Background: The preferred surgical approach for aortic coarctation with hypoplastic aortic arch remains controversial. Perception exists that performing a sternotomy imposes a significant recovery burden. We analyzed perioperative outcomes of coarctation repair to compare approaches. Methods: Excluding genetic disorders and single-ventricle anatomy, 320 patients ± hypoplastic arch underwent coarctation repair by thoracotomy (n = 281) or sternotomy (n = 39) from 2012 to 2023 at median (IQR) age 22 days (7-383) and weight 3.9 kg (3.2-9.0). Primary endpoints were postoperative intensive care unit (ICU) and hospital length of stay (LOS) and ventilation duration. Secondary outcomes included mortality and reintervention. Stratification by preoperative distal transverse arch (DTA) z-score was performed to assess the impact of arch hypoplasia on hospital course. Results: Sternotomy patients had longer median (IQR) ICU LOS (4.9 days [2.8-7.7] vs 2.0 days [1.3-3.3]), hospital LOS (11.3 days [6.1-16.3] vs 5.4 days [4.2-8.6]), and ventilation duration (2 days [1-4] vs 1 day [0-1]) than thoracotomy patients by 2.9, 5.9, and 1 day (P < .001 each). Thoracotomy patients had higher rates of antihypertensive medications at discharge (51% vs 33%, P = .042). At 2.2 years follow-up, there was one mortality. Although not statistically significant, of all reinterventions performed within each group, thoracotomy patients had a higher proportion within 90 days of repair (45% vs 0%, P = .49); eight-year freedom from reintervention was 93.0% for sternotomy and 88.5% for thoracotomy (P = .65). In a subgroup analysis of patients with DTA z-score ≤ −3, hospital LOS was similar between approaches (P = .063). Conclusions: Children undergoing coarctation repair via sternotomy had a longer hospital course than those undergoing thoracotomy, although differences diminished among those with DTA z-score ≤ −3. Either approach can be considered in patients with mild-to-moderate arch hypoplasia given minor numeric differences in perioperative outcomes; however, sternotomy may provide more complete relief of obstruction to mitigate risks associated with residual elevated arch resistance.
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