Abstract
Objection. Approaches to the treatment of coarctation of the aorta (CoAo) combined with the borderline left heart (BLH) have never been fully explored, not only in Russia but in the world as well. The purpose of this study was a retrospective analysis of results of surgical treatment of CoAo in combination with BLH in children in the first year of life.
Material and methods. After the analysis of 856 clinical records of patients in the first year of life, operated on CoAo between 2005 and 2015, 89 patients were selected for the study with CoAo and indexed end-diastolic volume (EDV) of the left ventricle (LV) less than 30 ml/m2. The age of patients ranged from 5 hours up to 358 days (27 ± 62.7), there were 75 (84.3%) newborns; body weight ranged from 1.65 to 8.30 (3.41 ± 1.02) kg; LV EDV - from 11 to 30 (24.91 ± 4.77) ml/m2; LV end-diastolic size Z-score (Z LV EDS) - from -6.63 to 0.26 (-2.44 ± 1.23); annulus of the mitral valve Z-score (Z MV) - from -3.91 to 0.92 (-1.5 ± 0.98); aortic valve Z-score (Z AV) - from -5.09 to 2.51 (-0.64± 1.28).
Results. Hospital mortality was 11.2% (n =10), all below the age of 28 days at the time of the operation. Cause of death with a high degree of confidence (p = 0.001) was initial severity of the condition before the operation: of 31 children admitted in critical condi-tion 8 (25.8%) died, and of 58 children in serious or satisfactory condition only 2 (3.4%) died. When comparing echocardiographic parameters (Z AV, Z-score of proximal and distal aortic archs, Z-score of Ao isthmus, Z LV EDS, LV EDV, Z MV, the pressure gradient on the isthmus of the aorta, MV, AV, the size of the ductus arteriosus and atrial septal defect, pressure in the right ventricle, the degree of tricuspid regurgitation) in groups of discharged and deceased patients significant difference was not obtained. Only the size of MV significantly (p =0.012) influenced on the fatal outcome. To determine the prognostic significance of Z MV ROC-analysis (AUC = 0.746) was carried out with the definition of the split point, which corresponds to Z MV -1.4. Among 49 patients with Z MV less than -1.4 mortality was 20.4% (n = 10). The catamnesis for more than 2 years was available in 51 patients, in whom Z LV EDS, Z MV, Z AV in 4, 12, 24 and 48 months after surgery were determined. In the first 4 months after surgery there was a significant increase in Z-score of all studied parameters (p =0.0001). A year after surgery Z LV EDS and Z MV (p =0.0001) significantly increased, and increase in the size of Z AV is not significant (p = 0.372). In more long-term study, the change of structures sizes has no statistical significance (p > 0.05).
Conclusions. BLH with LV EDV 30 ml/m2 and less in newborns and children in the first year of life are not the contraindications to resolve CoAo, but on the contrary require a radical adjustment, after which a significant increase up to the age norm is noted. Risk factor for lethal outcome is the critical condition before surgery, Z MV less than -1,4 (p = 0.002).
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About the authors
- Levchenko Elena Grigor'evna, MD, PhD, Senior Research Associate, Cardiologist;
- Svobodov Andrey Andreevich, MD, DM, Chief Research Associate, Cardiac Surgeon;
- Anderson Aleksey Georgievich, MD, PhD, Leading Research Associate, Cardiologist;
- Tumanyan Margarita Rolandovna, MD, DM, Professor, Head of Department
