Single-Stage Surgical Management of Atrioventricular Septal Defects with Coarctation of the Aorta

Abstract

Surgical options for coarctation of aorta (CoA) with atrioventricular septal defect (AVSD) include single-stage repair vs. staged approach with neonatal CoA repair and delayed AVSD repair. The durability of left atrioventricular valve (LAVV) function after neonatal repair is questioned, and the optimal approach remains controversial. Eighteen CoA-AVSD patients who underwent single-stage repair 2005–2015 by a single surgeon were retrospectively analyzed. Fifteen patients had complete and three had partial AVSD. Birth weight was 3.19 kg (2.17–4.08). Age at surgery was 16 days (6–127). One- and ten-year survival were 80% and 69%. Freedom from reintervention was 60% and 40% at one and ten-year respectively. Reinterventions included relief of left ventricular outflow tract obstruction (LVOTO) ( n = 4), repair of cleft LAVV ( n = 3), and LAVV and aortic valve replacement ( n = 1). Freedom from LAVV reintervention was 85.6% and 66% at 1 and 10 years respectively. There were four deaths: two post-operative and two following hospital discharge. Mortality was due to sepsis in three patients, and heart failure related to LVOTO and LAVV insufficiency in one. At 68-month (0.6–144) follow-up the majority had mild or less LAVV regurgitation, and all had normal LV dimension and systolic function. There was no recurrent arch obstruction. Single-stage surgical repair of CoA-AVSD is feasible and reasonable. Survival and freedom from reintervention in our cohort approximate those outcomes of two-stage repair with durable left AV valve function and no recurrent arch obstruction. These patients are frequently syndromic and demonstrate mortality risk from non-cardiac causes. Consideration of a single-staged approach is warranted for appropriate patients with CoA-AVSD.

From Crafoord’s End-to-End Anastomosis Approach to Percutaneous Interventions: Coarctation of the Aorta Management Strategies and Reinterventions

“…When coarctation of the aorta is diagnosed in conjunction with other congenital cardiac anomalies, clinicians must carefully consider the optimal treatment strategy. Most patients we encounter in this setting are newborns presenting with coarctation and either a ventricular septal defect (VSD), transposition of the great arteries, truncus arteriosus, or atrioventricular septal defect (AVSD) [33]. The single-stage approach involves repairing all cardiac defects at once, including the coarctation.…”