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

Published online by Cambridge University Press:  04 April 2023

Dominique L. Tucker Open the ORCID record for Dominique L. Tucker [Opens in a new window] ,
Leah J. Lee ,
Munir Ahmad ,
Naseeb Shaheen ,
Sohini Gupta ,
Hani K. Najm ,
Miza Salim Hammoud ,
Justin T. Tretter  and
Tara Karamlou
Dominique L. Tucker
Affiliation:
Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA Case Western Reserve University School of Medicine, Cleveland, OH, USA
Leah J. Lee
Affiliation:
Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
Munir Ahmad
Affiliation:
Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
Naseeb Shaheen
Affiliation:
Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
Sohini Gupta
Affiliation:
Department of Thoracic and Cardiothoracic Surgery, Cleveland Clinic, Cleveland, OH, USA Case Western Reserve University School of Medicine, Cleveland, OH, USA
Hani K. Najm
Affiliation:
Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
Miza Salim Hammoud
Affiliation:
Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
Justin T. Tretter
Affiliation:
Department of Pediatric Cardiology, Cleveland Clinic Children’s, and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
Tara Karamlou*
Affiliation:
Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
*
Author for correspondence: Tara Karamlou, MD, MSc, Professor of Surgery, Division of Pediatric Cardiac Surgery, Cleveland Clinic Children’s, 9500 Euclid Avenue, M41-022A, Cleveland, OH 44195, USA. E-mail: karamlt@ccf.org
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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.

Keywords

Congenitalcomplex aortic surgeryleft ventricular outflow tractanterior aorticoventriculoplastyaorta
Type
Original Article
Information
Cardiology in the Young , Volume 33 , Issue 12 , December 2023 , pp. 2559 - 2566
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Copyright
© The Author(s), 2023. Published by Cambridge University Press

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Footnotes

Leah Lee and Dominique Tucker are sharing first authorship for this study.

Presented at the 68th Annual Meeting of the Southern Thoracic Surgical Association, Atlanta, Georgia.

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