What is the optimal management of infants with coarctation and ventricular septal defect?

BACKGROUND The management of patients with aortic coarctation and ventricular septal defect (VSD) remains controversial. We reviewed our experience with coarctation and VSD from 2002 to 2006. METHODS Three approaches were used to manage 36 consecutive infants with coarctation and VSD. Group I had staged coarctation repair with or without pulmonary artery banding, followed by VSD closure with two separate operations (two-stage, n = 11); Group II had coarctation repair and VSD closure on cardiopulmonary bypass (CPB) with circulatory arrest or regional perfusion during coarctation repair (one-stage, one-incision, n = 10); Group III had coarctation repair without CPB through a thoracotomy, followed by VSD closure during the same operation (one-stage, two-incisions, n = 15). RESULTS No patients died. One recoarctation occurred in group II. Group II had significantly longer times for CPB (135.6 +/- 31.8 versus 94.3 +/- 29.8 minutes for group I; 67.6 +/- 16.7 minutes for group III; p < 0.001) and combined regional perfusion/circulatory arrest (30.0 +/- 17.0 versus 5.3 +/- 11.9 minutes for group I, 1.1 +/- 4.4 minutes for group III, p < 0.0001). Group III compared with group II had significantly shorter lengths of stay in the intensive care unit (119.5 +/- 64.8 versus 220.8 +/- 198.8 hours, p = 0.04) and hospital (8.4 +/- 3.8 versus 24.4 +/- 24.4 days, p = 0.01). Combining values for the two hospitalizations in the group I infants, lengths of stay in the intensive care unit (178.8 +/- 70.8 hours) and hospital (20.5 +/- 11.6 days) were intermediate between groups II and III. CONCLUSIONS Primary repair of infants with coarctation and VSD using a one-stage approach through separate incisions affords excellent clinical results. One can avoid prolonged aortic cross-clamping, CPB, and circulatory arrest/regional perfusion. Compared with the group undergoing combined coarctation and VSD repair simultaneously by sternotomy, total lengths of stay in the intensive care unit and hospital were significantly decreased.