\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Coarctation of the aorta with aortic arch hypoplasia: Tackle from the
front or the side?}



\author[1]{Sandeep Sainathan}%
\author[1]{Leonardo Mulinari }%
\affil[1]{University of Miami Miller School of Medicine}%


\vspace{-1em}



  
  \date{May 21, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
This is a commentary on a single-institution retrospective review that
describes the short-term outcomes of the pediatric patients who
underwent re-operative surgery for residual or recurrent coarctation
after a previous coarctation repair. There were 51 patients over 12
years.%
\end{abstract}%



\sloppy


Title

Coarctation of the aorta with aortic arch hypoplasia: Tackle from the
front or the side?

Authors and affiliations

Sandeep Sainathan, MD

Assistant Professor

University of Miami

Leonardo Mulinari, MD, PhD

Associate Professor of Surgery

University of Miami

Corresponding author

Leonardo Mulinari, MD, PhD

1611 NW 12th Ave

East Tower Suite 3016

Miami, FL, USA 33136-1015

Coarctation of the aorta with aortic arch hypoplasia: Tackle from the
front or the side?

In their single-institution retrospective review, Egunov and colleagues
describe the short-term outcomes of the pediatric patients who underwent
re-operative surgery for residual or recurrent coarctation after a
previous coarctation repair {[}1{]}. There were 51 patients over 12
years. The indication for the operation was the recurrence of
coarctation with a significant gradient as measured by the arm to leg
blood pressure difference or by echocardiography and presence of an
associated transverse arch hypoplasia (Z score [?] -2). Thus, these
patients were unsuitable for a percutaneous approach or re-operative
surgery via a left thoracotomy {[}2{]}. Hence, the approach was via a
median sternotomy using moderate hypothermia and antegrade cerebral
perfusion. 14\% of the patients underwent re-operative median
sternotomy, and all these had their first surgery as a neonate.
Prosthetic patch aortoplasty (45\%) was the most common re-repair
technique used, followed by a resection with an extended end-to-end
anastomosis (29\%) and an interposition graft implantation (25\%). Their
outcomes were excellent, with no operative mortality and no residual
coarctation. The only morbidity recorded was the occurrence of
chylothorax. At a median follow-up of 2 -years, there were no
recurrences or any mortality. Also, there was a resolution of systemic
hypertension in most patients.

For the first operation, thoracotomy was the most common approach
(73\%), whereas sternotomy was used in 14\% of the patients, all of whom
were neonates. Resection and end-to-end anastomosis was the most common
technique used (63\%), and for patients below one year of age, it was
used in 85\% of the cases. Other techniques used were prosthetic patch
aortoplasty (16\%) and interposition graft insertion (8\%). As expected,
interposition graft was used in children \textgreater{} five years of
age. Interestingly, 14\% of the patients had balloon dilation as the
first intervention for the coarctation, including a neonate.

The occurrence of re-coarctation was analyzed using time interval
clusters of less than one year, 1 to 5 years, 5 to 10 years, and later
than ten years. There was a similar incidence of 20 to 30\% in the first
three clusters each, and there was a drop to 15\% when the recurrence
occurred beyond ten years. Thus, recurrence of coarctation is a
time-dependent variable with similar risk up to 10 years and a drop
after that. Patients, who had a rapid recurrence within a year, as
expected, were infants at a median age of 5 months of age and were more
likely to have an end-to-end repair from the side and could be
re-repaired with an end-to-end repair but from the front. Very few
needed a prosthetic patch angioplasty.

The independent risk factors for re-intervention after a coarctation
repair in this study are in line with previous studies, such as younger
age at operation, presence of associated arch hypoplasia, and the type
of the initial operation {[}2, 3, and 4{]}. More than 50\% of the
patients were less than one year of age at the initial operation in this
series. These patients have the steepest of somatic growths, and thus
repaired segments of the aorta may not catch up, leading to a
recurrence. Unaddressed transverse aortic arch hypoplasia is another
risk factor for reoperation, and all the patients in this series had
transverse arch hypoplasia (Z score[?] -2). As previously mentioned,
thoracotomy and end-to-end anastomosis was the most common first
procedure, and it does not directly address proximal transverse aortic
arch hypoplasia. However, information about the severity of the
hypoplasia at the initial presentation is unknown in this study as
thoracotomy and end to end anastomosis is still an acceptable approach
when the proximal transverse arch hypoplasia is less than moderate ( Z
score\textgreater{} -4 to- 5), in which case the arch hypoplasia can
improve with time {[}3,4{]}. Besides, patients receiving a reoperation
in this series had the first operation at \emph{variousoutside} centers,
and thus the \emph{denominator} is unknown, leading to a skewing of the
outcomes. The use of cardiopulmonary bypass with selective cerebral
perfusion does carry an additional risk beyond an off-pump technique
from the side due to stroke risk, end-organ injury, and possible impact
on neurodevelopmental outcomes and this should be taken in to
consideration when electing a midline approach {[}3, 5{]}.

Inadequate technical repair at the first operation may be responsible
for the need for a reoperation as 14\% of the neonates did have a
midline approach, and this approach should have adequately addressed the
concomitant arch hypoplasia. The risk factor could have been an
inadequate resection of ductal tissue, use of patch material that is
susceptible to shrinkage, and inability for the repaired segments to
catch up with tremendous somatic growth. Arch augmentation from the
front is thus not entirely recurrence risk-free {[}1, 3{]}. The authors
in this series have used a PTFE patch, which has a lesser susceptibility
for contraction and reactive residual ductal tissue is not a factor in
reoperations. Recurrence of coarctation is a time-dependent outcome as
shown in this study and other studies, and hence a follow-up beyond the
current median of 2 years is required to evaluate continued success of
this series {[}1, 2{]}.

In conclusion, coarctation resection via a thoracotomy approach should
still be considered especially when there is less than moderate
transverse arch hypoplasia. In cases where there is a lack of expectant
growth, a reoperation from the front can be performed with excellent
outcomes, as shown in this study.

References:

\begin{enumerate}
\tightlist
\item
  Egunov O, Krivoshchekov EV, Cetta F, et al. Surgery for aortic
  re-coarctation in children less than 10 years old. A single center
  experience in Siberia, Russia. \emph{In press}
\item
  Brown JW, Ruzmetov M, Hoyer MH, et al. Recurrent coarctation: is
  surgical repair of recurrent coarctation of the aorta safe and
  effective? Ann Thorac Surg. 2009 Dec;88(6):1923-30.
\item
  Gray WH, Wells WJ, Starnes VA, et al. Arch Augmentation via Median
  Sternotomy for Coarctation of Aorta With Proximal Arch Hypoplasia. Ann
  Thorac Surg. 2018 Oct;106(4):1214-1219.
\item
  Gropler MRF, Marino BS, Carr MR, et al. Long-Term Outcomes of
  Coarctation Repair Through Left Thoracotomy. Ann Thorac Surg. 2019
  Jan;107(1):157-164.
\item
  Andropoulos DB, Easley RB, Brady K, et al. Neurodevelopmental outcomes
  after regional cerebral perfusion with neuromonitoring for neonatal
  aortic arch reconstruction. Ann Thorac Surg. 2013 Feb;95(2):648-54.
\end{enumerate}

\selectlanguage{english}
\FloatBarrier
\end{document}

