Sternotomy or thoracotomy for neonatal repair of coarctation of the aorta with aortic arch hypoplasia

Abstract

Objective: For neonatal repair of coarctation of the aorta, patients may either undergo thoracotomy with extended end-to-end anastomosis or sternotomy for aortic arch reconstruction with cardiopulmonary bypass. The objective of this study was to evaluate the comparative effectiveness of the 2 approaches in patients with arch hypoplasia.

Methods: This is a single-center retrospective cohort study from July 2005 through May 2022 of patients who underwent neonatal repair for isolated coarctation of the aorta with additional arch hypoplasia. Inverse probability of treatment weighting is a statistical method for creating comparable pseudopopulations and was used to account for baseline differences in population. The primary outcome was aortic reintervention, and secondary outcomes were vocal cord dysfunction, length of stay, chylothorax, and phrenic nerve palsy.

Results: There were 130 patients who met inclusion criteria. After weighting, the interaction between distal transverse arch size and operative approach (sternotomy vs thoracotomy) was statistically significant, P < .05 for interaction. Among patients with a distal arch z-score <-3.5, patients undergoing thoracotomy with extended end-to-end anastomosis had an increased hazard for reintervention. Sternotomy was associated with an increased length of stay in the intensive care unit by 4.7 days, P < .001, and odds of vocal cord dysfunction were also greater, odds ratio 7.1 (95% confidence interval, 1.66 to 41.26; P = .01).

Conclusions: Among patients with a distal arch z-score smaller than -3.5, the hazard of reintervention was increased for patients undergoing thoracotomy with extended end-to-end anastomosis. However, length of stay and risk of vocal cord paresis was reduced in patients undergoing thoracotomy.

Keywords: aortic arch hypoplasia; aortic arch reconstruction; coarctation of the aorta; neonatal arch.

The hazard ratio for reintervention depended on distal arch z-score.

Figure 1

Cumulative incidence with 95% confidence intervals of reintervention for patients undergoing repair via thoracotomy (blue) versus sternotomy (red). There was no difference between the populations before accounting for the interaction between operative approach and distal arch size.

Figure 2

Plot demonstrating the relative hazard of thoracotomy compared with sternotomy as a function of distal transverse arch size. Patients with a distal arch z-score <−3.5 appear to have lower risk of reintervention via sternotomy; patients with a distal arch z-score larger than −3 appeared to have reduced risk of reintervention via thoracotomy. HR, Hazard ratio.

Figure E1

Overall cohort, before trimming. In blue, patients undergoing thoracotomy with extended end-to-end anastomosis; in red, patients undergoing sternotomy with aortic arch reconstruction. The yellow line marks a distal arch z-score of −2. Above a distal arch z-score of −2, patients do not appear to routinely undergo sternotomy for aortic arch reconstruction. Below a distal arch z-score of −2, there appears to be common support.

Figure E2

Overall cohort, before trimming. In blue, patients undergoing thoracotomy with extended end-to-end anastomosis; in red, patients undergoing sternotomy with aortic arch reconstruction. The yellow line marks an aortic annular z-score of −1. Above an aortic annulus of z-score of −1, patients do not appear to routinely undergo sternotomy for aortic arch reconstruction. Below an aortic annular z-score of −1, there appears to be common support.

Figure E3

A density plot of the 2 approaches demonstrating adequate common support.

Figure E4

As a sensitivity analysis, extreme weights (1st and 99th percentile) were eliminated from the dataset. In doing so, stabilized weights smaller than 0.4 and greater than 3.69 were eliminated. The interaction between distal arch size and operative approach was once again tested. The interaction between surgical approach and distal arch size was once again statistically significant, P = .02. HR, Hazard ratio.

Figure E5

Catheter-based reintervention. There was no significant difference in the cumulative incidence of catheter-based reintervention when comparing thoracotomy (blue) with sternotomy (red); shaded areas represent 95% confidence intervals, before accounting for the interaction between operative approach and distal arch size.

Figure E6

Open reoperation. Before weighting, there were 3 open surgical reoperations with 2 occurring in the sternotomy group (red) and 1 in the thoracotomy group (blue); shaded areas represent 95% confidence intervals. Both patients who eventually underwent reoperation from the sternotomy group had previously undergone catheter based intervention. This makes inference somewhat challenging, but it may be the case that when an intervention is required after the sternotomy approach, it is more likely that a catheter-based reintervention will be inadequate.