Maladaptive aortic properties after the Norwood procedure: An angiographic analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial

• Type of Material: Article
• Authors: Sarah T. Plummer, Duke University; Christoph P. Hornik, Duke University; Hamilton Baker, Medical University of South Carolina; Gregory A. Fleming, Duke University; Susan Foerster, Children's Hospital of Wisconsin; Matthew Ferguson, Emory University; Andrew C. Glatz, Children's Hospital of Philadelphia; Russel Hirsch, Cincinnati Children's Hospital Medical Center; Jeffrey P. Jacobs, All Children's Hospital and Florida Hospital for Children; Kyong-Jin Lee, Hospital for Sick Children; Alan B. Lewis, Children's Hospital Los Angeles; Jennifer S. Li, Duke University; Mary Martin, University of Utah; Diego Porras, Children's Hospital Boston; Wolfgang A. K. Radtke, Nemours Children's Health System; John F. Rhodes, Miami Children's Hospital; Julie A. Vincent, Columbia University; Jeffrey D. Zampi, University of Michigan; Kevin D. Hill, Duke University
• Language: English
• Date: 2016-08
• Publisher: Elsevier
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2016 The American Association for Thoracic Surgery
• Final Published Version (URL): http://dx.doi.org/10.1016/j.jtcvs.2016.03.091
• Title of Journal or Parent Work: Journal of Thoracic and Cardiovascular Surgery
• ISSN: 0022-5223
• Volume: 152
• Issue: 2
• Start Page: 471
• End Page: 479.e3
• Grant/Funding Information: Funded by Grant Numbers HL068269, HL068270, HL068279, HL068281, HL068285, HL068292, HL068290, HL068288, HL085057, HL109737, and HL085057 from the National Heart, Lung, and Blood Institute.
• Keywords: SUCCESSFUL REPAIR; Life Sciences & Biomedicine; COMPUTATIONAL FLUID-DYNAMICS; coarctation; ASCENDING AORTA; MODIFIED ROSS OPERATION; Surgery; Science & Technology; PULMONARY AUTOGRAFT DILATATION; ROOT DILATION; Respiratory System; Cardiac & Cardiovascular Systems; FONTAN PROCEDURE; ARTERIAL SWITCH OPERATION; aorta; Cardiovascular System & Cardiology; Norwood; INITIAL SHUNT TYPE; CAVOPULMONARY CONNECTIONS
• Research Categories: Biology, Physiology; Health Sciences, Medicine and Surgery

Abstract

Objectives: Aortic arch reconstruction in children with single ventricle lesions may predispose to circulatory inefficiency and maladaptive physiology leading to increased myocardial workload. We sought to describe neoaortic anatomy and physiology, risk factors for abnormalities, and impact on right ventricular function in patients with single right ventricle lesions after arch reconstruction. Methods: Prestage II aortic angiograms from the Pediatric Heart Network Single Ventricle Reconstruction trial were analyzed to define arch geometry (Romanesque [normal], crenel [elongated] , or gothic [angular]), indexed neoaortic dimensions, and distensibility. Comparisons were made with 50 single-ventricle controls without prior arch reconstruction. Factors associated with ascending neoaortic dilation, reduced distensibility, and decreased ventricular function on the 14-month echocardiogram were evaluated using univariate and multivariable logistic regression. Results: Interpretable angiograms were available for 326 of 389 subjects (84%). Compared with controls, study subjects more often demonstrated abnormal arch geometry (67% vs 22%, P  <  .01) and had increased ascending neoaortic dilation (Z score 3.8 ± 2.2 vs 2.6 ± 2.0, P  <  .01) and reduced distensibility index (2.2 ± 1.9 vs 8.0 ± 3.8, P  <  .01). Adjusted odds of neoaortic dilation were increased in subjects with gothic arch geometry (odds ratio [OR], 3.2 vs crenel geometry, P  <  .01) and a right ventricle-pulmonary artery shunt (OR, 3.4 vs Blalock–Taussig shunt, P  <  .01) but were decreased in subjects with aortic atresia (OR, 0.7 vs stenosis, P  <  .01) and those with recoarctation (OR, 0.3 vs no recoarctation, P = .04). No demographic, anatomic, or surgical factors predicted reduced distensibility. Neither dilation nor distensibility predicted reduced right ventricular function. Conclusions: After Norwood surgery, the reconstructed neoaorta demonstrates abnormal anatomy and physiology. Further study is needed to evaluate the longer-term impact of these features.