Use of aortic arch measurements in evaluating significant arch hypoplasia in neonates with coarctation

Background: Surgical repair for neonatal arch hypoplasia with coarctation can be performed by a sternotomy or thoracotomy. Objectives: This study retrospectively investigates the use of pre-surgical absolute aortic arch measurements in guiding the optimal approach for neonates with coarctation and aortic arch hypoplasia. Methods: Patients <= 30 days old who underwent coarctation repair via a median sternotomy or lateral thoracotomy between January 2000 and July 2018 were retrospectively reviewed. Neonates requiring intracardiac surgery were excluded. Specific aortic arch measurements were obtained and 3 ratios calculated: distal transverse arch diameter/carotid artery diameter (DT/CA), distal transverse arch diameter/distance from the carotid to subclavian artery (CSA) and isthmus diameter/descending aorta diameter (I/D). Results: Of 118 patients, 65 had a lateral thoracotomy and 53 had a median sternotomy. Distal transverse arch, the carotid artery and isthmus diameters correlated with surgical approach. The DT/CA ratio was statistically significant with an ROC curve (p < 0.0001; AUC 0.761) identifying a ratio of 0.9 (sensitivity 91%, specificity 32%) or less as indicative of aortic arch hypoplasia which is likely best suited for a median sternotomy repair. Reintervention rates were similar for both approaches overall and within the first 6 months of operation. Conclusion: In neonates with coarctation, pre-surgical aortic arch measurements and ratios can be utilized to identify aortic arch hypoplasia and guide surgical approach. In our institution, neonates with a DT/CA ratio of 0.9 or less routinely underwent arch reconstruction by a median sternotomy. Re-intervention rates in the median sternotomy and lateral thoracotomy groups were comparable.