Surgical management of severe coarctation of the aorta in the first month of life.

Between March, 1978, and April, 1982, 48 neonates under 4 weeks of age were operated upon for severe coarctation of the aorta in our unit. Of these, 36 babies were in severe congestive cardiac failure and 11 had renal failure. Angiocardiography and echocardiography demonstrated intracardiac lesions in 29 patients. All had a patent ductus arteriosus. Surgical relief of the coarctation was effected within 48 hours of diagnosis. Those in severe cardiac and renal failure were intubated and ventilated in the intensive care unit before the operation. Continuous monitoring of the central venous and arterial pressures and rectal and skin temperature and periodic checks on the acid-base status were instituted, and acidosis was corrected carefully with a 4.2% solution of sodium bicarbonate. A dopamine infusion (4 to 8 micrograms/kg/min) was used to assist the renal and cardiac functions. Five babies were treated with prostaglandin E for 24 to 46 hours before the operation. Forty-five patients had subclavian flap repair of the coarctation and the other three had repair by polytetrafluoroethylene (PTFE) patch angioplasty. The patients were ventilated for 1 to 8 days postoperatively. Dopamine support was given to all the immediate postoperative period. Three patients with associated cardiac lesions died in the first 48 hours after operation. Three other patients died on the sixth, eighth, and eleventh postoperative days of noncardiac causes. Of the 42 survivors, three required revision of the repair because of restenosis 3 to 18 months later. Three patients with ventricular septal defect had closure of the defect within 8 months after birth. We believe that coarctation of the aorta presenting soon after birth should be treated by a combination of active resuscitation and early surgical relief, and that continuous monitoring for early detection and correction of hypoxia and acidosis is essential to achieve satisfactory results.