title: Do high-risk infants have a poorer outcome from primary repair of coarctation? Analysis of 192 infants over 20 years.
abstract: BACKGROUND
  Balloon angioplasty for infant coarctation is associated with a high recurrence rate, making operative repair the gold standard for low-risk infants. Debate exists as to whether high-risk infants might be better served with primary angioplasty. We compared the outcome in high-risk versus low-risk infants over 20 years, in a center that always used surgical repair as the primary intervention.
  
  
  METHODS
  Of 192 infants from 1986 to 2005, 56 were considered "high-risk," defined as requiring prostaglandin infusion together with either epinephrine infusion for 24 hours preoperatively, or ventilation and milrinone infusion for 24 hours preoperatively. All high-risk patients had a period of ventricular dysfunction prior to surgery, ranging from mild to severe. Outcomes were compared using Bonferroni comparison of means or the Fischer exact test as appropriate.
  
  
  RESULTS
  Although the high-risk patients were smaller (3.3 ± 0.1 vs 4.2 ± 0.2 kg, p < 0.01), younger (18 ± 4 vs 57 ± 7 days, p < 0.01), and more often required a concomitant pulmonary artery band (25% vs 15%, p = 0.05), their cross-clamp times were the same as the low-risk patients (18.9 ± 0.9 vs 18.0 ± 0.4 minutes, p = 0.27) and there was no difference in postoperative morbidity (7% vs 3%, p = 0.11). However, there was a trend toward higher perioperative mortality (7% vs 2%, p = 0.07). When compared with the published studies of primary angioplasty in comparable high-risk infants, the mortality rate in our surgically treated high-risk group is much lower. Additionally, only 11% of our high-risk group required reintervention, with two-thirds treated successfully with a single angioplasty at 3.8 ± 2.2 years later, far lower than recurrence rates with primary angioplasty.
  
  
  CONCLUSIONS
  We propose that primary surgical repair of coarctation in infants who are high risk should be the primary treatment, with angioplasty reserved for recurrent coarctation.
authors.affiliation: Department of Cardiothoracic Surgery, Our Lady's Childrens Hospital, Crumlin, Dublin, Ireland.
authors.forename: Jonathan G
authors.initials: JG
authors.lastname: McGuinness
authors.forename: Yahya
authors.initials: Y
authors.lastname: Elhassan
authors.forename: Sim Yee
authors.initials: SY
authors.lastname: Lee
authors.forename: Lars
authors.initials: L
authors.lastname: Nolke
authors.forename: Paul
authors.initials: P
authors.lastname: Oslizlok
authors.forename: Kevin
authors.initials: K
authors.lastname: Walsh
authors.forename: J Mark
authors.initials: JM
authors.lastname: Redmond
authors.forename: Alfred E
authors.initials: AE
authors.lastname: Wood
mesh_terms: D001017:Aortic Coarctation / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D015150:Echocardiography, Doppler; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007494:Ireland / Q000453:epidemiology; D008297:Male; D011379:Prognosis; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D013997:Time Factors