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Stephens EH, Feins EN, Karamlou T, Anderson BR, Alsoufi B, Bleiweis MS, d'Udekem Y, Nelson JS, Ashfaq A, Marino BS, St Louis JD, Najm HK, Turek JW, Ahmad D, Dearani JA, Jacobs JP. The Society of Thoracic Surgeons Clinical Practice Guidelines on the Management of Neonates and Infants With Coarctation. Ann Thorac Surg 2024; 118:527-544. [PMID: 38904587 DOI: 10.1016/j.athoracsur.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/06/2024] [Accepted: 04/22/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Although coarctation of the aorta without concomitant intracardiac pathology is relatively common, there is lack of guidance regarding aspects of its management in neonates and infants. METHODS A panel of experienced congenital cardiac surgeons, cardiologists, and intensivists was created, and key questions related to the management of isolated coarctation in neonates and infants were formed using the PICO (Patients/Population, Intervention, Comparison/Control, Outcome) Framework. A literature search was then performed for each question. Practice guidelines were developed with classification of recommendation and level of evidence using a modified Delphi method. RESULTS For neonates and infants with isolated coarctation, surgery is indicated in the absence of obvious surgical contraindications. For patients with risk factors for surgery, medical management before intervention is reasonable. For those stable off prostaglandin E1, the threshold for intervention remains unclear. Thoracotomy is indicated when arch hypoplasia is not present. Sternotomy is preferable when arch hypoplasia is present that cannot be adequately addressed through a thoracotomy. Sternotomy may also be considered in the presence of a bovine aortic arch. Antegrade cerebral perfusion may be reasonable when the repair is performed through a sternotomy. Extended end-to-end, arch advancement, and patch augmentation are all reasonable techniques. CONCLUSIONS Surgery remains the standard of care for the management of isolated coarctation in neonates and infants. Depending on degree and location, arch hypoplasia may require a sternotomy approach as opposed to a thoracotomy approach. Significant opportunities remain to better delineate management in these patients.
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Affiliation(s)
| | - Eric N Feins
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Bahaaldin Alsoufi
- Cardiovascular Surgery, Norton Children's Hospital, University of Louisville, Louisville, Kentucky
| | - Mark S Bleiweis
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Yves d'Udekem
- Children's National Heart Institute, Children's National Hospital, Washington, DC
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Awais Ashfaq
- Division of Cardiovascular Surgery, Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | | | - James D St Louis
- Departent of Surgery, Children's Hospital of Georgia, Augusta, Georgia; Departent of Surgery, Inova L.J. Murphy Children's Hospital, Falls Church, Virginia
| | - Hani K Najm
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph W Turek
- Duke Pediatric and Congenital Heart Center, Duke University Medical Center, Durham, North Carolina
| | - Danial Ahmad
- Cardiac Surgery Research Laboratory, Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, Florida; Congenital Heart Center, Division of Cardiovascular Surgery, Department of Pediatrics, University of Florida, Gainesville, Florida.
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Epinephrine stress testing during cardiac catheterization in patients with aortic coarctation. Am Heart J 2020; 225:78-87. [PMID: 32474207 DOI: 10.1016/j.ahj.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/07/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The severity of aortic coarctation (CoA) may be underestimated during cardiac catheterization. We aimed to investigate whether epinephrine stress testing improves clinical decision making and outcome in CoA. METHODS We retrospectively evaluated CoA patients >50 kg with a peak systolic gradient (PSG) ≤20 mm Hg during cardiac catheterization who underwent epinephrine stress testing. Subsequent interventional management (stenting or balloon dilatation), complications, and medium-term clinical outcome were assessed. RESULTS Fifty CoA patients underwent cardiac catheterization with epinephrine stress testing. Patients with a high epinephrine PSG (>20 mm Hg; n = 24) were younger and more likely to have a hypertensive response to exercise compared to patients with a low epinephrine PSG (≤20 mm Hg; n = 26). In total, 21 patients (88%) with a high epinephrine PSG underwent intervention, and 20 patients (77%) with a low epinephrine PSG were treated conservatively. After a mean follow-up of 25 ± 18 months, there was a lower prevalence of hypertension in patients with a high epinephrine PSG who underwent intervention compared to patients with a low epinephrine PSG treated conservatively (19% vs. 76%; P = .001). In a multivariate model, intervention was independently associated with a 14.3-mm Hg reduction in systolic blood pressure (P = .001) and a decrease in the use of antihypertensive agents. CONCLUSIONS In CoA patients with a low baseline PSG but high epinephrine PSG, percutaneous intervention is associated with a substantial reduction in systemic blood pressure and the use of antihypertensive medication. Accordingly, epinephrine stress testing may be a useful addition in the evaluation of CoA.
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Agasthi P, Pujari SH, Tseng A, Graziano JN, Marcotte F, Majdalany D, Mookadam F, Hagler DJ, Arsanjani R. Management of adults with coarctation of aorta. World J Cardiol 2020; 12:167-191. [PMID: 32547712 PMCID: PMC7284000 DOI: 10.4330/wjc.v12.i5.167] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Andrew Tseng
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Joseph N Graziano
- Division of Cardiology, Phoenix Children's Hospital, Children's Heart Center, Phoenix, AZ 85016, United States
| | - Francois Marcotte
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - David Majdalany
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States.
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Warmerdam EG, Krings GJ, Meijs TA, Franken AC, Driesen BW, Sieswerda GT, Meijboom FJ, Doevendans PAF, Molenschot MMC, Voskuil M. Safety and efficacy of stenting for aortic arch hypoplasia in patients with coarctation of the aorta. Neth Heart J 2019; 28:145-152. [PMID: 31784885 PMCID: PMC7052107 DOI: 10.1007/s12471-019-01353-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Despite a successful repair procedure for coarctation of the aorta (CoA), up to two-thirds of patients remain hypertensive. CoA is often seen in combination with abnormal aortic arch anatomy and morphology. This might be a substrate for persistent hypertension. Therefore, we performed endovascular aortic arch stent placement in patients with CoA and concomitant aortic arch hypoplasia or gothic arch morphology. The goal of this retrospective analysis was to investigate the safety and efficacy of aortic arch stenting. Methods A retrospective analysis was performed in patients who underwent stenting of the aortic arch at the University Medical Center Utrecht. Measurements collected included office blood pressure, use of antihypertensive medication, invasive peak-to-peak systolic pressure over the arch, and aortic diameters on three-dimensional angiography. Data on follow-up were obtained at the date of most recent outpatient visit. Results Twelve patients underwent stenting of the aortic arch. Mean follow-up duration was 14 ± 11 months. Mean peak-to-peak gradient across the arch decreased from 39 ± 13 mm Hg to 7 ± 8 mm Hg directly after stenting (p < 0.001). There were no major procedural complications. Mean systolic blood pressure decreased from 145 ± 16 mm Hg at baseline to 128 ± 9 mm Hg at latest follow-up (p = 0.014). Conclusion This retrospective study shows that stenting of the aortic arch is successful when carried out in a state-of-the-art manner. A direct optimal angiographic and haemodynamic result was shown. No major complications occurred during or after the procedure. At short- to medium-term follow-up a decrease in mean systolic blood pressure was observed.
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Affiliation(s)
- E G Warmerdam
- University Medical Center Utrecht, Utrecht, The Netherlands.
| | - G J Krings
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - T A Meijs
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - A C Franken
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - B W Driesen
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - G T Sieswerda
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - F J Meijboom
- University Medical Center Utrecht, Utrecht, The Netherlands
| | - P A F Doevendans
- University Medical Center Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, The Netherlands
| | | | - M Voskuil
- University Medical Center Utrecht, Utrecht, The Netherlands
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Runte K, Brosien K, Salcher-Konrad M, Schubert C, Goubergrits L, Kelle S, Schubert S, Berger F, Kuehne T, Kelm M. Hemodynamic Changes During Physiological and Pharmacological Stress Testing in Healthy Subjects, Aortic Stenosis and Aortic Coarctation Patients-A Systematic Review and Meta-Analysis. Front Cardiovasc Med 2019; 6:43. [PMID: 31024935 PMCID: PMC6467940 DOI: 10.3389/fcvm.2019.00043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/22/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction: Exercise testing has become a diagnostic standard in the evaluation and management of heart disease. While different methods of exercise and pharmacological stress testing exist, only little is known about their comparability. We aimed to assess hemodynamic changes during dynamic exercise, isometric exercise, and dobutamine stress testing at different stress intensities in healthy subjects and patients with aortic stenosis (AS) and aortic coarctation (CoA). Methods: A systematic literature search (PROSPERO 2017:CRD42017078608) in MEDLINE of interventional trials was conducted to identify eligible studies providing evidence of changes in hemodynamic parameters under different stress conditions acquired by MRI or echocardiography. A random effects model was used to estimate pooled mean changes in hemodynamics. Results: One hundred and twenty-eight study arms with a total of 3,139 stress-examinations were included. In healthy subjects/(where available) in AS, pooled mean changes (95% CIs) during light dynamic stress were 31.78 (27.82–35.74) bpm in heart rate (HR) and 6.59 (2.58–10.61) ml in stroke volume (SV). Changes during light pharmacological stress were 13.71 (7.87–19.56)/14.0 (9.82–18.18) bpm in HR, and 5.47 (0.3–10.63)/8.0 (3.82–12.18) ml in SV. Changes during light isometric stress were 18.44 (10.74–26.14)/5.0 (−1.17–11.17) bpm in HR and −4.17 (−14.37–6.03)/−4.0 (−16.43–8.43) ml in SV. Changes during moderate dynamic stress were 49.57 (40.03–59.1)/46.45 (42.63–50.27) bpm in HR and 11.64 (5.87–17.42) ml in SV. During moderate pharmacological stress, changes in HR were 42.83 (36.94–48.72)/18.66 (2.38–34.93) bpm and in SV 6.29 (−2.0–14.58)/13.11 (7.99–18.23) ml. During high intensity dynamic stress changes in HR were 89.31 (81.46–97.17)/55.32 (47.31–63.33) bpm and in SV 21.31 (13.42–29.21)/−0.96 (−5.27–3.35) ml. During high pharmacological stress, changes in HR were 53.58 (36.53–70.64)/42.52 (32.77–52.28) bpm, and in SV 0.98 (−9.32–11.27)/14.06 (−1.62–29.74) ml. HR increase and age were inversely correlated at high stress intensities. In CoA, evidence was limited to single studies. Conclusion: This systematic review and meta-analysis presents pooled hemodynamic changes under light, moderate and high intensity exercise and pharmacological stress, while considering the potential influence of age. Despite limited availability of comparative studies, the reference values presented in this review allow estimation of the expected individual range of a circulatory response in healthy individuals and patients with AS and may contribute to future study planning and patient-specific models even when stress testing is contraindicated.
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Affiliation(s)
- Kilian Runte
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Kay Brosien
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Salcher-Konrad
- Personal Social Services Research Unit, London School of Economics and Political Science, London, United Kingdom.,LSE Health, London School of Economics and Political Science, London, United Kingdom
| | - Charlotte Schubert
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Leonid Goubergrits
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Kelle
- Department of Internal Medicine/Cardiology, German Heart Center Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Stephan Schubert
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Titus Kuehne
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany.,German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Marcus Kelm
- Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
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6
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Poncelet AJ, Henkens A, Sluysmans T, Moniotte S, de Beco G, Momeni M, Detaille T, Rubay JE. Distal Aortic Arch Hypoplasia and Coarctation Repair: A Tailored Enlargement Technique. World J Pediatr Congenit Heart Surg 2018; 9:496-503. [DOI: 10.1177/2150135118780611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Several techniques have been described to correct coarctation associated with distal arch hypoplasia. However, in neonates, residual gradients are frequently encountered and influence long-term outcome. We reviewed our experience with an alternative technique of repair combining carotid–subclavian angioplasty and extended end-to-end anastomosis. Methods: From 1998 through 2014, 109 neonates (median age, 9 days) with coarctation and distal arch hypoplasia (n = 106) or type A interrupted aortic arch (n = 3) underwent repair using this technique. Thirty patients had isolated lesions (group 1), 44 associated ventricular septal defect (group 2), and 35 associated complex cardiac lesions (group 3). Median follow-up was 98 months. Results: Repair was performed via left thoracotomy in 97%. There was one procedural-related death (0.9%) and overall five patients died during index admission (4.6%). Ten deaths were recorded at follow-up. Actuarial five-year survival was 86% (100% in group 1, 91% group 2, and 66% in group 3). Recurrent coarctation (clinical or invasive gradient >20 mm Hg) developed in 15 patients, all but 2 successfully treated by balloon dilatation. Freedom from any reintervention (dilatation or surgery) at five years was 86%. Only two patients were on antihypertensive drugs at last follow-up. Conclusions: This combined technique to correct distal arch hypoplasia and isthmic coarctation results in low mortality and acceptable recurrence rate. It preserves the left subclavian artery and allows enlargement of the distal arch diameter. Late outcome is excellent with very low prevalence of late arterial hypertension.
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Affiliation(s)
- Alain J. Poncelet
- Department of Cardiovascular and Thoracic Surgery, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Arnaud Henkens
- Department of Cardiovascular and Thoracic Surgery, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Thierry Sluysmans
- Department of Pediatric Cardiology, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Stephane Moniotte
- Department of Pediatric Cardiology, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Geoffroy de Beco
- Department of Cardiovascular and Thoracic Surgery, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Mona Momeni
- Department of Anesthesiology, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Thierry Detaille
- Department of Pediatric Intensive Care, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
| | - Jean E. Rubay
- Department of Cardiovascular and Thoracic Surgery, Cliniques universitaires Saint-Luc, Universite catholique de Louvain, Brussels, Belgium
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Unmasking the borderline coarctation: the utility of isoproterenol in the paediatric cardiac catheterisation laboratory. Cardiol Young 2018. [PMID: 29534778 DOI: 10.1017/s1047951118000239] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND One indication for intervention in coarctation of the aorta is a peak-to-peak gradient >20 mmHg. Gradients may be masked in patients under general anaesthesia and may be higher during exercise. Isoproterenol was given during cardiac catheterisation to simulate a more active physiologic state. OBJECTIVES We aimed to describe the haemodynamic effects of isoproterenol in patients with coarctation and the impact of intervention on the elicited gradients. METHODS A retrospective study was performed on two-ventricle patients who underwent cardiac catheterisation for coarctation with isoproterenol testing. RESULTS 25 patients received isoproterenol before and after intervention. With isoproterenol, the mean diastolic (p=0.0015) and mean arterial (p=0.0065) blood pressures proximal to the coarctation decreased significantly. The mean systolic, diastolic, and mean arterial blood pressures distal to the coarctation decreased significantly (p20 mmHg. Post intervention, the median gradient decreased to 2 (0-29) mmHg, versus baseline, p=0.005, and with isoproterenol it decreased to 8 (0-27) mmHg, versus pre-intervention isoproterenol, p<0.0001. There were significant improvements in the gradients by Doppler (<0.0001) and by blood pressure cuff (p=0.0313). The gradients on isoproterenol best correlated with gradients by blood pressure cuff in the awake state (R2=0.76, p<0.0001). CONCLUSIONS Isoproterenol can be a useful tool to assess the significance of a coarctation and the effectiveness of an intervention. Percutaneous interventions can effectively reduce the gradients elicited by isoproterenol.
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Abstract
Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.
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Clinical Impact of Stent Implantation for Coarctation of the Aorta with Associated Hypoplasia of the Transverse Aortic Arch. Pediatr Cardiol 2017; 38:1016-1023. [PMID: 28396934 DOI: 10.1007/s00246-017-1611-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
Abstract
The aim of this study was to explore the clinical impact of transverse aortic arch hypoplasia (TAH) after stent implementation for isthmal coarctation of the aorta (CoA). From a retrospective chart review, 51 children (median age 11.1 years) were identified who had TAH and a CoA stent implanted between 10/1995 and 4/2015. Arm-leg cuff blood pressure measurements, echocardiographic arch imaging, and 24-h ambulatory blood pressure monitoring, prior to and after stent implantation, were reviewed. At catheterization, peak systolic gradients across the CoA's were 25 mmHg before and 4 mmHg after stent implantation. At a median 37-month follow-up, echocardiographic imaging showed no significant catch-up growth in the transverse arch (median z-score; proximal and distal arch -1.54 and -1.99 vs. -1.78 and -1.63, p = 0.13 and 0.90). A trend to increasing systolic blood pressure (SBP) differentials between the right and left arms was noted (11 mmHg [prior to]; 16 mmHg [follow-up], p = 0.09). Age-adjusted percentiles for right arm SBP decreased from 99.7% prior to, and 87.6% in follow-up (p < 0.001). The median time to re-intervention was 5.6 years (95% CI [2.8, 7.8]) and the proportion of children using anti-hypertensive in follow-up was not significantly different before the implantation (38% [prior to]; 45% [follow-up]). Elevated right arm blood pressure persists after successful stent implantation in the setting of associated TAH and there appears to be no catch-up growth of the transverse arch with time. Medical management can be difficult and approaches to surgical arch augmentation or stent implantation should be considered to avoid unilateral arm hypertension.
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10
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How successful is successful? Aortic arch shape after successful aortic coarctation repair correlates with left ventricular function. J Thorac Cardiovasc Surg 2017; 153:418-427. [DOI: 10.1016/j.jtcvs.2016.09.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 07/14/2016] [Accepted: 09/07/2016] [Indexed: 11/17/2022]
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11
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Liu JYJ, Jones B, Cheung MMH, Galati JC, Koleff J, Konstantinov IE, Grigg LE, Brizard CP, d'Udekem Y. Favourable anatomy after end-to-side repair of interrupted aortic arch. Heart Lung Circ 2013; 23:256-64. [PMID: 24060690 DOI: 10.1016/j.hlc.2013.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 07/13/2013] [Accepted: 08/09/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate cardiovascular outcomes in patients with aortic arch repair and their possible correlation with arch geometry. METHODS Ten patients who underwent end-to-side repair for aortic arch interruption (IAA), older than 10 years were compared to a cohort of 10 post coarctation (CoA) repair patients matched for age, sex and age at repair. Mean age at operation was 9.7±6.5 days. Patients underwent a resting and 24 h blood pressure measurements, exercise study, MRI, transthoracic echocardiography and vascular studies. RESULTS Seven patients developed hypertension, two from IAA group and five from CoA group. Nine patients (45%) had gothic arch geometry, three from IAA group and six from CoA group. Despite differences in arch geometry, both groups had normal LV mass, LV function and vascular function. CONCLUSION No differences in functional or morphologic outcomes could be demonstrated between the end-to-side repair of the arch by sternotomy and the conventional coarctation repair by thoracotomy. A favourable arch geometry can be achieved after the end-to-side repair of the aortic arch. In the present study, we could not correlate adverse arch geometry with any adverse cardio-vascular outcomes. After neonatal arch repair, the contributive role of aortic arch geometry to late hypertension remains uncertain.
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Affiliation(s)
- Jessamine Y J Liu
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Bryn Jones
- Department of Cardiology, Royal Children's Hospital, Melbourne, Australia
| | - Michael M H Cheung
- Department of Cardiology, Royal Children's Hospital, Melbourne, Australia
| | - John C Galati
- Clinical Epidemiology and Biostatistics Unit, Royal Children's Hospital, Melbourne, Australia
| | - Jane Koleff
- Department of Cardiology, Royal Children's Hospital, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Leeanne E Grigg
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Murdoch Children Research Institute, Melbourne, Australia.
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12
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Pushparajah K, Sadiq M, Brzezińska-Rajszys G, Thomson J, Rosenthal E, Qureshi SA. Endovascular stenting in transverse aortic arch hypoplasia. Catheter Cardiovasc Interv 2013; 82:E491-9. [PMID: 23494884 DOI: 10.1002/ccd.24735] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/29/2012] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Describe outcomes from stenting transverse aortic arch hypoplasia. BACKGROUND Hypoplasia of the transverse arch may result in residual systemic hypertension and may be amenable to stenting. METHODS Outcomes for transverse aortic arch hypoplasia stenting were collated from four centers between 2000 and 2010. Primary endpoints were reduction in peak systolic catheter gradient, dimensions of the stented segment, and systolic right arm blood pressure. Changes in antihypertensive medication and early and late complications were recorded. Data were collated for 21 patients (16 male, 5 female), median age of 16.5 years (range, 0.25-25.9 years) and median weight of 55 kg (range, 4.5-103 kg). 19/21 patients were hypertensive at baseline, excluding the two neonates after repair of interrupted aortic arch. RESULTS Median transverse arch diameter increased from 7 to 14 mm after stenting (P < 0.001). Median ratio of the transverse arch to descending aorta at the diaphragm level improved from 0.43 to 0.9 (P < 0.001). Mean gradient across the hypoplastic transverse arch was 38 mm Hg (range, 14-76) at baseline and 5 mm Hg (range, 0-13) after stenting (P < 0.001). There were no deaths and 6 early complications occurred in 5 patients. Follow-up (median 24 months) data were available for 19 patients. 17/19 hypertensive patients had follow-up data. Two neonates developed intimal hyperplasia within the stent with a stent fracture in one. Median systolic blood pressure was 153 mm Hg (range, 117-180) prestent and 130 mm Hg (range, 105-150) poststent (P = 0.0002). In 13/17 patients, the antihypertensive medication could be reduced. CONCLUSIONS Stenting of transverse aortic arch hypoplasia, although technically challenging, produced good angiographic and haemodynamic results with an early improvement in blood pressure control. These results appear to be sustained in the medium term.
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Affiliation(s)
- Kuberan Pushparajah
- Department of Congenital Cardiology, Evelina Children's Hospital, London, United Kingdom
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13
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Kim KS, Eryu Y, Asakai H, Hayashi T, Kaneko M, Kato H. Isoproterenol stress test during catheterization of patients with coarctation of the aorta. Pediatr Int 2012; 54:461-4. [PMID: 22299669 DOI: 10.1111/j.1442-200x.2012.03572.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The exercise test is considered useful in selecting high-risk patients with repaired coarctation of the aorta (CoA), but it is difficult to obtain the cooperation of pediatric patients. The present study determines the feasibility of the isoproterenol stress test (IST) among pediatric patients with CoA. METHODS Thirteen patients with repaired or mild preoperative CoA aged 1-207 (median 13) months underwent 16 IST during cardiac catheterization. Peak-to-peak pressure gradients (PG) over the coarctation site were measured at baseline and at IST. Balloon angioplasty (BAP) was applied to patients with significant stenosis on angiography. RESULTS The PG between the ascending and the descending aorta was significantly higher at IST than at baseline (20.5 ± 11.5 vs 5.6 ± 3.9 mmHg, P < 0.0001). Heart rate, the systolic blood pressure measured at the ascending aorta, and pulse pressure were all significantly higher at IST than at baseline. The PG at IST decreased >10 mmHg in three of six patients after BAP. CONCLUSIONS Significant pressure gradients over the coarctation site develop at IST in pediatric patients with repaired CoA or in preoperative patients with mild coarctation.
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Affiliation(s)
- Ki-Sung Kim
- Division of Cardiology, National Center for Child Health and Development, Tokyo, Japan.
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14
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Luijendijk P, Bouma BJ, Vriend JW, Vliegen HW, Groenink M, Mulder BJ. Usefulness of exercise-induced hypertension as predictor of chronic hypertension in adults after operative therapy for aortic isthmic coarctation in childhood. Am J Cardiol 2011; 108:435-9. [PMID: 21550580 DOI: 10.1016/j.amjcard.2011.03.063] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 03/18/2011] [Accepted: 03/20/2011] [Indexed: 10/18/2022]
Abstract
Chronic hypertension is a major concern in adults who have undergone resection of coarctation of the aorta (CoA) in childhood. In otherwise healthy subjects, exercise-induced hypertension is prognostic for chronic hypertension; however, the prognostic value in patients with CoA remains unknown. The aim of the present study was to evaluate the predictive value of exercise-induced hypertension for chronic hypertension in these patients. In the present prospective follow-up study, 74 patients with CoA (58% men, age 30.9 ± 9.5 years) underwent ambulatory blood pressure (BP) monitoring and exercise testing twice from 2001 to 2009 with a follow-up period of 6.3 ± 0.8 years. Hypertension was defined as a mean systolic BP ≥140 mm Hg and/or mean diastolic BP ≥90 mm Hg or the need for antihypertensive treatment. Exercise-induced hypertension was defined as a mean systolic BP of <140 mm Hg and peak exercise systolic BP of ≥200 mm Hg. At baseline, 27 patients (36%) were hypertensive, 11 (15%) had exercise-induced hypertension, and 36 (49%) were normotensive. At follow-up, all 27 hypertensive patients remained hypertensive. Of the 11 with exercise-induced hypertension, 7 (64%) had developed chronic hypertension, and 4 (36%) continued to have exercise-induced hypertension. Of the 36 normotensive patients, 7 (19%) had developed hypertension, 12 (33%) had developed exercise-induced hypertension, and 17 (47%) remained normotensive. On multivariate analysis, baseline maximum exercise systolic BP was independently associated with the mean systolic BP at follow-up (β = 0.13, p = 0.005). In conclusion, the maximum exercise systolic BP was a predictor for chronic hypertension in patients with CoA. These findings demonstrate the clinical importance of exercise-induced hypertension and warrant additional study into the long-term consequences of exercise-induced hypertension and the potential beneficial role of early antihypertensive treatment in adult patients after CoA repair with exercise-induced hypertension.
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McKenzie ED, Klysik M, Morales DLS, Heinle JS, Fraser CD, Kovalchin J. Ascending sliding arch aortoplasty: a novel technique for repair of arch hypoplasia. Ann Thorac Surg 2011; 91:805-10. [PMID: 21353003 DOI: 10.1016/j.athoracsur.2010.10.038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/14/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Coarctation of the aorta (CoA) is often associated with clinically significant hypoplasia of the aortic arch. Historically, patch aortoplasty or bypass procedures have been the preferred techniques when arch augmentation is required in children beyond infancy. While safe and effective, these approaches require prosthetic or biologic material without the potential for growth, or normal endothelial and physiologic elastic function. This retrospective study reviews the use of a novel technique, ascending sliding arch aortoplasty, that utilizes viable autologous tissue for repair of arch obstruction in children beyond infancy. METHODS Between April 2002 and January 2007, 8 patients ranging in age from 18 months to 15 years underwent repair of CoA with arch hypoplasia using ascending sliding arch aortoplasty. All patients were approached through median sternotomy, utilizing cardiopulmonary bypass and selective antegrade cerebral perfusion. RESULTS There was no mortality or major morbidity. One toddler had pneumonia, resulting in an increased length of stay. Median duration of hospitalization was 5.8 days, ranging from 3 to 10 days. No patient had evidence of residual obstruction or recurrent CoA at a mean follow-up interval of 36 months. CONCLUSIONS Ascending sliding arch aortoplasty for CoA with arch obstruction in children beyond infancy is a safe technique that can be accomplished without deep hypothermic circulatory arrest. There is no evidence of recurrence at midterm follow-up. Because the augmentation is accomplished with viable autologous aortic tissue, the potential for growth, preserved elasticity and endothelial function, and resistance to infection make this method attractive for use in the young.
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Affiliation(s)
- E Dean McKenzie
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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Liu JY, Kowalski R, Jones B, Konstantinov IE, Cheung MM, Donath S, Brizard CP, d'Udekem Y. Moderately hypoplastic arches: do they reliably grow into adulthood after conventional coarctation repair?☆. Interact Cardiovasc Thorac Surg 2010; 10:582-6. [DOI: 10.1510/icvts.2009.223776] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Mid-term results, and therapeutic management, for patients suffering hypertension after surgical repair of aortic coarctation. Cardiol Young 2009; 19:451-5. [PMID: 19674497 DOI: 10.1017/s1047951109990734] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We designed our study to investigate the efficacy of a new therapeutic approach to late onset hypertension in patients after surgical repair of aortic coarctation. Several studies have shown a higher incidence of hypertension during daily activities, and during exercise, in patients after surgical correction of coarctation. To the best of our knowledge, however, no data exists concerning haemodynamics, the response of arterial pressures, and the effects of medications for lowering blood pressure during exercise or during daily activities.We studied 128 patients, aged 15.6 +/- 4.3 years, to determine the response of blood pressure as we administered treatment in the attempt to achieve a normotensive state. We excluded patient with associated cardiac abnormalities, apart from those with bicuspid aortic valves. We evaluated blood pressure at rest in both the right arm and leg to establish presence of any gradient, as well as the blood pressure in the arm during exercise testing, and by 24-hour ambulatory monitoring.Atenolol was prescribed for those with elevated values of blood pressure but with a normal increment of heart rate during exercise. We prescribed Candesartan for those with elevated levels of blood pressure but with reduced increments of heart rate, specifically maximal heart rates of less than 85% of their predicted value. Both drugs were used when one alone was not effective. We found that, in young patients, candesartan provided better control of blood pressure with no side-effects, especially as demonstrated using 24-hour ambulatory monitoring, while atenolol was less effective, with more side-effects. Our experience suggests that both drugs should be used in patients who are non-responsive to monotherapy.
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Karamlou T, Bernasconi A, Jaeggi E, Alhabshan F, Williams WG, Van Arsdell GS, Coles JG, Caldarone CA. Factors associated with arch reintervention and growth of the aortic arch after coarctation repair in neonates weighing less than 2.5 kg. J Thorac Cardiovasc Surg 2009; 137:1163-7. [PMID: 19379984 DOI: 10.1016/j.jtcvs.2008.07.065] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2008] [Revised: 06/21/2008] [Accepted: 07/26/2008] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Neonates weighing less than 2.5 kg with aortic coarctation are challenging. We sought to find the prevalence of death or aortic arch reintervention and their determinants after coarctation repair. We also sought to define growth trajectories for postrepair aortic arch dimensions and identify factors associated with accelerated longitudinal growth. METHODS We reviewed neonates weighing less than 2.5 kg undergoing coarctation repair between 1993 and 2004. Competing-risks methods determined time-related prevalences of death, arch reintervention, and survival without subsequent reintervention. Mixed regression analysis modeled longitudinal growth trajectories of echocardiographically derived aortic arch dimensions. RESULTS Thirty-six neonates underwent coarctation repair. Initial repair type was simple end to end (n = 3), extended end to end (n = 16), subclavian flap aortoplasty (n = 15), and patch aortoplasty (n = 2). Median initial repair age was 11 days (range 2-69 days) and mean weight was 2.01 +/- 0.33 kg. Overall 1-year survival was 76%. After 1 year from initial repair, 19% had died without subsequent reintervention, 14% underwent arch reintervention, and 67% remained alive without arch reintervention. Neonates with extended end-to-end repairs had increased transverse aortic arch Z-scores (P = .004). Although patients with larger initial transverse aortic arch Z-scores had higher scores across all time points (P < .001), neonates with the smallest transverse aortic arch Z-scores had accelerated growth trajectories (P < .001). Aortic isthmus growth was likewise accelerated in neonates with the smallest initial aortic isthmus Z-score (P < .001). CONCLUSIONS Mortality and arch reintervention are common after initial repair of coarctation of the aorta in neonates weighing less than 2.5 kg. Catch-up growth of both the transverse arch and isthmus occurs after coarctation repair, especially in those with the smallest arch parameters, and may be increased by using an extended end-to-end technique.
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Affiliation(s)
- Tara Karamlou
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
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Weber HS, Cyran SE. Endovascular Stenting for Native Coarctation of the Aorta Is an Effective Alternative to Surgical Intervention in Older Children. CONGENIT HEART DIS 2008; 3:54-9. [DOI: 10.1111/j.1747-0803.2007.00148.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Giardini A, Piva T, Picchio FM, Lovato L, Donti A, Rocchi G, Gargiulo G, Fattori R. Impact of transverse aortic arch hypoplasia after surgical repair of aortic coarctation: An exercise echo and magnetic resonance imaging study. Int J Cardiol 2007; 119:21-7. [PMID: 17049653 DOI: 10.1016/j.ijcard.2006.07.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2006] [Revised: 06/03/2006] [Accepted: 07/08/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND We sought to assess the impact of persistent hypoplasia of the transverse aortic arch (TAA) after repair of aortic coarctation (AoC), on blood pressure response to exercise, left ventricular (LV) hypertrophy and presence of collateral circulation. METHODS 34 consecutive patients with end-to-end repair of AoC (age at repair 3.2+/-2.5 years) underwent exercise echocardiography and magnetic resonance imaging (MRI) at 24+/-7 years of age (range 11.3 to 44.6 years). Systolic Doppler pressure gradient (SPG) across the descending aorta and blood pressure at the right arm were measured at baseline and every minute throughout all exercise. Magnetic resonance imaging was used to measure LV mass index, presence and amount of collateral flow, and the diameters of the aortic isthmus and TAA indexed to the diameter of the diaphragmatic. RESULTS Aortic isthmus index was higher than that of the TAA (p=0.006). We observed LV hypertrophy in 15 patients (45%) and presence of collateral circulation in 14 (41%). Eighteen patients (53%) had an abnormal blood pressure response to exercise. Patients with abnormal pressure response to exercise had smaller TAA index (p=0.0005), but similar aortic isthmus index (p=0.09). They also had higher exercise SPG (p<0.0001), higher LV mass index (p<0.0001) and prevalence of LV hypertrophy (p=0.007), higher prevalence of collateral circulation (p<0.0001) and a higher amount of collateral flow (p<0.0001). TAA index, but not aortic isthmus index, correlated with exercise blood pressure (r=-0.59, p=0.003), exercise SPG (r=-0.70, p=0.0005), amount of collateral flow (r=-0.74, p=0.0002) and LV mass index (r=-0.68, p=0.0007). CONCLUSIONS After repair of AoC, hypoplasia of the TAA may be responsible for abnormal blood pressure response to exercise, persistence of collateral circulation and LV hypertrophy.
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Affiliation(s)
- Alessandro Giardini
- Pediatric Cardiology and Adult Congenital Unit, University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
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De Caro E, Trocchio G, Smeraldi A, Calevo MG, Pongiglione G. Aortic arch geometry and exercise-induced hypertension in aortic coarctation. Am J Cardiol 2007; 99:1284-7. [PMID: 17478158 DOI: 10.1016/j.amjcard.2006.12.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 12/07/2006] [Accepted: 12/07/2006] [Indexed: 11/16/2022]
Abstract
Hypertension at rest or during effort is not uncommon in patients with aortic coarctation (CoA), even those with a successful repair or mild degree of obstruction. Anatomic factors and functional abnormalities have been proposed as causes of this finding. Recently, aortic arch geometry was reported in association with hypertension at rest in patients with successful CoA repair. Forty-one patients (age 15.7 +/- 4.6 years) without significant obstruction at rest (mean systolic Doppler gradient at rest < or =25 mm Hg) were selected for the study. All patients underwent a maximal cardiopulmonary exercise test and magnetic resonance imaging of the aorta. Aortic arch shape was defined on global geometry as normal, gothic, and crenel. Percentage of anatomic narrowing (AN) was also calculated. Twenty-four patients (58%) showed exercise-induced hypertension (EIH). Regarding the shape of the aortic arch, normal geometry was present in 17 patients (41%), 9 (21%) had gothic geometry, and 15 (36%) had crenel geometry. There were no differences among the 3 geometries in regard to the incidence of EIH (70.6% in normal, 55.6% in gothic, and 46.7% in crenel) or AN (36.9% in normal, 33.5% in gothic, and 36.6% in crenel). In conclusion, our results fail to show a correlation between a specific aortic arch shape and the incidence of EIH and significant AN in patients with native or residual CoA or repeat CoA. Therefore, at present, the role of aortic arch geometry in identifying patients at risk of EIH is still uncertain.
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Affiliation(s)
- Enrico De Caro
- Cardiovascular Department, Scientific Directorate, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
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Boshoff D, Budts W, Mertens L, Eyskens B, Delhaas T, Meyns B, Daenen W, Gewillig M. Stenting of hypoplastic aortic segments with mild pressure gradients and arterial hypertension. Heart 2006; 92:1661-6. [PMID: 16644857 PMCID: PMC1861222 DOI: 10.1136/hrt.2005.084822] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To determine the safety, feasibility and effectiveness of stent expansion of hypoplastic aortic segments with pressure gradients in patients with arterial hypertension. DESIGN Non-randomised prospective clinical trial. SETTING Tertiary referral centre, congenital cardiac unit. PATIENT SELECTION 20 consecutive patients (median age 14.5 years, range 11.6-38.8 years) with arterial hypertension and a hypoplastic segment of the aorta. Seventeen patients had successful previous arch interventions in a coarctation site. INTERVENTIONS Stent deployment in hypoplastic arch segments. MAIN OUTCOME MEASURES Gradient across the aortic arch; complications early and during follow up; residual hypertension. RESULTS 23 stents were deployed: 13 in the cross and 10 in the isthmus. The mean gradient across the aortic arch decreased from 16 (SD 6) (median 17) to 3 (4) (median 1) mm Hg (p < 0.001). In a few patients a mild gradient persisted just distal to the left carotid artery due to residual orificial narrowing or acute angulation. No complications occurred during or after the procedure. During follow up of 2.2 years (range 0.2-4.8 years) arterial hypertension resolved in 10 patients and 10 required residual drug treatment with better control of blood pressures. CONCLUSIONS Pressure loss due to residual hypoplastic aortic segments can be treated effectively and safely with stent expansion. Some patients remain mildly hypertensive and require additional drug treatment.
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Affiliation(s)
- D Boshoff
- Paediatric and Adult Congenital Heart Unit, University Hospitals Leuven, Leuven, Belgium
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Vriend JWJ, Mulder BJM. Late complications in patients after repair of aortic coarctation: implications for management. Int J Cardiol 2005; 101:399-406. [PMID: 15907407 DOI: 10.1016/j.ijcard.2004.03.056] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2003] [Revised: 12/18/2003] [Accepted: 03/05/2004] [Indexed: 12/29/2022]
Abstract
Survival of patients with aortic coarctation has dramatically improved after surgical repair became available and the number of patients who were operated and reach adulthood is steadily increasing. However, life expectancy is still not as normal as in unaffected peers. Cardiovascular complications are frequent and require indefinite follow-up. Concern falls chiefly in seven categories: recoarctation, aortic aneurysm formation or aortic dissection, coexisting bicuspid aortic valve, endocarditis, premature coronary atherosclerosis, cerebrovascular accidents and systemic hypertension. In this review, these complications, with particular reference to late hypertension, are discussed and strategies for the clinical management of post-coarctectomy patients are described.
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Affiliation(s)
- Joris W J Vriend
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
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Agnoletti G, Bonnet C, Bonnet D, Sidi D, Aggoun Y. Mid-term effects of implanting stents for relief of aortic recoarctation on systemic hypertension, carotid mechanical properties, intimal medial thickness and reflection of the pulse wave. Cardiol Young 2005; 15:245-50. [PMID: 15865825 DOI: 10.1017/s1047951105000521] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Primary implantation of stents is an accepted technique for treating aortic recoarctation, albeit that the effects of stenting on pressure profiles, carotid mechanical properties, intimal medial thickness, and reflection of the pulse wave have not been systematically investigated. METHODS Over the period from 1 January, 1999, to 31 December, 2002, we implanted stents to relieve aortic recoarctation in 15 patients, with a median age of 17 years, and a range from 7 to 29 years, with a median weight of 56 kilograms, ranging from 20 to 96 kilograms. Indications were a gradient of 20 millimetres of mercury or more measured in all, systemic hypertension at rest in 8, and systemic hypertension at exercise in all. Of the patients, 5 were receiving anti-hypertensive treatment. Before implantation of the stents, and after a mean follow-up of 22 months, all patients underwent an exercise test, vascular echography, and examination of the common carotid artery so as to determine its cross sectional compliance and distensibility, and the augmentation index. results: The stents were implanted successfully in all patients. The mean gradient was reduced from 27 to 4 millimetres of mercury (p < 0.001). Systolic blood pressure at rest diminished from 140 to 131 millimetres of mercury (p = 0.04), while hypertension at rest regressed in 4 patients. Systolic blood pressure at exercise diminished from 245 to 222 millimetres of mercury (p = 0.018), and hypertension at exercise regressed in 1 patient. Anti-hypertensive treatment is still required for 4 patients. A correlation was found between systolic blood pressure at rest and initial peak-to-peak gradient (r = 0.8), and between initial gradient and percentage reduction of systolic blood pressure at rest at follow-up (r = -0.73). Compliance and distensibility of the common carotid artery were not significantly modified, albeit that the intimal medial thickness diminished from 0.64 to 0.57 millimetres (p = 0.04), and the augmentation index decreased from 5 to -1 (p = 0.012). CONCLUSIONS Primary implantation of stents is effective in mid-term repair of aortic recoarctation. Although there is an improvement in systemic hypertension, the tensional profile and vascular sonography are not normalized. At long term follow-up, the suppression of an early reflection site of the pulse wave could decrease the wall stress of the great elastic vessels, reducing the thickness of the arterial walls.
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Crepaz R, Cemin R, Romeo C, Bonsante E, Gentili L, Trevisan D, Pitscheider W, Stellin G. Factors affecting left ventricular remodelling and mechanics in the long-term follow-up after successful repair of aortic coarctation. Cardiol Young 2005; 15:160-7. [PMID: 15845159 DOI: 10.1017/s104795110500034x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIMS To identify factors predisposing to abnormal left ventricular geometry and mechanics in 52 patients after successful repair of aortic coarctation. METHODS AND RESULTS We evaluated left ventricular remodelling, systolic midwall mechanics, and isthmic gradient by echo-Doppler, systemic blood pressure at rest/exercise and by ambulatory blood pressure monitoring, and the aortic arch by magnetic resonance imaging. Echocardiographic findings were compared with those of 142 controls. The patients with aortic coarctation showed an increased indexed left ventricular end-diastolic volume, increased mass index, increased ratio of mass to volume and systolic chamber function. The contractility, estimated at midwall level, was increased in 21 percent of the patients. In 26 (50 percent) of the patients, we found abnormal left ventricular geometry, with 9 percent showing concentric remodelling, 33 percent eccentric hypertrophy, and 8 percent concentric hypertrophy. These patients were found to be older, underwent a later surgical repair, and to have higher systolic blood pressures at rest and exercise as well as during ambulatory monitoring. The relative mural thickness and mass index of the left ventricle showed a significant correlation with different variables on uni- and multivariate analysis. Age and diastolic blood pressure at rest are the only factors associated with abnormal left ventricular remodelling. CONCLUSIONS Patients who have undergone a seemingly successful surgical repair of aortic coarctation may have persistently abnormal geometry with a hyperdynamic state of the left ventricle. This is more frequent in older patients, and in those with higher diastolic blood pressures.
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Affiliation(s)
- Roberto Crepaz
- Department of Cardiology, S. Maurizio Regional Hospital of Bolzano, 39100 Bolzano, Italy.
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Kim GB, Kang SJ, Bae EJ, Yun YS, Noh CI, Lee JR, Kim YJ, Lee JY. Elastic properties of the ascending aorta in young children after successful coarctoplasty in infancy. Int J Cardiol 2004; 97:471-7. [PMID: 15561335 DOI: 10.1016/j.ijcard.2003.10.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2003] [Revised: 07/06/2003] [Accepted: 10/23/2003] [Indexed: 11/27/2022]
Abstract
BACKGROUND Based on the hypothesis that vascular dysfunction in the ascending aorta can cause morbidity, we undertook this study on the elastic properties of ascending aorta and left ventricular (LV) function in young children who received coarctoplasty in early infancy. METHODS Blood pressures (BP) in the right arm and ascending aortic internal diameters determined by M-mode ultrasound at rest and after exercise were measured in 25 patients (mean age, 6.4+/-3 years) and 22 control subjects (mean age, 5.8+/-2.4 years). Ascending aortic stiffness index and distensibility were calculated using BP measurements and ascending aortic internal diameters. In addition, LV parameters (systolic and diastolic function, mass index) were evaluated. RESULTS Compared with control subjects, patients had increased stiffness index (at rest: 4.87+/-1.94 versus 3.57+/-1.19, P=0.021; after exercise: 4.33+/-1.91 versus 3.2+/-1.26, P=0.034) and decreased distensibility (at rest: 6.90+/-3.15 versus 8.72+/-2.77, P=0.02; after exercise: 5.69+/-2.39 versus 7.88+/-3.44 cm2 dyn(-1) 10(-6), P=0.023). BP and LV parameters showed no consistent differences between the two groups. In patients, distensibility was significantly correlated with systolic BP (at rest: P=0.008; after exercise: P=0.014) and pulse pressure (at rest: P=0.013; after exercise: P=0.001). CONCLUSIONS This study suggests that vasculopathy of ascending aorta is possible in some young children despite early correction. However, long-term tracking study is needed to clarify the significance of the study.
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Affiliation(s)
- Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea
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Vriend JWJ, Zwinderman AH, de Groot E, Kastelein JJP, Bouma BJ, Mulder BJM. Predictive value of mild, residual descending aortic narrowing for blood pressure and vascular damage in patients after repair of aortic coarctation. Eur Heart J 2004; 26:84-90. [PMID: 15615804 DOI: 10.1093/eurheartj/ehi004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The significance of mild residual descending aortic narrowing in post-coarctectomy patients is not known. The aim of our study was to investigate the influence of mild residual descending aortic narrowing on blood pressure and vascular damage in patients after repair of aortic coarctation. METHODS AND RESULTS In 107 consecutive post-coarctectomy patients, magnetic resonance imaging, ambulatory blood pressure monitoring, and B-mode ultrasound of the carotid arteries were performed. A significant residual aortic narrowing was defined as: (i) a resting blood pressure gradient > or =30 mmHg with hypertension or exercise-induced hypertension (European Society of Cardiology guidelines); and/or (ii) a site of repair/diaphragmatic aorta ratio <0.7. Thirty-four patients (32%) had a significant residual aortic narrowing and were excluded from the analysis. Of the remaining 73 patients (43 male) with no or only mild residual descending aortic narrowing, median age was 29.8 years (range 17.1-52.5 years), mean age at repair 8.1 years (range 0.02-37.3 years), mean arm/leg gradient 2+/-12 mmHg, and mean common carotid intima-media thickness 0.612+/-0.118 mm. Thirty-three (45%) of these patients had hypertension. In multivariable regression analysis the site of repair/diaphragmatic aorta ratio was a strong and independent predictor of mean daytime systolic blood pressure (P<0.001) and common carotid intima-media thickness (P=0.027). CONCLUSION Mild residual descending aortic narrowing in post-coarctectomy patients is independently associated with mean daytime blood pressure and carotid intima-media thickness. Our data suggest that a threshold for re-intervention of residual aortic narrowing lower than posed in current guidelines may be desirable to improve long-term outcome in these patients. However, further research on such aggressive interventional approaches is needed.
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Affiliation(s)
- Joris W J Vriend
- Department of Cardiology, Room B2-240, Academic Medical Centre, Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands
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Vriend JWJ, van Montfrans GA, Romkes HH, Vliegen HW, Veen G, Tijssen JGP, Mulder BJM. Relation between exercise-induced hypertension and sustained hypertension in adult patients after successful repair of aortic coarctation. J Hypertens 2004; 22:501-9. [PMID: 15076155 DOI: 10.1097/00004872-200403000-00012] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To investigate whether exercise-induced hypertension in successfully repaired adult post-coarctectomy patients is associated with hypertension on 24-h blood pressure measurement and increased left ventricular mass. METHODS One hundred and forty-four consecutive post-coarctectomy patients (mean age 31.5 years, range 17-74 years; mean age at repair 7.9 years, range 0-45 years) from three tertiary referral centres were studied using ambulatory blood pressure monitoring, treadmill exercise testing and echocardiography. RESULTS Of the 144 patients, 27 (19%) were known to have sustained hypertension, based on their history, and all were on antihypertensive medication. However, 32 (27%) of the remaining 117 patients showed elevated mean daytime systolic blood pressure readings at 24-h ambulatory blood pressure monitoring (systolic blood pressure > or = 140 mmHg). Of the remaining 85 patients with normal mean daytime systolic blood pressure, 18 patients (21%) had exercise-induced hypertension (maximal exercise systolic blood pressure > 200 mmHg). Mean daytime systolic blood pressure was higher in the exercise-induced hypertensive patients compared to the normotensive patients with normal exercise blood pressure (134 +/- 5 versus 129 +/- 7 mmHg, P = 0.008). By multivariate analysis, both maximal exercise systolic blood pressure (P = 0.007) and resting systolic blood pressure (P < 0.0001) were independently associated with mean daytime systolic blood pressure. Maximal exercise systolic blood pressure had no independent predictive value for left ventricular mass (P = 0.132). CONCLUSIONS In adult post-coarctectomy patients, maximal exercise systolic blood pressure is independently associated with mean daytime systolic blood pressure at ambulatory blood pressure monitoring. In this study no independent predictive value of maximal exercise systolic blood pressure for left ventricular mass could be demonstrated.
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Affiliation(s)
- Joris W J Vriend
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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Elgamal MA, McKenzie ED, Fraser CD. Aortic arch advancement: the optimal one-stage approach for surgical management of neonatal coarctation with arch hypoplasia. Ann Thorac Surg 2002; 73:1267-72; discussion 1272-3. [PMID: 11998817 DOI: 10.1016/s0003-4975(01)03622-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal surgical treatment for neonatal coarctation with aortic arch hypoplasia (NCoAo/AAH) is controversial. Important long-term concerns include arch growth. We report our results obtained with a one-stage radical approach of coarctectomy and aortic arch advancement for NCoAo/AAH. METHODS From June 1995 to December 2000, 65 newborns with NcoAo/AAH underwent coarctectomy and aortic arch advancement via a median sternotomy under deep hypothermic circulatory arrest. Patients were classified by diagnosis: group 1, isolated NCoAo/AAH (n = 13); group 2, NCoAo/AAH with ventricular septal defect (n = 20); and group 3, NCoAo/AAH with complex cardiac lesions (n = 32). RESULTS The study population included 36 boys and 29 girls. Mean age was 13 +/- 1.7 days (range 1 to 43 days). Mild to moderate left ventricular outflow tract obstruction was present in 15 patients. Mean body weight was 3.4 +/- 0.1 kg (range 1.6 to 5 kg). Eight babies were premature. The mean Z value for the aortic arch was -4 +/- 0.3 (range -2 to -4.5) and for the isthmus -4.5 +/- 0.2 (range -3 to -7). Mean deep hypothermic circulatory arrest time was 28 +/- 2 minutes (range 14 to 60 minutes). Mean intensive care unit stay was 6 +/- 1 days (range 2 to 30 days). There were three early deaths (all in groups 2 and 3) and two late deaths (in group 3) (5-year actuarial survival, 91% +/- 7.9%). There was one recurrence (5-year actuarial freedom from recurrence, 98% +/- 4%). Peak Doppler velocity across the arch in the remaining patients was 1 +/- 0.1 m/s (range 0 to 2.2 m/s). CONCLUSIONS Coarctectomy and aortic arch advancement is the optimal surgical method for management of NCoAo/AAH. It has low operative morbidity and mortality and a very low incidence of recoarctation or arch obstruction.
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Affiliation(s)
- Mohamed-Adel Elgamal
- Congenital Heart Surgery Service, Texas Children's Hospital, and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston 77030-2399, USA
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Verhaaren H, De Mey S, Coomans I, Segers P, De Wolf D, Matthys D, Verdonck P. Fixed region of nondistensibility after coarctation repair: in vitro validation of its influence on Doppler peak velocities. J Am Soc Echocardiogr 2001; 14:580-7. [PMID: 11391286 DOI: 10.1067/mje.2001.113256] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
After coarctectomy, local loss of distensibility is noted in addition to mild anatomic narrowing. We hypothesize that the increased Doppler peak velocities measured at the aortic isthmus in these patients partly reflect obstruction secondary to the stiff surgical scar. The hypothesis was studied in a pulsatile hydraulic model. Thirty-one patients (13.0 +/- 4.0 years of age), 10.5 +/- 4.7 years after coarctectomy by end-to-end anastomosis, were studied clinically and echocardiographically. Indexes of distensibility were calculated. The effect of isolated increased stiffness was studied in vitro with a stiff and a compliant 1:1 scale latex model of the aorta mounted in a pulsatile full-scale circulation loop. Local stiffening was obtained by a rigid ring mounted around the aorta, fitted to the dimension of the unloaded aorta. For different pressure and flow regimens, pressures and Doppler velocities were measured across the ring. Mean peak velocities at the surgical scar were 2.2 +/- 0.4 m/s. Mild anatomic stenosis was present. All distensibility indexes indicated locally increased stiffness (P <.001). In the stiff latex model, Doppler peak velocities increased from 1.89 +/- 0.04 m/s to 2.32 +/- 0.06 m/s (P <.03); in the compliant model, from 1.15 +/- 0.03 m/s to 1.79 +/- 0.05 m/s (P <.001). The increase of Doppler peak velocities depends on model compliance only and is independent of flow rate, length of the noncompliant segment, and viscosity of the perfusion fluid. Velocities do not change when semicircular stiffening is applied. We have demonstrated in vitro that isolated local nondistensibility leads to vessel narrowing during vascular distension. The relative contribution of local scar stiffness in the increase of Doppler peak velocities after coarctectomy was hereby assessed.
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Affiliation(s)
- H Verhaaren
- Division of Pediatric Cardiology and Department of Hydraulics, Ghent University, Belgium
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Hauser M, Kuehn A, Wilson N. Abnormal responses for blood pressure in children and adults with surgically corrected aortic coarctation. Cardiol Young 2000; 10:353-7. [PMID: 10950332 DOI: 10.1017/s1047951100009653] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite successful surgical repair of aortic coarctation, life expectancy is reduced, and up to one-third of patients remain or become hypertensive. So as to characterize the responses for blood pressure, we have studied 55 patients with surgically repaired coarctation. Their mean age was 11.3 +/- 5.97 years. We documented maximal uptake of oxygen, anaerobic threshold, plasma renin activity and blood pressures during a Bruce protocol treadmill test. The velocity across the site of repair as imaged by cross-sectional echocardiography was measured before and after exercise. We measured the changes in heart rate and blood pressure subsequent to an infusion of 1 ug per kg of isoprenalin, monitoring blood pressure over 24 hours in all patients. RESULTS When compared with 40 healthy age-matched controls, the patients with coarctation had a normal exercise capacity. Resting systolic blood pressures above the 95th percentile were present in 45% of the patients. Exercise-induced hypertension, and an elevation in the average systolic 24 hour blood pressures, were observed, but less frequently than elevated baseline values, suggesting that so-called white-coat" hypertension may be present in this population. Abnormal reactions and elevation of plasma renin activity were related to a history of paradoxical hypertension at the time of surgery. Attenuation of the circadian rhythm for blood pressure was a frequent finding, and may have implications in the development of long-term damage to end-organs. A high correlation was found between mean systolic blood pressure measured by 24 hour monitoring and left ventricular hypertrophy (r=0.65, p<0.05). CONCLUSIONS Abnormalities in blood pressure occurred independently of significant mechanical obstruction. Despite successful surgical repair, abnormalities in the shape of the aortic arch, reduced sensitivity of baroreceptor reflexes, and neurohumoral factors may all contribute to the development of hypertension.
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Affiliation(s)
- M Hauser
- Deutsches Herzzentrum, Department of Paediatric Cardiology, Munich, Germany.
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Daebritz S, Fausten B, Sachweh J, Mühler E, Franke A, Messmer BJ. Anatomically positioned aorta ascending-descending bypass grafting via left posterolateral thoracotomy for reoperation of aortic coarctation. Eur J Cardiothorac Surg 1999; 16:519-23. [PMID: 10609902 DOI: 10.1016/s1010-7940(99)00315-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Operation for aortic recoarctation and/or residual hypoplastic arch represents a surgical challenge because of surrounding scar tissue in the coarctation area, hazard of spinal cord ischemia due to aortic cross-clamping, laceration of the recurrent nerve, and the choice of the best approach. We demonstrate the first results of an anatomically guided technique via the prior left thoracotomy approach without establishment of cardiopulmonary bypass. METHODS Since 1989, five patients underwent anatomically positioned ascending-descending bypass grafting for treatment of recoarctation. Indication was a non-dilatable hypoplastic aortic arch segment; in two cases an additional isthmic restenosis was present. Inclusion criteria for our technique was an aorta ascending diameter large enough to allow partial clamping. Primary repair of aortic coarctation was end-to-end anastomosis in four patients and patch angioplasty in one. Mean age at primary repair was 5.5 years and at reoperation 16.1 years. Systolic pressure gradients at rest ranged from 35 to 70 mmHg; upper extremity hypertension was present in all patients. Operative technique consisted of performing a dacron or PTFE aorta ascending-descending bypass graft parallel to the aortic arch, size 18 or 20 mm in diameter, via the prior left thoracotomy. RESULTS There were no intraoperative complications and all patients survived. Postoperative complications were left lung atelectasis with necessity of reintubation, pericardial effusion, and transient left diaphragm elevation, each in one patient. After 7-90 months all patients are free of symptoms, have normal blood pressure (with two patients being under anti-hypertensive medication), and have no echocardiographically measurable pressure gradients. CONCLUSIONS Anatomically positioned aorta ascending-descending bypass grafting via the prior left posterolateral thoracotomy without cardiopulmonary bypass is a safe and efficient method for operation of complex recoarctation in patients with an acceptable size of the aorta ascendens.
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Affiliation(s)
- S Daebritz
- Department of Thoracic and Cardiovascular Surgery, Klinik für Thorax-, Herz- und Gefässchirurgie, Universitätsklinikum der RWTH, Aachen, Germany.
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Abstract
This study describes the initial hemodynamic results and early to late clinical follow-up, including magnetic resonance imaging and exercise testing, following balloon angioplasty for native coarctation of the aorta. We advocate this approach as an alternative to surgical intervention in select patients based on age, aortic arch anatomy, or in those patients who have coexisting cardiac defects that are amenable to transcatheter intervention.
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Affiliation(s)
- H S Weber
- Department of Pediatrics (Cardiology), The Pennsylvania State University Children's Hospital, Hershey 17033, USA
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Affiliation(s)
- A Rothman
- Division of Pediatric Cardiology, University of California-San Diego, USA
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Tantengco MV, Ross RD, Humes RA, Sullivan NM, Joshi VM, Clapp SK, Epstein ML. Enhanced resting left ventricular filling in patients with successful coarctation repair and exercise-induced hypertension. Am Heart J 1997; 134:1082-8. [PMID: 9424069 DOI: 10.1016/s0002-8703(97)70029-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
M-mode and Doppler echocardiographic analyses of left ventricular (LV) shortening and filling were performed in 50 patients who underwent coarctectomy (median follow-up 9.5 years) and in 16 athletes in a control group before an exercise stress test with upright bicycle ergometry was performed. Thirty-two of 50 patients and 18 of 50 patients had a normotensive and hypertensive response to exercise, respectively. Preexercise echocardiographic data were compared among the control, normotensive, and hypertensive patient groups. LV peak filling rates (dD/dt, diastole) were increased in the hypertensive group (18.3 +/- 3.5) compared with those in the normotensive group (14.4 +/- 3.2; p < 0.001) and the control group (13.6 +/- 2.8; p < 0.001). LV shortening was enhanced in the coarctectomy group compared with that in the control group. A higher aortic isthmus Doppler gradient at peak exercise was not found in the hypertensive group compared with that in the normotensive group. Therefore patients with successful coarctectomy in childhood have enhanced LV shortening and relaxation at rest. Demonstration of enhanced LV peak filling rates may help identify patients at risk for exercise-induced hypertension.
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Affiliation(s)
- M V Tantengco
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit 48201, USA
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Rhodes J, Geggel RL, Marx GR, Bevilacqua L, Dambach YB, Hijazi ZM. Excessive anaerobic metabolism during exercise after repair of aortic coarctation. J Pediatr 1997; 131:210-4. [PMID: 9290605 DOI: 10.1016/s0022-3476(97)70155-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To determine whether survivors of surgery for coarctation of the aorta (CoA) have an excessive reliance on anaerobic metabolism during exercise. BACKGROUND Patients with peripheral vascular disease cannot increase blood flow to their muscles normally during exercise. Consequently they acquire an early, excessive reliance on anaerobic metabolism and have depression of the ventilatory anaerobic threshold (VAT) and of the slope of the oxygen consumption-work rate relationship (delta VO2/delta WR). We speculated that the capacity to augment blood flow to the lower extremities during exercise may be impaired after CoA surgery and would result in similar metabolic disturbances. STUDY DESIGN Progressive exercise tests were performed on 15 patients (ages 19 +/- 7 years; range, 10 to 32) after successful repair of CoA (residual resting gradient, 7.7 +/- 7.1 mm Hg; range, 0 to 18), 15 age- and sex-matched healthy control subjects, and 10 patients (ages 13 +/- 3 years; range, 10 to 20) who had undergone ligation of a patent ductus arteriosus. RESULTS The CoA patients' VAT averaged 14.8 +/- 3.8 ml O2/kg per minute versus 19.3 +/- 3.1 ml O2/kg per minute for the control subjects (p < 0.01), and their delta VO2/delta WR averaged 8.2 +/- 1.8 ml/watt compared with 10.1 +/- 1.4 ml/watt for control subjects (p < 0.01). Furthermore, 10 of 15 CoA patients had a VAT of less than 40% of predicted maximal oxygen consumption, and 9 of 16 had a delta VO2/delta WR of less than 8.7 ml O2/watt (generally accepted abnormal values). Patients with patent ductus arteriosus resembled the healthy control subjects with regard to anaerobic metabolism during exercise. CONCLUSIONS Patients who have had CoA repairs commonly manifest an excessive reliance on anaerobic metabolism during exercise. This phenomenon may result from persistent blood flow abnormalities across the aortic arch during exercise, which may be present even after apparently successful surgery.
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Affiliation(s)
- J Rhodes
- Division of Pediatric Cardiology, Floating Hospital for Children, Tufts-New England Medical Center, Boston, Massachusetts, USA
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Johnson D, Bonnin P, Perrault H, Marchand T, Vobecky SJ, Fournier A, Davignon A. Peripheral blood flow responses to exercise after successful correction of coarctation of the aorta. J Am Coll Cardiol 1995; 26:1719-24. [PMID: 7594109 DOI: 10.1016/0735-1097(95)00382-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The purpose of this study was to characterize peripheral flow kinetics in response to progressive discontinuous maximal exercise in 10 patients who underwent repair of coarctation of the aorta and 11 age-matched healthy adolescents. BACKGROUND An impairment of leg blood flow has been suggested on the basis of exaggerated femoral muscle lactate accumulation in patients with successful repair of coarctation. Few data are available describing blood flow kinetics of the exercising leg in such patients. METHODS Duplex ultrasound provided transcutaneous measurements of peak systolic and end-diastolic flow velocities of the femoral, humeral and renal arteries at rest and immediately after mild, moderate and maximal exercise intensities for computation of mean velocity, resistance index and femoral blood flow. RESULTS Femoral mean velocity and femoral blood flow increased linearly with exercise intensity in both groups, but the slope of this increase was significantly lower in patients. Similarly, humeral mean velocity increased significantly less in patients than in control subjects. Femoral resistance index sharply decreased from that at rest (patients [mean +/- SE] 1.4 +/- 0.04; control subjects 1.4 +/- 0.03) to mild exercise intensity in both groups (patients 0.69 +/- 0.03; control subjects 0.72 +/- 0.03). A further decrease was observed at maximal exercise in patients (0.60 +/- 0.04, p = 0.08) but not in control subjects (0.69 +/- 0.02). CONCLUSIONS These observations suggest that despite a greater exercise-induced femoral vasodilation, patients with successful correction of coarctation of the aorta demonstrate an impaired lower limb blood flow in response to strenuous dynamic exercise. In the absence of stenosis at rest, this alteration could result from exaggerated flow turbulence in the descending aorta distal to the site of correction because of loss of elasticity at the site of the resection of the coarcted segment.
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Affiliation(s)
- D Johnson
- Cardiology and Cardio-Thoracic Surgery Units, Sainte-Justine Hospital, Montreal, Quebec, Canada
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Abdulla S, Malmgren N, Björkhem G, Lundström NR. A postoperative follow-up study of infantile coarctation of the aorta. ACTA PAEDIATRICA (OSLO, NORWAY : 1992). SUPPLEMENT 1995; 410:69-73. [PMID: 8652921 DOI: 10.1111/j.1651-2227.1995.tb13848.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Follow-up investigations were performed in 16 patients operated on for coarctation during infancy. The follow-up period ranged from 4.5 to 11 years (median 5.5 years). Four different surgical techniques were used: resection with end-to-end anastomosis (REE) (4 patients), subclavian flap aortoplasty (SFA) (10 patients), patch aortoplasty (1 patient) and resection and SFA (1 patient). One patient developed recoarctation (6%). She had been operated on by REE at 7 days of age. The other three patients operated on by REE had equal pulses in the arms and legs; none had hypertension and all had normal arm/leg pressure gradients at rest. Seven (58%) of the 12 patients operated on by SFA or aortoplasty had weak radial pulses in the left arm but no limitation of left arm function. The left a rm showed a normal bone age but was smaller and shorter than the right arm in 9 (81%) of the patients. None of the patients operated on by SFA had hypertension and the arm/leg gradient at rest was normal.
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Affiliation(s)
- S Abdulla
- Department of Paediatrics, Al Wasl Hospital, Dubai, United Arab Emirates
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Bogaert J, Gewillig M, Rademakers F, Bosmans H, Verschakelen J, Daenen W, Baert AL. Transverse arch hypoplasia predisposes to aneurysm formation at the repair site after patch angioplasty for coarctation of the aorta. J Am Coll Cardiol 1995; 26:521-7. [PMID: 7608459 DOI: 10.1016/0735-1097(95)80032-c] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES This study used magnetic resonance imaging (MRI) to evaluate the morphology and pathophysiology of aneurysm formation after patch angioplasty for coarctation of the aorta. BACKGROUND Late aneurysm formation at the repair site is a well known and frequent complication after patch angioplasty. However, because the underlying mechanisms remain unresolved, postoperative outcome is unpredictable and adequate follow-up difficult. METHODS Seventy-three of 85 patients with patch angioplasty for coarctation of the aorta were screened for aneurysm formation. Magnetic resonance imaging was performed in all 33 patients with an aneurysm, and results were compared with those for 13 control patients and 10 normal subjects. Mean (+/- SD) time between operation and MRI was 12.0 +/- 2.0 years. Aneurysm was defined as the ratio of the diameter of the aorta at the repair site to the diaphragmatic aorta > or = 1.5. Hypoplasia of the transverse arch and recoarctation at the repair site were defined as a ratio < 0.9. Transverse arch ratios on MRI were compared with those on preoperative cineangiography and the pressure gradient between the patient's right and left arm. RESULTS All 33 patients with an aneurysm had a hypoplastic transverse arch. The 13 patients with a normal ratio at the repair site had a normal transverse arch ratio (chi square, p < 0.0001). Logarithmic regression showed a significant negative correlation (r = 0.62) between the repair site and transverse arch ratios. A significant pressure difference between the patient's right and left arm was found in patients with versus those without aneurysm (p = 0.0009). No significant difference was found between transverse arch ratios on preoperative cineangiography and postoperative MRI (mean 0.014 +/- 0.1, p = 0.4). CONCLUSIONS Aneurysm formation at the repair site is highly related to hypoplasia of the transverse arch. Sufficient catch-up growth of a hypoplastic transverse arch is rare after late patch angioplasty. Dynamic phenomena, such as flow acceleration and turbulence, originating in a narrow transverse arch, may contribute to aneurysm formation at the repair site after patch angioplasty.
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Affiliation(s)
- J Bogaert
- Department of Radiology, University Hospitals, Catholic University of Leuven, Belgium
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Johnson MC, Gutierrez FR, Sekarski DR, Ong CM, Canter CE. Comparison of ventricular mass and function in early versus late repair of coarctation of the aorta. Am J Cardiol 1994; 73:698-701. [PMID: 8166068 DOI: 10.1016/0002-9149(94)90937-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Left ventricular (LV) mass and function in 11 patients (group I) with coarctation of the aorta repaired at a mean age of 35 days were compared with that of 14 patients (group II) who underwent repair at a mean age of 8 years. Each group was compared to age- and sex-matched normal control subjects. All patients were normotensive and had resting arm-leg peak systolic blood pressure gradients < 20 mm Hg. Quantitative M-mode echocardiography was used to determine LV mass index and systolic performance. Magnetic resonance imaging was performed to assess residual narrowing of the descending aorta. LV mass index was increased in both groups when compared with control subjects (group I p = 0.01; group II p = 0.007). Whereas systolic performance in group I was similar to its control group, group II patients had enhanced LV systolic performance as measured by shortening fraction (p = 0.007). Multiple regression analysis of combined group I and II patients demonstrated a significant positive correlation of residual aortic narrowing with LV mass index (p = 0.01). Thus, LV mass remains increased in normotensive patients without major blood pressure gradients after repair of coarctation of the aorta in infancy or childhood. Small degrees of residual aortic narrowing were associated with increased postoperative LV mass regardless of the age at repair.
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Affiliation(s)
- M C Johnson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
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Aortic obstructions in infants and children: Surgery for simple aortic coarctation. PROGRESS IN PEDIATRIC CARDIOLOGY 1994. [DOI: 10.1016/s1058-9813(05)80009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Cyran SE. Coarctation of the aorta in the adolescent and adult: echocardiographic evaluation prior to and following surgical repair. Echocardiography 1993; 10:553-63. [PMID: 10146331 DOI: 10.1111/j.1540-8175.1993.tb00070.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The combination of two-dimensional and continuous-wave (CW) Doppler echocardiographic imaging forms the cornerstone of diagnostic imaging in pre- or postoperative coarctation of the aorta. Because of the frequent association of other congenital heart defects, e.g., bicuspid aortic valve, a segmental imaging approach with multiple image planes should be used. CW Doppler examination from the suprasternal notch should be utilized to assess the degree of obstruction at the coarctation site in all patients. This enhances diagnostic sensitivity. CW Doppler examination can also be applied throughout exercise. Such application allows detection of relative degrees of aortic obstruction following surgical repair of coarctation that may only manifest at elevated levels of cardiac output, e.g., exercise. It aids in the identification of individuals with exercise related systolic hypertension following "successful" coarctectomy and provides a rationale for treatment with beta blockade. The methodology for applying this relatively new technique is discussed.
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Affiliation(s)
- S E Cyran
- Division of Cardiology, Department of Pediatrics, The Milton S. Hershey Medical Center, The Pennsylvania State University 17033
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Cyran SE, Grzeszczak M, Kaufman K, Weber HS, Myers JL, Gleason MM, Baylen BG. Aortic "recoarctation" at rest versus at exercise in children as evaluated by stress Doppler echocardiography after a "good" operative result. Am J Cardiol 1993; 71:963-70. [PMID: 8465790 DOI: 10.1016/0002-9149(93)90915-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The mechanism for exercise systolic hypertension after a "good" operative repair of coarctation of the aorta remains speculative. Twenty-four children (mean age +/- SD 10.3 +/- 3.8 years) were studied with continuous-wave Doppler echocardiography while they performed continuous, graded, maximal treadmill exercise. Patients were free of "recoarctation" based on conventional resting echocardiography. Measurements of ascending and descending aortic peak instantaneous systolic velocity were obtained at rest, throughout exercise and during recovery. Results were compared with 24 age- and gender-matched control subjects. Fifteen patients were normotensive (group 1) (peak systolic blood pressure, 147 +/- 21 mm Hg) and 9 developed systolic hypertension during exercise (group 2) (196 +/- 32 mm Hg) (p < 0.05) (control subjects, 143 +/- 21 mm Hg). Descending aortic peak systolic velocity at rest ranged from 1.50 +/- 0.27 m/s in the control group to 2.57 +/- 0.57 m/s (group 1) and 2.93 +/- 0.43 m/s (group 2) (p < 0.05, group 2 vs control). Differences were amplified at peak exercise with systolic velocity increasing to 4.26 +/- 0.61 m/s in group 2 but only to 3.61 +/- 0.70 m/s in group 1 and 2.26 +/- 0.38 m/s in control subjects (p < 0.05, group 2 vs group 1 and control). Seven patients developed a descending aortic diastolic velocity during exercise. Stepwise linear regression analysis identified 2 variables to be significant determinants of peak exercise systolic blood pressure in the "total" patient group: (1) age at exercise testing, and (2) descending aortic peak systolic velocity at peak exercise (r2 = 0.88, p < 0.001) (group 2, alone - r2 = 0.98, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- S E Cyran
- Department of Pediatrics, Milton S. Hershey Medical Center, Hershey 17033
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