic peak velocity was reduced from preoperative 3.0m/s (IQR 2.6-3.4m/s) to 2.1m/s (IQR 1.4-2.6m/s). One fatality (3.8%) occurred 33days postoperatively. At a median follow-up of 3.7years, all remaining patients were alive. 20/25 patients (80%) were free from re-intervention.Conclusions:Neonatal bail-out stenting for CoA results in increased complexity of the subsequent surgical therapy. Nevertheless, this staged approach enables treatment of high-risk patients with reduced perioperative risk and good mid-term outcomes.
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