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

• 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
• Journal Title: Journal of Thoracic and Cardiovascular Surgery
• Volume: Volume 152, Number 2
• Publisher: Elsevier | 2016-08, Pages 471-479.e3
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jtcvs.2016.03.091
• Subjects: Health Sciences, Medicine and Surgery; Biology, Physiology
• Keywords: Science & Technology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems; Respiratory System; Surgery; Cardiovascular System & Cardiology; Norwood; aorta; coarctation; COMPUTATIONAL FLUID-DYNAMICS; PULMONARY AUTOGRAFT DILATATION; ARTERIAL SWITCH OPERATION; MODIFIED ROSS OPERATION; INITIAL SHUNT TYPE; ROOT DILATION; CAVOPULMONARY CONNECTIONS; SUCCESSFUL REPAIR; FONTAN PROCEDURE; ASCENDING AORTA

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.