Neonatal coarctation repair via thoracotomy with proximal arch hypoplasia up to a z score of −4.5 is safe and durable

Objective: Hypoplasia of the proximal transverse arch (PTA) can be associated with coarctation. Management is via sternotomy with arch reconstruction or thoracotomy with extended end-to-end anastomosis (T-EEEA). Our preferred approach is T-EEEA with expectations that the arch will grow. We hypothesized that T-EEEA is safe, durable, and permits aortic growth. Methods: We retrospectively identified neonates (<1 month of age) treated from 2012 to 2023 for coarctation and PTA hypoplasia (z score <−2.5), and no other cardiac lesion that would mandate sternotomy and cardiopulmonary bypass. We compared sternotomy with arch augmentation versus T-EEEA. Outcomes included morbidity, mortality, freedom from reintervention, and echocardiographic measurements at last follow-up. Results: Of 91 neonates, 76 (83.5%) underwent T-EEEA and 15 (17%) sternotomy at an overall median age of 12 days and weight of 3.2 kg. Prematurity (19%), cardiogenic shock (23%), and mechanical ventilation (29%) were similar between groups. Preoperative proximal arch z score was −3.9 for the entire cohort and was different between groups (T-EEEA −3.9 vs sternotomy −5.2; P = .01). Median ventilator and discharge times were shorter with T-EEEA (1 vs 4 days, P < .0001; 11 vs 22 days, P = .0015; respectively). Two hospital deaths occurred (1 per group). Morbidities included 7 recurrent nerve injuries, 1 chylothorax, and 1 stroke. Eight patients (T-EEEA 7, 9% vs sternotomy 1, 7%; P = .75) required reintervention (5 catheter, 3 surgical). All 3 surgical reinterventions occurred in patients who underwent T-EEEA with preoperative PTA z scores <−4.5. Freedom from reintervention at 5 years was similar between groups (T-EEEA 92% vs sternotomy 94%) and at a median follow-up of 58 months, there was adequate growth of the proximal arch with a median z score of −1.6 (T-EEEA −1.7, sternotomy −1.3, P = .13). Conclusions: Repair of neonatal coarctation via thoracotomy with proximal arch hypoplasia up to a z score of −4.5 is safe, durable, with low rate of reintervention. Patients with a proximal arch z score <−4.5 should undergo aortic arch reconstruction via sternotomy.