Surgical strategies to address re-operative complex left ventricular outflow tract and thoracic aortic pathology: Cleveland Clinic children’s experience

Abstract

Background: Complex patients requiring operations on the left ventricular outflow tract, aortic valve, or thoracic aorta after previous repair of aortopathy constitute a challenging group, with limited information guiding decision-making. We aimed to use our institutional experience to highlight management challenges and describe surgical pearls to address them. Methods: Forty-one complex patients with surgery on the left ventricular outflow tract, aortic valve, or aorta at Cleveland Clinic Children’s between 2016 and 2021 following previous repair of aortic pathology were retrospectively reviewed. Patients with known connective tissue disease or single ventricle circulation were excluded. Results: Median age at index procedure was 23 years (range 0.25–48) with median of 2 prior sternotomies. Previous aortic operations included subvalvular (n = 9), valvular (n = 6), supravalvular (n = 13), and multi-level surgeries (n = 13). Four deaths occurred in median follow-up of 2.5 years. Mean left ventricular outflow tract gradients improved significantly for patients with obstruction (34.9 ± 17.5 mmHg versus 12.6 ± 6.0 mmHg; p < 0.001). Technical pearls include the following: 1) liberal use of anterior aortoventriculoplasty with valve replacement; 2) primarily anterior aortoventriculoplasty following the subpulmonary conus in contrast to more vertical incision for post-arterial switch operation patients; 3) pre-operative imaging of mediastinum and peripheral vasculature for cannulation and sternal re-entry; and 4) proactive use of multi-site peripheral cannulation. Conclusions: Operation to address the left ventricular outflow tract, aortic valve, or aorta following prior congenital aortic repair can be accomplished with excellent outcomes despite high complexity. These procedures commonly include multiple components, including concomitant valve interventions. Cannulation strategies and anterior aortoventriculoplasty in specific patients require modifications.

Multi-modality imaging evaluation and pre-surgical planning for aortic valve-sparing operations in patients with aortic root aneurysm

“…Variability in these gross anatomical features correlate with variability seen in the ventricular components of the conduction axis relative to the aortic root ( Figure 10A-10C ) ( 3 , 31 , 32 , 54 ). We have recently reported our surgical experience in pediatric and adult patients with both congenital and acquired complex left ventricular outflow tract and thoracic aortic pathology, including an overall incidence of need for pacemaker as 10% ( 59 ). This was in keeping with reported values of this higher risk population, with a large multi-center study reporting incidences up to 15% depending on the complexity and need for subvalvular manipulation ( 60 ).…”

“…This was in keeping with reported values of this higher risk population, with a large multi-center study reporting incidences up to 15% depending on the complexity and need for subvalvular manipulation ( 60 ). In applying this predictive approach towards our last twenty-four congenital cardiac patients undergoing aortic root and left ventricular outflow tract surgeries, we have had a 0% incidence of need for pacemaker or occurrence of left bundle branch block ( 59 ). Although promising in its infancy, this predictive approach requires further validation.…”