The Annals of thoracic surgery · 2026
Isolated Ventricular Septal Defect Closure in Mild Aortic Coarctation: Hemodynamic and Anatomic Evolution of Aortic Isthmus.
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Hui Chengyi, Zhou Shuheng, Qiu Min, Cui Hujun, Li Xiaohua, Sun Ling, Chen Jimei, Wen Shusheng
Аннотация
BACKGROUND: Optimal management of ventricular septal defect (VSD) with mild aortic coarctation (isthmus velocity ≥1.5 m/s below intervention thresholds) remains contentious because of limited evidence on post-VSD closure aortic remodeling.
METHODS: This retrospective cohort study analyzed 231 children with mild aortic coarctation undergoing isolated VSD closure. Primary interests included survival, aortic coarctation reintervention, longitudinal evolution of isthmic velocity and z scores, and predictors of persistent obstruction (velocity ≥1.5 m/s at 3-year follow-up).
RESULTS: With a median of 5.5 (4.3-6.4) years of follow-up, survival was 99.6% (95% CI, 96.9-99.9) at 7 years; only 5 patients (2.2%) required aortic coarctation reintervention within 3.7 years. Isthmic velocity showed a triphasic trajectory: transient postoperative rise, rapid decline through 3 years (71.4% of total reduction), and subsequent stabilization. Anatomically, z scores demonstrated parallel catch-up growth, with the steepest improvement also within the first 3 years. Patients with a concomitant patent ductus arteriosus had lower preoperative velocity and greater early rise, but long-term outcomes matched those of patients without patent ductus arteriosus. By 3-year follow-up, 76.1% of patients achieved normalized velocity (<1.5 m/s). Multivariable analysis identified elevated preoperative aortic valve velocity (odds ratio, 6.82; 95% CI, 1.56-36.28; P = .032) and a smaller preoperative isthmus z score (odds ratio, 0.77; 95% CI, 0.63-0.94; P = .028) as independent predictors of persistent obstruction.
CONCLUSIONS: Isolated VSD closure achieves coupled hemodynamic and anatomic aortic remodeling in most children with mild aortic coarctation, yielding excellent long-term survival and low reintervention rates. Elevated preoperative aortic valve velocity and a smaller isthmus z score identify high-risk patients who may benefit from intensified surveillance, supporting a physiology-guided, deferred intervention strategy.
METHODS: This retrospective cohort study analyzed 231 children with mild aortic coarctation undergoing isolated VSD closure. Primary interests included survival, aortic coarctation reintervention, longitudinal evolution of isthmic velocity and z scores, and predictors of persistent obstruction (velocity ≥1.5 m/s at 3-year follow-up).
RESULTS: With a median of 5.5 (4.3-6.4) years of follow-up, survival was 99.6% (95% CI, 96.9-99.9) at 7 years; only 5 patients (2.2%) required aortic coarctation reintervention within 3.7 years. Isthmic velocity showed a triphasic trajectory: transient postoperative rise, rapid decline through 3 years (71.4% of total reduction), and subsequent stabilization. Anatomically, z scores demonstrated parallel catch-up growth, with the steepest improvement also within the first 3 years. Patients with a concomitant patent ductus arteriosus had lower preoperative velocity and greater early rise, but long-term outcomes matched those of patients without patent ductus arteriosus. By 3-year follow-up, 76.1% of patients achieved normalized velocity (<1.5 m/s). Multivariable analysis identified elevated preoperative aortic valve velocity (odds ratio, 6.82; 95% CI, 1.56-36.28; P = .032) and a smaller preoperative isthmus z score (odds ratio, 0.77; 95% CI, 0.63-0.94; P = .028) as independent predictors of persistent obstruction.
CONCLUSIONS: Isolated VSD closure achieves coupled hemodynamic and anatomic aortic remodeling in most children with mild aortic coarctation, yielding excellent long-term survival and low reintervention rates. Elevated preoperative aortic valve velocity and a smaller isthmus z score identify high-risk patients who may benefit from intensified surveillance, supporting a physiology-guided, deferred intervention strategy.