title: Aortic arch obstruction neonates with biventricular physiology: left-open compared to closed inter-atrial communication during primary repair--a retrospective study.
abstract: BACKGROUND
  Leaving an inter-atrial communication (IAC) open for left atrial decompression is often recommended in neonates with aortic arch obstruction undergoing primary repair. In this study, outcomes in these patients were compared to those with intact atrial septum after repair.
  
  
  METHODS
  Between 2000 and 2013, 53 consecutive neonates with severe aortic arch obstruction (hypoplasia: n = 45, interruption: n = 8) underwent primary repair from an anterior approach. Median age and weight were 8 days (range: 2-30) and 3.2 kg (range: 2.4-4.4), respectively. Cardiac morphology included a ventricular septal defect (VSD, large: n = 28, small: n = 7), malposition of great arteries (n = 10), and severe left ventricular outflow tract obstruction (LVOTO, n = 10). During corrective surgery IAC was closed (group-I, n = 37) or partially left-open (group-II, n = 16). Primary endpoints were hospital death, and re-intervention (surgery and/or balloon) due to aortic arch re-coarctation or recurrent LVOTO. Statistically significant variables by univariate analysis were incorporated in the corresponding multivariable regression model.
  
  
  RESULTS
  Regarding morphological discrepancies more patients in group-II presented with LVOTO (p = 0.05), or the combination of arch hypoplasia, intact ventricular septum and normal ventriculo-arterial connection (p = 0.017). Hospital mortality was 8.1% in group-I and 37.5% in group-II (p = 0.016). Re-intervention was performed in 13 patients (group-I: n = 6 vs. group-II: n = 7) due to aortic arch re-coarctation (n = 12) and/or recurrent LVOTO (n = 3), and resulted in a Kaplan-Meier freedom from re-intervention of 87 ± 6% and 79 ± 8% in group-I, and 64 ± 14% and 64 ± 14% in group-II after 1 and 5 years, respectively (p = 0.016). Multivariate analysis revealed LVOTO as an independent risk factor for hospital death (p = 0.042), whereas both LVOTO and left-open IAC (p = 0.001 and 0.01) were independent risk factors for re-intervention.
  
  
  CONCLUSIONS
  A left-open IAC increases risk of re-intervention at the left heart aorta complex. Sustained left-to-right shunting on atrial level seems to induce preload reduction of the often restrictive left ventricle leading to decreased aortic blood flow.
authors.affiliation: Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany. andre.rueffer@uk-erlangen.de.
authors.forename: André
authors.initials: A
authors.lastname: Rüffer
authors.affiliation: Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany. Caroline.Bechtold@uk-erlangen.de.
authors.forename: Caroline
authors.initials: C
authors.lastname: Bechtold
authors.affiliation: Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany. Ariawan.Purbojo@uk-erlangen.de.
authors.forename: Ariawan
authors.initials: A
authors.lastname: Purbojo
authors.affiliation: Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany. Okan.Toka@uk-erlangen.de.
authors.forename: Okan
authors.initials: O
authors.lastname: Toka
authors.affiliation: Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany. Martin.Gloeckler@uk-erlangen.de.
authors.forename: Martin
authors.initials: M
authors.lastname: Glöckler
authors.affiliation: Department of Pediatric Cardiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Germany, University Hospital Erlangen, Loschgestraße 15, Erlangen, 91054, Germany. Sven.Dittrich@uk-erlangen.de.
authors.forename: Sven
authors.initials: S
authors.lastname: Dittrich
authors.affiliation: Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Loschgestraße 15, 91054, Erlangen, Germany. Robert.Cesnjevar@uk-erlangen.de.
authors.forename: Robert Anton
authors.initials: RA
authors.lastname: Cesnjevar
mesh_terms: D001013:Aorta, Thoracic / Q000002:abnormalities* / Q000601:surgery; D001017:Aortic Coarctation / Q000150:complications / Q000601:surgery*; D001018:Aortic Diseases / Q000150:complications / Q000601:surgery; D006348:Cardiac Surgical Procedures / Q000379:methods*; D005260:Female; D006325:Heart Atria / Q000601:surgery; D006345:Heart Septal Defects, Ventricular / Q000150:complications / Q000601:surgery; D006352:Heart Ventricles / Q000601:surgery; D017052:Hospital Mortality; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D012086:Reoperation; D012189:Retrospective Studies; D014188:Transposition of Great Vessels / Q000150:complications / Q000601:surgery; D014694:Ventricular Outflow Obstruction / Q000150:complications / Q000601:surgery