Aortic Growth after Arch Reconstruction with Patch Augmentation: A Two Decade Experience.

OBJECTIVE: Optimal aortic sizing during aortic arch reconstruction remains unknown. Negative effects of arch under- or oversizing are well-published. We aimed to characterize longitudinal aortic growth after patch-augmented arch reconstruction to identify initial reconstructed arch size that results in normal mid-term arch dimensions.

METHODS: Single-centre, retrospective review of infants undergoing Damus-Kaye-Stansel or non-Damus-Kaye-Stansel patch-augmented aortic arch reconstruction between 2000-2021. Ascending aorta, proximal and distal transverse arch, aortic isthmus, and descending aorta dimensions were measured in postoperative echocardiograms (<3mo from index operation) and cross-sectional imaging (>12mo). Longitudinal changes to aortic dimensions and z-scores were analysed. Secondary outcomes included reintervention, valve and ventricular function, mortality, and transplantation.

RESULTS: Fifty-four patients (16 Damus-Kaye-Stansel, 38 non-Damus-Kaye-Stansel) were included. At 6.3[2.2,12.0]yr follow-up, all aortic segments grew significantly in both groups, while z-scores remained unchanged except for non-Damus-Kaye-Stansel proximal and distal transverse arch z-scores, which significantly increased (p < 0.05 each). When stratified by initial postoperative z-score (z<-1,-1≤z ≤ 1, z > 1), non-Damus-Kaye-Stansel patients with initial aortic isthmus z-score<-1 had a final z-score significantly smaller than both the targeted z-score zero (p = 0.014) and final z-score in group with initial postoperative z-score ±1 (p = 0.009). Valve and ventricular function remained stable. Eighteen patients required reintervention, one died, and one underwent transplant.

CONCLUSIONS: Over mid-term follow-up, aortic growth after arch reconstruction with patch augmentation was proportional when repaired to normal z-score dimensions, aside from proximal transverse arch, which disproportionately dilated. Aortic isthmus undersizing prevailed mid-term and trended towards a higher reintervention rate. Initial reconstruction between z-score zero and +1 resulted in maintenance of that z-score size at mid-term follow-up. Overall, it is crucial to achieve targeted aortic sizing at index operation to maintain appropriate aortic dimensions over time and reduce reintervention risk with specific focus on the aortic isthmus.