Early and late results of surgical treatment of coarctation of the aorta in infants less than six months of life--including the propriety of pulmonary artery banding

During an 8-year period, 53 infants less than six months of life underwent repair of coarctation of the aorta (CoA). Preoperatively 58 percent of patients received intensive circulatory and/or respiratory care. The diagnosis was established by echocardiography and counter current aortography via a radial artery in the majority of recent cases and the surgical relief of CoA was effected within 24 hours of the diagnosis. The last 51 patients were managed under the policy of simple repair of the CoA in patients with significant VSD (Group II), with the addition of pulmonary artery banding for patients with complex cardiac lesions with VSD (Group III) or for patients with incremental risk factors in Group II such as prematurity of body weight of less than 1500 gm, other organ anomalies requiring major operation in neonate, pulmonary complications or severe malnutrition. There was no intraoperative death, one (2%) postoperative and five (10%) late deaths among the lost 51 patients. Only one (2%) showed sign of recurrence among 46 patients followed for 16-112 (mean 47) months.(ABSTRACT TRUNCATED AT 250 WORDS)     

Early and late results of surgical treatment of coarctation of the aorta in the first three months of life

Forty infants under 3 months of age underwent repair of coarctation of the aorta (CoA) during an 8-year period. Preoperatively, 55% of the patients received intensive circulatory and/or respiratory care, and surgical relief of CoA was effected within 24 hours of diagnosis. The last 38 patients were managed by simple repair of the CoA in patients with significant VSD (Group II), with the addition of pulmonary artery banding in patients with complex cardiac lesions with VSD, or patients with incremental risk factors in Group II. There were no intraoperative deaths, one (2.6%) postoperative, and four (11%) late deaths in the last 38 patients. Only one (2.9%) showed signs of recurrence in 34 patients followed for 10 to 104 (mean 46) months. Improvement in the survival rate in this study can be attributed to: (1) aggressive preoperative care, (2) early noninvasive diagnosis and operation, (3) refinement in the surgical technique, and (4) appropriate use of pulmonary artery banding.     

Surgical treatment of interrupted aortic arch in infants under three months of age

From March, 1982, through March, 1988, 8 infants less than 3 months of age underwent surgical treatment of interrupted aortic arch. Five patients had IAA type A and 3 patients had type B. Seven patients with associated VSD underwent staged operations and 1 infant with aortopulmonary window underwent primary repair off cardiopulmonary bypass. Aortic arch reconstruction was by subclavian aortic anastomosis (6) or large tube graft (8 mm) interposition (2) combined with pulmonary artery banding (5). All seven patients with associated VSD survived the first-stage operation. One patient subsequently underwent pulmonary artery banding, two underwent patch aortoplasty and four patients underwent intracardiac repair and removal of a pulmonary artery band, with six survivors (86%). The operative death occurred in an infant in whom modified Damus-Kaye-Stansel operation was carried out for severe subaortic stenosis, which rerouting all left ventricular blood through VSD and the main pulmonary artery into the ascending aorta and reconstructing right ventricular-distal pulmonary artery connection by a valved external conduit. All six surviving patients are doing well at present (mean follow up of 3 years) without any significant pressure gradient between the ascending and thoracic aorta. Based on these data we conclude: (1) Aortic arch reconstruction and pulmonary artery banding can be reliably performed even in critically ill infants with IAA and isolated VSD. (2) The primary repair will provide better chance of survival in infants with IAA associated with significant LVOTO, truncus arteriosus or aortopulmonary window that do not readily lend themselves to pulmonary artery banding.     

Results of surgical treatment of coarctation of the aorta in the critically ill neonate. Including the influence of pulmonary artery banding

During a 7 year period, 64 consecutive neonates (less than 30 days of age) underwent surgical repair of coarctation of the aorta. There were no intraoperative deaths, four (6%) postoperative deaths, and seven (12%) late deaths. Improvement in the survival rate in this study can be attributed to improved perioperative care, avoidance of hypothermia during the operation, use of prostaglandin E1 to stabilize the patient's condition before the operation, emergency cardiac catheterization and operations, adequate relief of the aortic obstruction, and appropriate use of pulmonary artery banding. The last of these factors may further reduce the mortality. Banding of the pulmonary artery in patients with complex cardiac lesions associated with a ventricular septal defect has significantly lowered the mortality compared with the mortality of those without pulmonary artery banding. In contrast, the absence of pulmonary artery banding in those with a large ventricular septal defect did not affect the mortality or postoperative ventilator requirements as compared to patients having banding and coarctation repair. One late death was related to complications of the pulmonary artery band.     

Surgical management of transposition of great arteries associated with multiple ventricular septal defects.

OBJECTIVE: The presence of associated multiple ventricular septal defects (VSDs) increases the risk of the anatomic repair for transposition of the great arteries (TGA). The aim of this study was to define the optimal management of this complex anomaly. METHODS: Between January 1988 and December 1998, 45 patients underwent anatomic repair of TGA associated with multiple VSDs. The median age was 50 days and the median weight 4 kg. Eighteen (40%) had undergone previous palliation including 17 pulmonary artery banding procedure (PAB), seven associated with coarctation repair and one isolated coarctation repair. The perimembraneous septum was involved in 24 patients, the trabecular in 43, the inlet in seven and the infundibular in two. Closure of the VSDs included Dacron or pericardial patchs and matress sutures. The initial approach was through right atriotomy which was sufficient in 15 patients. VSDs were closed through right ventriculotomy in 13 patients, through pulmonary artery in six, through the aorta in one and in the remaining (n = 10) combined approaches were used. Only one patient required left apical ventriculotomy. RESULTS: There were five hospital deaths (11%; 70% CL: 6-18%) including the one early reoperation for residual VSD closure. Five patients had successful early reoperation for secondary PAB for residual VSD. Three late deaths occurred (7%; 70% CL: 3-13%). At the last visit, 95% of survivors were asymptomatic and without any cardiac medication. CONCLUSION: Mid-term survival with good quality of life can be achieved following either one or two-stage repair of this complex anomaly. In the presence of VSD closure failure a secondary PAB may be the procedure of choice.     

Repair of aortic coarctation in the first three months of life: immediate and long-term results

The optimum surgical procedure for treatment of coarctation of the aorta in the neonatal period remains controversial. To assess immediate and long-term results of using primarily the subclavian flap angioplasty procedure (SFA), we reviewed our initial 5-year experience. The average follow-up was 6 years. From 1977 to 1981, 25 infants under 3 months of age (1 to 86 days, mean 21) required emergency surgery for repair of coarctation of the aorta. Three groups of patients were identified. Group I consisted of 10 patients with or without patent ductus arteriosus. In group II, 10 patients had coarctation association with one or multiple ventricular septal defects (VSDs) without other congenital defects. In group III, 5 patients had coarctation associated with more complex congenital heart lesions. Twenty-three SFAs and two patch aortoplasties were performed. No patient with isolated VSD was banded. All patients except one in group III with an associated atrioventricular canal survived initial hospitalizations. Four late deaths occurred, all in patients with associated complex heart defects. There were three recurrent coarctations requiring surgery or balloon angioplasty (12%)--one in each group, with a total rate of 0.77 recurrences per 100 patient-months. SFA for coarctation in the neonatal period is a safe and effective operation with a low initial mortality (4%, 0-19%, 70% confidence limits) well tolerated in this group of ill patients. Long-term outcome is primarily related to the presence of associated complex congenital defects. Infants with VSD associated with coarctation did not require pulmonary artery banding unless primary intracardiac repair was not feasible.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical management of ventricular septal defects in infants

Infants with ventricular septal defect (VSD) who are symptomatic despite intensive medical therapy require surgical intervention. Choice of treatment depends upon the cumulative mortality and morbidity rates of the two-stage approach of initial pulmonary artery banding followed by debanding and VSD closure as compared to the risk of primary intracardiac repair in infancy. Sixteen infants underwent pulmonary artery banding at Columbia-Presbyterian Medical Center between 1967 and 1976, with one operative death but with a significant incidence of morbidity and late death. Forty patients underwent pulmonary artery debanding and closure of VSD with three operative deaths. This second-stage procedure was frequently complicated by repair of acquired lesions. During the same 10 year period 37 infants underwent primary closure of VSD with eight operative deaths. The morbidity related to this procedure is low. With the use of profound hypothermia and circulatory arrest, results have significantly improved and the risk of early correction now compares favorably with the cumulative mortality rate of the two-stage approach. Primary intracardiac repair is the procedure of choice.     

Reparative operations for interrupted aortic arch with ventricular septal defect

From January, 1975, through September, 1982, 24 infants underwent primary or staged repair of interrupted aortic arch (IAA) with ventricular septal defect (VSD). Seven patients had IAA type A and 17 patients had type B. Eleven of the patients, median age 5 days, underwent staged operations and 13 infants, median age 6 days, underwent primary repair. Palliation was by tube graft interposition (six), subclavian-aortic anastomosis (three), left carotid-aortic anastomosis (one), or end-to-side aortic anastomosis (one) combined with pulmonary artery banding (eight) or early VSD closure. With palliation, there were three (27%) early deaths among the eleven patients and one (13%) late death among the eight remaining. Delayed repair at 5 days to 14 months (median 7 months) in seven patients incurred three (43%) early and no late deaths. Primary repair in 13 patients consisted of VSD closure combined with graft interposition (12) or end-to-side aortic anastomosis (one), with three (23%) early and no late deaths. Nine of 14 survivors had hemodynamic evaluation by catheterization 1 to 3 years following repair. None had a significant residual VSD or pressure gradients between the ascending and thoracic aorta. Six had subaortic stenosis, two mild (gradient less than 20 mm Hg) and four severe (gradient greater than 50 mm Hg), necessitating operation. Results of operations in neonates with IAA continue to improve. Essential in management is an awareness that subaortic stenosis and hypocalcemia may be accompaniments of this anomaly. Based on these data, we prefer primary repair for IAA with VSD.     

Repair of type B interruption of the aortic arch. Results and follow-up

Surgical repair of type B interruption of the aortic arch and ventricular septal defect (VSD) in the newborn period is difficult and the optimal approach is controversial. We report here our early and late results using a two-staged approach in the repair of these lesions in seven consecutive neonates whose weights ranged from 2.9 to 3.8 kg and who were all less than 21 days of age. Each underwent aortic arch reconstruction off cardiopulmonary bypass with placement of a large (6 to 10 mm) polytetrafluoroethylene (PTFE) graft and pulmonary artery banding for interruption of the aortic arch (six) or extreme hypoplasia (one) of the arch. All seven (100%) survived the first-stage operation. No significant (greater than 10 mm Hg) conduit gradient was found in the seven patients studied 3 to 18 months postoperatively. One death occurred in a patient at 1 year of age with severe subaortic stenosis. Six patients subsequently underwent closure of VSD and removal of a pulmonary artery band, with five survivors (83%). The operative death occurred in an infant in whom pulmonary hypertension developed from an inadequate pulmonary artery band. One late death occurred at home when a tracheostomy tube, required because of severe tracheomalacia, became plugged. The long-term survival rate for completion of both stages is 57%. We conclude: (1) Aortic arch reconstruction and pulmonary artery banding can be reliably performed even in critically ill infants, and the 8 or 10 mm grafts should be adequate for several years. (2) Significant subaortic stenosis occurred in only one patient. (3) Pulmonary artery banding was the greatest source of difficulty, and distortion of the pulmonary arteries, inadequate banding, and compression of the trachea were all seen. Therefore, the staged repair will provide good results with this complex anomaly, and most of the problems associated with this approach may be eliminated by early second-stage repair.     

Pulmonary artery banding and ventricular septal defect enlargement in patients with univentricular atrioventricular connection and the aorta originating from an incomplete ventricle.

BACKGROUND: In patients with univentricular atrioventricular connection and the aorta originating from an incomplete ventricle, subaortic stenosis is generally due to a restrictive ventricular septal defect (RVSD), that may be present at birth or develop after palliative procedures. In particular, a primary role in the genesis of the RVSD has been ascribed to pulmonary artery banding (PAB). The aim of this paper is to analyse the possible risk factors for the development of an RVSD, including PAB, and the results of one of the proposed procedures for treatment of this condition (RVSD enlargement). METHODS: We retrospectively reviewed clinical records and outpatient records of 24 consecutive patients with univentricular atrioventricular connection and the aorta originating from the incomplete ventricle that received their first treatment at our institution from January 1991 to April 2000. The variables age, sex, weight, diagnosis, surgical procedures, associated anomalies, associated surgical procedures, were considered. RESULTS: Four patients (16.7%) had absent left atrioventricular connection, seven (29.7%) had absent right atrioventricular connection and discordant ventriculo-arterial connection, and 13 (54.7%) had double inlet left ventricle and discordant ventriculo-arterial connection. Five patients (20.8%) had associated coarctation or hypoplasia of the aorta, and eight (33.3%) had pulmonary stenosis or atresia. Median age at the first operation was 7.5 days (range: 1-376). Median weight was 3.5 kg (range: 1.9-6.3). Seventeen patients underwent pulmonary artery banding, one underwent a Damus-Kaye-Stansel connection, one received a Glenn shunt and five a modified Blalock-Taussig shunt. Early mortality was 12.5%. The only variable associated with operative mortality was the presence of coarctation or hypoplasia of the aorta (P=0.004). Ten patients (41.6%) developed subaortic stenosis. None of the tested variables, including pulmonary artery banding, was associated with the development of subaortic stenosis. Subaortic stenosis was due to a restrictive VSD in eight patients, six of whom underwent direct VSD enlargement by muscular resection and are well at last follow-up (four complete repairs). None of the procedures was complicated by complete heart block. In two cases subaortic stenosis was treated by a Damus-Kaye-Stansel connection. A single patient died during follow-up, and 11 patients have achieved a complete one-ventricle repair. CONCLUSION: In our experience, pulmonary artery banding was not associated with an increased risk of developing an RVSD. VSD enlargement proved to be safe and effective for treatment of subaortic stenosis due to an RVSD.     

Arterial repair for simple and complex forms of transposition of the great arteries

Transposition of the great arteries (TGA) has traditionally been repaired by redirection of atrial flow. Concern over the late development of right ventricular and sinus node dysfunction has prompted increased use of the arterial repair. This approach was utilized in 11 patients ranging in age from 7 days to 22 months (mean 5.3 months) and in weight from 2.6 to 12.2 kg (mean 5.1 kg). Five patients had intact ventricular septum and underwent primary repair electively or after poor response to balloon atrial septostomy. A large ventricular septal defect (VSD) was present in 6 patients, one of whom had coarctation of the aorta and one with type B interrupted aortic arch. Pulmonary artery banding was done in 3 of these patients in addition to subclavian artery aortoplasty and primary arch repair. Spontaneous VSD closure occurred in 2 banded patients. All patients had normal coronary artery distribution. Conduits were not used in any repair. There were 2 operative deaths caused by injury to the right coronary artery prior to establishing bypass in one patient and to left ventricular (LV) failure in a patient operated on at 5 months of age with an LV pressure of only one-half systemic level. The 9 surviving patients are well from 4 to 38 months after operation (mean 15 months). No patient has congestive heart failure and 5 receive no medications. Catheterization in 4 patients revealed widely patent coronaries in each. Trivial aortic insufficiency was noted in 1 patient. Each had mild to moderate supravalvar pulmonary stenosis (12 to 51 mmHg). LV function was normal in each case.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical repair of coarctation of the aorta during infancy]

Fourty-six infants less than 1 year of age underwent repair of coarctation of the aorta in our institution between 1972 and 1991. Pathologic types and numbers of patients were simple coarctation (Group 1) in 7 patients, with ventricular septal defects (Group 2) in 22 patients and with complex cardiac anomalies (Group 3) with 17 patients. A patent ductus arteriosus was present in 43 of these patients. Operative technique used were resection and end-to-end anastomosis (RETE) in 30 patients, subclavian flap angioplasty (SFA) in 15 and Blalock-Park operation in one patient. RETE procedures were employed from 1972 until 1980 and SFA procedures were employed between 1981 and 1985. After 1986 RETE procedures were employed again. The operative mortality rates were 0% (0/7) in Group 1, 9.1% (2/22) in Group 2 and 82.3% (14/17) in Group 3. The high mortality rate in Group 3 are thought to be related to severe associated cardiac anomalies. There were no significant differences in the operative mortality and recurrent coarctation rates between RETE and SFA procedures in Group 1 and 2. In patient with a large associated intracardiac shunt (Group 2 and 3) banding of the main pulmonary artery (PAB) was performed with coarctectomy simultaneously. In Group 2 VSD closure and debanding could be done a few months later with excellent results, but in Group 3 primary repair of cardiac anomalies may be worth to try since results of coarctectomy with palliative procedures in these group of patients were poor.(ABSTRACT TRUNCATED AT 250 WORDS)     

The early and long-term results of surgery for coarctation of the aorta in the 1st year of life

The cases of 110 infants less than 1 year of age, who had surgical repair for coarctation of the aorta between June 1974 and February 1988, were analysed. Three groups of patients were identified. In group 1 there were 39 patients with isolated coarctation. In group 2 there were 25 infants with additional ventricular septal defects (VSD), while in group 3 there were 46 infants with other associated congenital cardiac defects. Repair was performed using the subclavian flap aortoplasty (SFA) procedure in 83 patients, resection with end-to-end anastomosis (EEA) in 23, patch aortoplasty in 3 and Goretex tube bypass in 1. Twenty-eight patients had simultaneous pulmonary artery banding and one concomitant closure of the VSD. The overall early mortality rate was 8.2% (5.1% in group 1, 0% in group 2, and 15.2% in group 3). Age at operation (under 1 month, p = 0.04) and other associated cardiac anomalies (p = 0.03) increased early mortality significantly. There were 11 late deaths (10.8%) among 101 patients followed from 1 to 15 years (mean 5.3 years). Twelve patients underwent further surgery for recoarctation, eight of them within 11 months. A further 11 patients currently have a Doppler gradient across their coarctation site of more than 20 mmHg, but have not undergone further surgery to the coarctation repair site.     

Repair of aortic coarctation in the first year of life

Twenty-five infants under 1 year of age (mean, 10.3 weeks and 4.0 kg) underwent coarctation repair. Eight had ventricular septal defect (VSD), 3 had transposition of the great arteries with VSD, and 5 had severe tubular hypoplasia. One infant required mitral valve replacement, and 1 required repair of total anomalous pulmonary venous return. Fifteen had repair by primary anastomosis. Seven underwent Dacron or subclavian aortoplasty; the advantages and technique of angioplasty are reviewed. Three patients required bypass grafts. Seventeen patients survived operation. All 5 patients who had severe tubular hypoplasia died postoperatively. The mortality for repair of coarctation with VSD by simultaneous pulmonary artery banding was high; for coarctation with VSD we currently recommend repair without banding, followed by VSD closure if indicated. Three infants have been treated successfully in this manner, with early VSD closure in 1 and regression of the VSD during follow-up in 2. The 17 survivors have been followed for a mean of 41 months with 3 late deaths. Of the 17 survivors, all of whom had a primary anastomosis, 3 have residual gradients. Of the 11 survivors who had preoperative hypertension, 6 are still hypertensive; 3 of these have a gradient between the upper and lower extremities. It is striking that 3 have persistent hypertension despite repair under the age of 1 year.     

Anatomic correction of double-outlet right ventricle with subpulmonary ventricular septal defect (the "Taussig-Bing" anomaly)

Seven patients with double-outlet right ventricle and subpulmonary ventricular septal defect (the Taussig-Bing anomaly) underwent anatomical repair at the arterial level with transfer of the coronary arteries. At the time of operation, patient ages ranged from 6 weeks to 33 months (mean 14.1 months) and weight ranged from 3.7 to 11.5 kg (mean 7.0 kg). Four patients had prior pulmonary artery banding: Two of these four also had coarctation repairs, and one had a Blalock-Hanlon septectomy. Three different patterns of coronary artery distribution were encountered. Five patients had side-to-side great arteries, and two had more or less anteroposterior great arterial relationships. There was one operative death (14.3%: 70% confidence limits 1.9 - 40.7%) resulting from muscular subvalvular right ventricular outflow tract obstruction (RVOTO). There have been no late deaths in the six survivors followed 6 to 31 months postoperatively (mean 14.8 months). One patient required closure of a residual ventricular septal defect (VSD) and infundibular resection for RVOTO 4 months postoperatively. All other survivors are functionally NYHA Class I. Five of the six survivors have undergone postoperative catheterization (mean interval 5.8 months). There was no aortic insufficiency and good ventricular function in all patients. In addition to the patient with the residual VSD, two other asymptomatic patients had mild or moderate RVOTO. Compared with alternative surgical procedures for this anomaly, anatomic correction has the advantages of acceptable operative mortality, use of the left ventricle as the systemic ventricle, no need for extracardiac conduits, and applicability to patients with all variations of coronary artery and great artery anatomy.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

Successful repair of a coarctation complex with an anomalous right subclavian artery in an infant

A 46-day-old infant weighing 2250 g with the coarctation of the aorta, ventricular septal defect, PDA, the anomalous right subclavian artery, and the persistent left superior vena cava initially underwent by the reversed subclavian flap aortoplasty with the anomalous right subclavian artery and pulmonary arterial banding. The reversed subclavian flap aortoplasty was useful for the coarctation complex with the anomalous right subclavian artery. Two months later he gained weight to 2500 g, and then VSD closure and debanding of PAB was performed successfully. This two-staged operation was recommended for the poor risk coarctation complex with the anomalous subclavian artery.     

Late results of the subclavian flap repair of coarctation in infancy

From June 1979 through January 1985, 22 infants under 20 months of age (mean 8 months and 4 kg) underwent coarctation repair with a left subclavian aortoplasty. The most commonly associated lesions were ventricular septal defect (50%), hypoplastic aortic arch (45%), patent ductus arteriosus (41%), transposition of great arteries (22.7%) and other intracardiac lesions comprised 30%. Indication for surgery was congestive heart failure refractory to medical management. All patients were on inotropic support. Two patients required mechanical ventilation preoperatively. Subclavian flap angioplasty was performed with 7.0 continuous polypropylene suture. Ligation of a patent ductus arteriosus was simultaneously done in 8 patients and pulmonary artery banding in 8 others. Four patients (18%) died within 30 days after operation; 3 of them had severe tubular hypoplasia of the aortic arch. Three transient postoperative complications were encountered; chylothorax, subclavian steal syndrome and Horner's syndrome. No hospital deaths occurred in patients with isolated coarctation of the aorta. All survivors were followed for a period varying from 3 to 6.5 years (mean, 2 years). There were 3 late deaths (13.6%). Non invasive studies have shown a satisfactory result in 14 patients with a residual gradient less than 20 mmHg and in 10 of them, cardiac catheterization and cineangiography showed no evidence of significant stenosis. In one patient only, femoral pulses were absent 4 months postoperatively. These results and reports of others indicate, contrary to the age, that the presence of associated disease affects mortality. Prompt repair of coarctation of the aorta in all infants with or without symptoms is recommended and the subclavian flap procedure appears to be a simple and safe method for relief of coarctation of the aorta in critically ill infants.     

Pulmonary artery banding: analysis of a 25-year experience

A 25-year experience (May 1962 through April 1987) with pulmonary artery banding in 183 patients was reviewed and analyzed. Pulmonary artery banding was performed in a heterogeneous group of patients aged two days to 60 months (median, 10 weeks; mean, 21.8 weeks) and weighing 1.4 to 13.8 kg (mean, 4.2 kg). Diagnosis was ventricular septal defect in 76 (41.5%) and atrioventricular communis in 41 (22.4%). Pulmonary artery banding was also used in patients with d-transposition of the great vessels with ventricular septal defect, double-outlet right ventricle, univentricular heart, tricuspid atresia, and truncus arteriosus. Early death occurred in 39 of 175 patients who underwent pulmonary artery banding at Ochsner Foundation Hospital (22.3%). Definitive operation has been performed in 37 of the patients who underwent pulmonary artery banding since 1979 with excellent outcome in 32 (86.5%). Pulmonary artery banding is a useful palliative procedure for a diverse group of patients with congenital cardiac anomalies and unrestricted pulmonary blood flow. With improved results of primary repair of intracardiac anomalies in small infants, however, pulmonary artery banding should be reserved for severely ill patients with complex lesions not amenable to early definitive correction. Currently, pulmonary artery banding is indicated in patients with excessive pulmonary blood flow and single ventricle or tricuspid atresia. Pulmonary artery banding is also appropriate in certain patients with atrioventricular communis and in patients with muscular or multiple ventricular septal defects. Pulmonary artery banding is an option in patients with ventricular septal defect and coarctation of the aorta.     

Total Simultaneous Repair of Coarctation and Intracardiac Pathology in Adult Patients

Background. Thoracic aortic coarctation accompanied by a second surgically reparable lesion is a rare combination in the adult patient. The simultaneous operative management of both lesions is desirable because of the higher morbidity and mortality that would occur with staged procedures.

Methods. We describe the simultaneous operative management in three adult patients with coarctation and a second cardiac lesion. All 3 patients had intrapericardial ascending aorta–descending aorta bypass and concomitant repair of a cardiac lesion. The attendant repairs in the 3 patients, respectively, were aortic valve replacement, orthotopic heart transplantation, and coronary artery bypass grafting.

Results. Double arterial cannulation, retrograde cardioplegia, large-bore aorto–aortic bypass grafts, and early use of -agonists to stabilize systemic pressure were all key to ensuring safe conduct of the operation. Each patient had an essentially uneventful postoperative course.

Conclusions. Thoracic coarctation and concomitant cardiac pathology can be safely and readily managed with a single-stage approach involving cardiac repair and extraanatomic ascending aorta–descending aorta bypass grafting. A review of the English-language literature of patients managed similarly is included.