Procedural results and acute complications in stenting native and recurrent coarctation of the aorta in patients over 4 years of age: a multi-institutional study

Percutaneous Balloon-Expandable Stent Implantation to Treat Transverse Aortic Arch Obstruction: Medium- to Long-Term Outcomes of a Retrospective Multicenter Study

BACKGROUND

Transverse aortic arch obstruction is a challenging lesion for which stent implantation provides a potentially important alternate therapy. The objectives were to evaluate the technical, procedural, and medium-to-long-term clinical outcomes of percutaneous stent implantation of transverse aortic arch obstruction.

METHODS

This is a retrospective, multicenter study of transverse aortic arch stent implantation. Univariable and multivariable analyses were performed.

RESULTS

Index catheterization included 187 stent implants in 146 patients. The median age is 14.3 years (interquartile range, 9.3-19), weight is 53 kg (30-69), and follow-up is 53 months (12-120). The most common stent design was open cell (n=90, 48%). Stents overlapped 142 arch vessels (37 carotid arteries) in 118 (81%) cases. Technical and procedural success rates were 100% and 88%, respectively. Lower weight (P=0.018), body surface area (P=0.013), and minimum-to-descending aortic diameter ratio (P<0.001) were associated with higher baseline aortic gradient. The residual gradient was inversely associated with implant and final dilation diameters (P<0.001). The combined incidence of aortic injury and stent-related complications was 14%. There were no reports of abnormal brain scans or stroke. Blood pressure cuff gradient, echocardiographic arch velocity, and hypertension rates improved within 1-year follow-up with increased antihypertensive medication use. Reintervention was reported in 60 (41%) patients at a median of 84 (22-148) months to first reintervention. On multivariable logistic regression, residual aortic gradient >10 mm Hg was associated with increased odds of reintervention at all time points when controlling for each final dilation diameter, weight, and minimum-to-descending aortic diameter ratio.

CONCLUSIONS

Transverse aortic arch stent implantation has high rates of technical, procedural, and medium-to-long-term clinical success. Aortic gradient >10 mm Hg is associated with increased odds of reintervention at 1-year and most recent follow-ups. Open cell stent design was frequently used for its advantages in conformability, perfusion of arch vessels, low fracture rate, and the ability to perform effective angioplasty of side cells.

Five-Year Outcomes of Coarctoplasty with Stents in the Pediatric Population: Results from a Retrospective Single-Center Cohort with Centrally Adjudicated Outcomes

Transcatheter stent implantation is a widely performed procedure for treating native coarctation of the aorta (CoA) in pediatric patients. However, data on mid- to long-term outcomes are limited. The aim of this study was to evaluate the mid-term safety and efficacy of transcatheter CoA stenting based on centrally adjudicated outcomes. This retrospective cohort study included patients aged 15 years or younger undergoing de novo stenting for CoA or recoarctation (reCoA) between 2006 and 2017. Immediate and 5-year outcomes were assessed. Immediate outcomes (procedural and in-hospital) were retrieved from electronic records. Rates of 5-year reCoA, stent fractures, aneurysmal/pseudoaneurysmal formation, and all-cause mortality were mid-term outcomes. The study included 274 patients (64% male and 36% female) with a median (interquartile range) age of 9 (6-12) years. Procedural success was achieved in 251 patients (91.6%). Procedural complications occurred in 4 patients (1.4%), consisting of stent migration in 1 (0.3%) and small non-expanding non-flow-limiting aortic wall injuries in 3 (1.1%). Major vascular access complications were observed in 18 patients (6.6%), acute limb ischemia in 8 (2.9%). In-hospital mortality occurred in 4 patients (1.4%). Five-year cumulative incidence rates of stent fractures, reCoA, and aortic aneurysmal/pseudoaneurysmal formation were 17/100 (17%), 73/154 (48%), and 8/101 (7.92%), respectively. Of 73 reCoAs, 47 were treated with balloon angioplasty, and 15 underwent a second stent implantation. Five-year all-cause mortality occurred in 4/251 (1.6%) patients. Coarctoplasty with stents was safe and effective in our pediatric population during a 5-year follow-up despite a high rate of reCoA.

Coarctation of Aorta With Tricuspid Aortic Valve Is Not Associated With Ascending Aortic Aneurysm

BACKGROUND

Aortic aneurysm is common in patients with coarctation of aorta (COA), but it is unclear whether the risk of aortic aneurysms is due to COA or related to the presence of other risk factors such as bicuspid aortic valve (BAV) and hypertension.

OBJECTIVES

The purpose of this study was to assess the relationship among COA, BAV, and thoracic aortic aneurysms.

METHODS

A total of 867 patients with COA (COA group) were matched 1:1:1 to 867 patients with isolated BAV (BAV group) and 867 patients without structural heart disease (SHD) (no-SHD group). The COA group was further subdivided into a COA+BAV subgroup (n = 304 [35%]), and COA with tricuspid aortic valve (TAV) (COA+TAV subgroup [n = 563 (65%)]). Aortic dimensions were assessed at baseline and at 3, 5, and 7 years.

RESULTS

Compared with the no-SHD group, the COA+BAV subgroup had larger aortic root diameter (37 mm [Q1-Q3: 30-43 mm] vs 32 mm [Q1-Q3: 27-35 mm]; P < 0.001) and mid ascending aorta dimeter (34 mm [Q1-Q3: 29-40 mm] vs 28 mm [Q1-Q3: 24-31 mm]; P = 0.008). Similarly, the BAV group had larger aortic root diameter (37 mm [Q1-Q3: 30-42 mm] vs 32 mm [Q1-Q3: 27-35 mm]; P < 0.001), and mid ascending aorta dimeter (35 mm [Q1-Q3: 30-40 mm] vs 28 mm [Q1-Q3: 24-31 mm]; P < 0.001). Compared with the COA+TAV subgroup, the COA+BAV subgroup and BAV group were associated with larger aortic root and mid ascending aorta diameter at baseline and follow-up. The risk of acute aortic complications was low in all groups.

CONCLUSIONS

These findings suggest that BAV (and not COA) was associated with ascending thoracic aorta dimensions, and that patients with COA+TAV were not at a greater risk of developing ascending aortic aneurysms as compared with patients without SHD.

Determinants and prognostic implications of left atrial reverse remodelling after coarctation of aorta repair in adults

AIMS

Left atrial (LA) dysfunction and atrial fibrillation are also relatively common in adults with coarctation of aorta (COA), and the severity of LA dysfunction is associated with a higher risk of atrial fibrillation in this population. The purpose of this study was to determine whether LA function improved after COA repair (LA reverse remodelling), and the relationship between LA reverse remodelling and atrial fibrillation.

METHODS AND RESULTS

Retrospective cohort study of adults undergoing COA repair (2003-20). LA reservoir strain was assessed pre intervention and 12-24 months post intervention, using speckle tracking echocardiography. Incident atrial fibrillation was assessed from COA repair to last follow-up. Of 261 adults who underwent COA repair [age 37 ± 13 years; males 148 (57%)], 124 (47%) and 137 (53%) presented with native vs. recurrent COA, respectively. Of 261 patients, 231 (82%) and 48 (18%) underwent surgical and transcatheter COA repair, respectively. The LA reservoir strain increased from 32 ± 8% (pre intervention) to 39 ± 7% (post intervention), yielding a relative increase of 21 ± 5%. Older age [β ± standard error (SE) -0.16 ± 0.09 per 5 years, P = 0.02], higher systolic blood pressure (β ± SE -0.12 ± 0.04 per 5 mmHg, P = 0.005), and higher residual COA mean gradient (β ± SE -0.17 ± 0.06 per 5 mmHg, P = 0.002) post intervention were associated with less LA reverse remodelling, after adjustment for sex, hypertension diagnosis, and left ventricular indices. LA reverse remodelling (hazard ratio 0.97, 95% confidence interval 0.96-0.98 per 1% increase from pre-intervention LA function, P = 0.006) was associated with a lower risk of atrial fibrillation after adjustment for age, sex, pre-intervention LA reservoir strain, and history of atrial fibrillation.

CONCLUSION

COA repair resulted in improved LA function and decreased risk for atrial fibrillation, especially in patients without residual hypertension or significant residual COA gradient.

Endovascular treatment of a ruptured aortic pseudoaneurysm and its complications in an 8-year-old child with Ehlers-Danlos syndrome type VI

The procollagen-lysine, 2-oxoglutarate 5-dioxygenase 1 (PLOD1) gene may affect arterial integrity through enzymatic roles and the modulation of vascular smooth muscle cells. We present a complicated vascular case of an 8-year-old male child with Ehlers-Danlos syndrome type VI. The patient was diagnosed with a ruptured pseudoaneurysm of the infrarenal abdominal aorta. Endovascular treatment was performed using a covered self-expandable endograft. However, complications arose at the vascular access sites during the procedure, highlighting arterial fragility. PLOD1 mutations can be associated with false abdominal aortic aneurysms or arterial fragility. Open repair poses a high risk for patients with Ehlers-Danlos syndrome. Although the long-term results are unknown, endovascular stent grafts may be a suitable option for emergency clinical scenarios such as ruptured abdominal aortic pseudoaneurysms.

Long-term follow-up after endovascular treatment of aortic coarctation with bare and covered Cheatham platinum stents

BACKGROUND

Endovascular treatment of aortic coarctation (CoA) in children and adults frequently requires stent implantation. The aim of this study was to analyze long-term results after CoA treatment with bare and covered Cheatham-PlatinumTM (CP) stents in our institution and to derive recommendations for the differential use of these stent types.

METHODS

In this retrospective single institution study, 212 patients received endovascular CoA treatment with bare (n = 71) and covered (n = 141) CP stents between September 1999 and July 2021, respectively. The indications for treatment were native CoA in 110/212 patients (51.9%) and re-coarctation after primary surgical or interventional treatment in 102/212 patients (48.1%). Median patient age at endovascular CoA treatment was 18.8 years [IQR 11.9; 35.8]. Long-term follow-up was available in 158/212 patients (74.5%) with a median follow-up of 7.3 years [IQR 4.3; 12.6].

RESULTS

Procedural success was achieved in 187/212 (88.2%) patients. Survival rate was 98.1% after 5, and 95.6% after 10 and 15 years, respectively. The probability of freedom from re-intervention was 93.0% after 5, 82.3% after 10 and 77.8% after 15 years, respectively. Freedom from re-interventions (44/158, 27.8%) did not differ between patients who received bare or covered CP stents (p = 0.715). Multivariable risk factor analysis identified previous CoA surgery (HR: 2.0, 95% confidence interval (CI): 1.1-3,9, p = 0.029), postdilatation (HR: 2,9, 95% CI: 1.1-6.3, p = 0.028) and age at intervention (HR: 0.96, 95% CI: 0.94-0.99, p = 0.002) as independent risk factors for re-intervention. Peri-procedural complications occurred in 15/212 (7.1%) patients (dissection/thrombosis of vascular access vessel: n = 9; bleeding: n = 1; stent dislocation: n = 2; aortic dissection/aortic wall rupture: n = 3). Long-term complications were observed in 36 patients and included stent fracture (n = 19), aneurysm formation (n = 14), endoleak (n = 1) and subclavian artery stenosis (n = 2). Peri-procedural and long-term complications did not differ between patients who received CoA treatment with bare or covered CP stents (all p > 0.05).

CONCLUSION

Endovascular treatment of CoA using bare or covered CP stents can be performed safely and effectively with excellent long-term results. Survival, re-intervention and complication rate did not significantly differ between both stent types. However, individual stent selection is advisable with regard to CoA morphology and severity as well as patient age.

Descending thoracic aortic dissection after covered stent for adult aortic coarctation: Technical or physiopathologic?

Covered stent graft implantation is currently the most commonly used modality for the management of adult aortic coarctation. Although the risk of descending thoracic aortic dissection after covered stent graft implantation is low, sometimes it may cause serious medical consequences or even death. We report one adult aortic coarctation patient with early postoperative descending thoracic aortic dissection after covered stent graft implantation. The patient underwent second operation of thoracic endovascular aortic reconstruction and was discharged 6 days after the operation. This case is not rare, but we hope that the complete diagnosis and treatment process of this case and discussion pertaining to surgical treatment method and its complications could serve as a reference for clinicians in dealing with such situations.

Transcatheter Intervention for Coarctation of the Aorta: A Nordic Population-Based Registry With Long-Term Follow-Up

BACKGROUND

Coarctation of the aorta (CoA), a congenital narrowing of the proximal descending thoracic aorta, is a relatively common form of congenital heart disease. Untreated significant CoA has a major impact on morbidity and mortality. In the past 3 decades, transcatheter intervention (TCI) for CoA has evolved as an alternative to surgery.

OBJECTIVES

The authors report on all TCIs for CoA performed from 2000 to 2016 in 4 countries covering 25 million inhabitants, with a mean follow-up duration of 6.9 years.

METHODS

During the study period, 683 interventions were performed on 542 patients.

RESULTS

The procedural success rate was 88%, with 9% considered partly successful. Complications at the intervention site occurred in 3.5% of interventions and at the access site in 3.5%. There was no in-hospital mortality. During follow-up, TCI for CoA reduced the presence of hypertension significantly from 73% to 34%, but despite this, many patients remained hypertensive and in need of continuous antihypertensive treatment. Moreover, 8% to 9% of patients needed aortic and/or aortic valve surgery during follow-up.

CONCLUSIONS

TCI for CoA can be performed with a low risk for complications. Lifetime follow-up after TCI for CoA seems warranted.

Evaluating the Effectiveness of Stenting for Aortic Coarctation

BACKGROUND

 Coarctation of the aorta (CoA) is a congenital cardiovascular malformation involving narrowing of the thoracic aorta just distal to the left subclavian artery. The aim of our study was to evaluate the hemodynamic effects of endovascular treatment for CoA by using invasive aortic catheterization.

METHODS

 All patients with CoA who underwent treatment by aortic stent implantation between September 1, 2003, and February 1, 2019, at the "Onassis Cardiac Surgery Center," in Athens, Greece, were evaluated. Patients were treated with either bare (uncovered) Cheatham-Platinum (bCP) or covered Cheatham-Platinum (cCP) stent implantations. Invasive aortic pressure measurements were recorded before and after the endovascular intervention.

RESULTS

 A total of 48, eight zig CP stents, comprising 24 bCP and 24 cCP stents were implanted in 47 patients. The mean aortic diameter (mm) at the CoA lesion increased from 9.7 ± 3.3 to 19.2 ± 2.9 mm (p <0.01) after the endovascular procedure. The invasive mean blood pressure (BP; mm Hg) from catheterization in the descending aorta increased (before = 114.2 ± 12.8 vs. after = 135.5 ± 28.1; p <0.01), while the invasive mean BP (mm Hg) from catheterization in the ascending aorta was decreased (before = 156.8 ± 25.0 vs. after = 138.4 ± 27.5; p <0.01) after the intervention. The mean aortic BP gradient decreased in both types of stents after intervention (BP gradient among patients with cCP stents = 30.9 +/- 23.6 mmHg and BP gradient among patients with bCP stents = 38.0 +/-23.1 mmHg). However, there was no statistically significant difference between the two types of stents; p = 0.36.

CONCLUSIONS

 Invasive aortic catheterization provided evidence that endovascular stenting with either bare or covered stents is efficient in treating patients with CoA.

Late open conversion after endovascular treatment for the coarctation of aorta in adult due to restenosis with thrombus

A 22-year-old man was referred to our hospital for rib notching found on a radiograph and hypertension. Computed tomography revealed coarctation of the descending aortic isthmus. Because he refused open surgery, endovascular treatment was performed. The 2-year follow-up computed tomography scan showed infolding of the stent graft and thrombus formation. He had presented with intermittent claudication; therefore, graft interposition was performed. Endovascular surgery plays an important role in the treatment of coarctation of the aorta. However, insufficient dilatation can lead to restenosis accompanied by thrombus formation, and excess ballooning can cause aortic wall injury. Careful performance of the procedure and close postoperative follow-up are essential.

Procedural Characteristics and Outcomes of Transcatheter Interventions for Aortic Coarctation: A Report From the IMPACT Registry

Background

Although surgical repair was the traditional first-line treatment for native coarctation of the aorta (CoA), balloon angioplasty (BA) and stenting are now increasingly being performed. We aimed to determine the practice patterns and acute outcomes of transcatheter interventions for native coarctation in the largest multicenter registry for congenital catheterization.

Methods

CoA interventions from the IMPACT (IMproving Pediatric and Adult Congenital Treatment) National Cardiovascular Data Registry were analyzed. The procedure choice and acute outcomes were compared among patients with no prior interventions on the aortic isthmus (native CoA). Procedural success was defined as no major adverse events (MAEs) and a final peak gradient of <20 mm Hg and optimal outcome as no MAEs and a final gradient of <10 mm Hg.

Results

Over the 8-year study period, 5928 CoA procedures were performed, of which 1187 were performed in patients with native CoA. In this group, stenting was performed in more then half of children aged >1 year and >90% of those aged >8 years. Procedural success was achieved in >90% of stenting procedures but in only 69% of BAs. Stent implantation was associated with a higher likelihood of optimal gradient (<10 mm Hg) after adjustment for age and baseline characteristics. MAEs were most common in children aged <1 year (14%), occurred in 2% to 2.5% of those aged 1 to 18 years and in 6.6% of adults (P < .001), and were more likely after BA than after stenting (odds ratio, 0.5; 95% CI, 0.28-0.9; unadjusted P = .02).

Conclusions

Catheter interventions for native coarctation are performed safely in older children and adults, with a high degree of immediate procedural success, particularly with stenting.

Outcomes of one-staged procedures to treat aortic coarctation complicated by cardiac anomalies

OBJECTIVE

One-staged surgical treatment of aortic coarctation combined with cardiac anomalies is challenging. We aim to evaluate the feasibility of bilateral aortofemoral bypass technique in one-staged surgery treating coractation by comparing surgical outcomes with catheter intervention plus stent (hybrid).

METHODS

Between January 2012 and December 2017, 50 patients underwent one-staged surgical procedures to treat coarctation and repair concomitant cardiac anomalies, like aortic root dilatation, cardiac valvular disease and so on. Among them, 30 patients underwent bilateral aortofemoral bypass and 20 patients underwent hybrid procedure to treat coarctation. We retrospectively analyzed the data of these patients and compared the early and late results.

RESULTS

All the baseline clinical characteristics were comparable between groups except that the mean age of bypass group was 39.5 ± 14.0 years which was older than hybrid group (27.9 ± 8.5 years, P = 0.002). Technical success was achieved in all patients, with no hospital death or other severe complications. Immediately after surgery, in bypass and hybrid group, the mean upper-limb systolic blood pressure decreased from 159.4 to 119.7 mmHg and 148.4 to 111.6 mmHg, the median peak systolic gradient decreased from 68.0 to 10 mmHg and 46.5 to 10 mmHg respectively (P = 0.09). And the mean upper-lower limbs gradient decreased from 21.7 to 5.9 mmHg and 21.0 to 2.7 mmHg respectively (P = 0.104). The mean follow-up time was 76.92 ± 18.7 in bypass group and 85.4 ± 20.6 months in hybrid group. There were 4 late deaths in bypass group (one died of gastrointestinal bleeding, one died of pulmonary embolism and the other two died of heart failure caused by mechanical prosthetic valve dysfunction). The follow-up peak systolic gradient and other blood pressure parameters showed stable and no differences between two groups.

CONCLUSIONS

The bilateral aortofemoral bypass surgery is a safe and effective method which can be used in one-staged surgical strategy to treat coarctation complicated by cardiac anomalies and can be an alternative to the hybrid method.

Endovascular treatment of aortic coarctation with a novel BeGraft aortic stent in children and young adults: a single-centre experience with short-term follow-up results

OBJECTIVES

We present our experience and outcomes with the BeGraft in the treatment of aortic coarctation in a predominantly paediatric population.

METHODS

This study includes a retrospective analysis of patients who had Begraft aortic stent implantation between 2018 and 2020 from a single centre.

RESULTS

The BeGraft aortic stent was used in 11 patients (7 males, 4 females) with a median age of 14 (13-21) years and a median weight of 65 (46-103) kg. Coarctation was native in five patients and recurrent in six patients. Median stent diameter and length were 16 mm and 38 mm, respectively. The median peak-to-peak pressure was 30 (12-55) mmHg before the procedure and 5 (0-17) mmHg after the procedure. The stenting procedure was successful in 10 of the 11 patients. Stent migration to the abdominal aorta occurred on post-procedure day 1 in the 21-year-old patient, who had previously undergone surgical closure of the ventricular septal defect and balloon angioplasty for coarctation. After repositioning failed, the stent was safely fixed in the abdominal aorta. Strut distortion also occurred during balloon retrieval in one patient, but no aneurysm or in-stent restenosis was observed at 1-year follow-up. The patients were followed for a median of 14 (4-25) months and none required redilation.

CONCLUSIONS

Our initial results demonstrated that the BeGraft aortic stent effectively reduced the pressure gradient in selected native and recurrent cases. Despite advantages such as a smaller sheath and low profile, more experience and medium- to long-term results are needed.

Transcatheter management of proximal stent migration in coarctation of the aorta

Proximal stent migration in setting of transcatheter management of coarctation of the aorta is a rare complication, which may require emergency surgery. Herein, we report a successful transcatheter management of proximal stent migration in a high surgical risk, a 14-year-old girl, which caused partial occlusion of both the descending aorta and the left subclavian artery.

Large Diameter Advanta V12 Covered Stent Trial for Coarctation of the Aorta: COARC Study

BACKGROUND

Covered stent implantation for treatment of coarctation of the aorta (CoA) is effective and can prevent aortic wall injury. Prospective studies with long-term follow-up, including imaging, are lacking. We report the acute and long-term outcomes for use of the Large Diameter Advanta V12 covered stent for treatment of native and recurrent CoA.

METHODS

A prospective, multicenter, nonrandomized study was performed including 70 patients (43 male), median age 17 years, median weight 57.4 kg with CoA who underwent implantation of the Large Diameter Advanta V12 covered stent. Annual follow-up for 5 years included Doppler echocardiography to calculate diastolic velocity: systolic velocity ratio.

RESULTS

CoA diameter increased from 5.6±3.6 to 14.9±3.9 mm (P<0.0001) and the pressure gradient decreased from 35.8±16.2 to 5.6±7.9 mm Hg (P<0.0001). Preimplantation diastolic velocity:systolic velocity of 0.6±0.16 dropped to 0.34±0.13 (P<0.0001) and was maintained at 5 years. Computed tomography angiograms at 12 months postimplantation demonstrated the stent:transverse arch diameter to be similar, 0.91±0.09 to postprocedure 0.86±0.14. Major adverse vascular events at 30 days and 12 months were 1.4% and 4.3%, respectively. Significant adverse events included three patients who required stent implantation to treat infolding. There were no mortalities.

CONCLUSIONS

The Large Diameter Advanta V12 covered stent is safe and effective for the treatment of CoA with an immediate and sustained reduction of the pressure gradient over 12 months and 5 years as assessed by preimplantation and postimplantation Doppler echocardiography and 12-month computed tomography angiography.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00978952. URL: http://www.anzctr.org.au; Unique identifier: ACTRN12612000013864.

Aortenisthmusstenose – eine lebenslange Systemerkrankung

Koarktation der Aorta (CoA) ist eine Systemerkrankung aller prästenotischen Arterien. Während im Säuglingsalter die chirurgische Behandlung im Vordergrund steht, werden erwachsene Patienten mit CoA oder Re-CoA nach chirurgischer Initialbehandlung, heute überwiegend mit Stents behandelt, wenn dies technisch möglich ist. Trotz erfolgreicher Beseitigung der aortalen Enge bleiben viele Patienten hypertensiv. Die Ursache des arteriellen Hypertonus ist multifaktoriell. Erwachsene CoA-Patienten müssen zum einen regelmäßig in einem EMAH-Zentrum evaluiert werden und benötigen zum anderen häufig eine permanente antihypertensive medikamentöse Therapie.

Predictors of left ventricular reverse remodelling after coarctation of aorta intervention

AIMS

Several coarctation of aorta (COA) severity indices are used for timing of COA intervention, and to define severity of residual coarctation post-intervention. However, it is unclear how many of these COA indices are required in order to recommend intervention, and what degree of residual coarctation results in suboptimal recovery of the left ventricle (LV). Our aim was to assess the correlation between different COA indices and effects of chronic LV pressure overload (LV hypertrophy, diastolic, and systolic dysfunction), and to determine the effect of residual coarctation on LV reverse remodelling after COA intervention.

METHODS AND RESULTS

COA severity indices were defined as Doppler COA gradient, systolic blood pressure (SBP, upper-to-lower-extremity SBP gradient, aortic isthmus ratio. LV remodelling indices were defined as LV mass index (LVMI), LV global longitudinal strain (LVGLS), e' and E/e'. LV reverse remodelling was defined as the difference between indices obtained pre-intervention and 5-year post-intervention (delta LVMI, e', E/e', LVGLS).Of the COA indices analysed in 546 adult COA patients, aortic isthmus ratio had the strongest correlation with LVMI (β ± standard error -28.3 ± 14.1, P < 0.001), LVGLS (1.51 ± 0.42, P = 0.005), e' (3.11 ± 1.10, P = 0.014), and E/e' (-13.4 ± 6.67, P = 0.008). Residual aortic isthmus ratio also had the strongest correlation with LV reverse remodelling, and residual aortic isthmus ratio <0.7 was predictive of suboptimal LV reverse remodelling post-intervention.

CONCLUSION

Considering the known prognostic implications of LV remodelling and reverse remodelling in response to pressure overload, these results support the use of aortic isthmus ratio for timing of COA intervention, and for prognostication post-intervention.

Persistent Hypertension and Left Ventricular Hypertrophy After Repair of Native Coarctation of Aorta in Adults

[Figure: see text].

Transcatheter Intervention for Congenital Defects Involving the Great Vessels: JACC Review Topic of the Week

Since the development of balloon angioplasty and balloon-expandable endovascular stent technology in the 1970s and 1980s, percutaneous transcatheter intervention has emerged as a mainstay of therapy for congenital heart disease (CHD) lesions throughout the systemic and pulmonary vascular beds. Congenital lesions of the great vessels, including the aorta, pulmonary arteries, and patent ductus arteriosus, are each amenable to transcatheter intervention throughout the lifespan, from neonate to adult. In many cases, on-label devices now exist to facilitate these therapies. In this review, we seek to describe the contemporary approach to and outcomes from transcatheter management of major CHD lesions of the great vessels, with a focus on coarctation of the aorta, single- or multiple-branch pulmonary artery stenoses, and persistent patent ductus arteriosus. We further comment on the future of transcatheter therapies for these CHD lesions.

Long-Term Outcomes of the Coarctation of the Aorta Stent Trials

[Figure: see text].

Descending Thoracic Aorta Stenosis Treated by Percutaneous Transluminal Angioplasty and Stenting with Coaxial Sheath Introduction Technique in a Small Child

A 10-year-old girl (23 kg) having a medical history of uncontrolled hypertension was presented to our hospital because of acute left heart failure. Transthoracic echocardiography showed stenosis of descending thoracic aorta with a maximum trans-stenotic pressure gradient of 50 mmHg and severe left ventricular systolic dysfunction with an ejection fraction of 20%. She was diagnosed with Takayasu arteritis with a long severe stenosis of segment III of the thoracic aorta. The procedure of percutaneous transluminal angioplasty was performed and helped to reduce the pressure gradient significantly. After a 6-month follow-up, the left ventricular function was unimproved. Hence, aortic angiography was done and revealed the descending thoracic aorta restenosis with a pressure gradient of 46 mmHg. Despite the difficulties of small vascular access and the disease severity, this patient was intervened by cover stent without any complications. The trans-stenotic pressure gradient decreased remarkably to 5 mmHg. The stent implantation should be considered in the severe stenosis of descending thoracic aorta because of its benefit and safety.

Coarctation of aorta intervention: When covered stents should have been first choice?

Coarctation of aorta (CoA) is one of the common congenital heart diseases. The two approaches for intervention in CoA include surgical and transcatheter (TC). Out of the two TC interventions available, stenting has been proved better than balloon angioplasty. We have two types of stents; the conventional ones – balloon expandable and the covered stent grafts. The elective covered stent implantation in all CoA has not offered any advantage. However, there are peculiar situations, apart from acute aortic complications, when they should be considered the first choice. We describe our experience of three cases of coarctation stenting, in which covered stenting should have been the preferred choice. A 32-year-old female with Turner's syndrome and severe CoA developed dissection after balloon angioplasty which was successfully managed with a covered stent. A 27-year-old female with near atresia of aorta was managed with balloon expandable stent which remained underexpanded despite post dilatation. A 17-year-old girl with severe CoA and patent ductus arteriosus (PDA) was managed with balloon angioplasty for the CoA and Amplatzer Duct Occluder I for the PDA. However, she developed re-coarctation in 6 months which was managed with a covered stent. Not all CoA requires the covered stents, but there are certain “high risk” CoA which require covered stent as first choice.

Endovascular stent implantation for aortic coarctation: parameters affecting clinical outcomes

OBJECTIVE

To evaluate safety and efficacy of endovascular stenting for aortic coarctation (AC) and to explore the effect of clinical parameters and stent characteristics on outcomes.

MATERIAL AND METHODS

Clinical data of all patients with AC who had attempted transcatheter stenting between 2004 and 2019 were retrospectively reviewed. Eligible patients had native or recurrent AC with systemic arterial hypertension and resting arm-leg pressure gradient > 20 mmHg. Exclusions included distance between takeoff of cervical arteries and stenotic aortic lesion < 10 mm, contraindication to antithrombotic therapy, bodyweight < 25 kg, and secondary hypertension.

RESULTS

A total of 20 patients (75.0% with native lesions) were included with a mean age of 18.4 years and a mean bodyweight of 59.2 kg. Procedure was successful in 90.0% of cases with an immediate drop in the invasive pressure gradient across lesions. On a median follow-up of 12 months (range, 8 to 144.9 months), coarctation reoccurred in five patients, but four of them required intervention after a median of 104.4 months with successful outcomes. Cheatham Platinum stents were significantly associated with lower rates of recoarctations and reinterventions. At the latest follow-up, three out of six patients with persistent hypertension had no recoarctation. Analysis showed that the need for antihypertensive therapy was not influenced by clinical parameters, aortic arch geometry, or stent characteristics.

CONCLUSION

Treating AC with stent implantation is a safe and successful procedure. Using Cheatham Platinum stents appears to be associated with better outcomes. The persistence of arterial hypertension despite successful stenting remains a complex and challenging phenomenon.

Acute and medium term results of balloon expandable stent placement in the transverse arch-a multicenter pediatric interventional cardiology early career society study

OBJECTIVES AND BACKGROUND

Coarctation of the aorta represents 5-8% of all congenital heart disease. Although balloon expandable stents provide an established treatment option for native or recurrent coarctation, outcomes from transverse arch (TAO) stenting, including resolution of hypertension have not been well studied. This study aims to evaluate immediate and midterm results of TAO stenting in a multi-center retrospective cohort.

METHODS

TAO stenting was defined as stent placement traversing any head and neck vessel, with the primary intention of treating narrowing in the transverse aorta. Procedural details, complications and medications were assessed immediately post procedure, at 6 month follow-up and at most recent follow-up.

RESULTS

Fifty-seven subjects, 12 (21%) native, and 45 (79%) surgically repaired aortic arches, from seven centers were included. Median age was 14 years (4 days-42 years), median weight 54 kg (1.1-141 kg). After intervention, the median directly measured arch gradient decreased from 20 mmHg (0-57 mmHg) to 0 mmHg (0-23 mmHg) (p < .001). The narrowest arch diameter increased from 9 mm (1.4-16 mm) to 14 mm (2.9-25 mm) (p < .001), with a median increase of 4.9 mm (1.1-10.1 mm). One or more arch branches were covered by the stent in 55 patients (96%). There were no serious adverse events. Two patients warranted stent repositioning following migration during deployment. There were no late complications. There were 8 reinterventions, 7 planned, and 1 unplanned (6 catheterizations, 2 surgeries). Antihypertensive management was continued in 19 (40%) at a median follow-up of 3.2 years (0.4-7.3 years).

CONCLUSIONS

TAO stenting can be useful in selected patients for resolution of stenosis with minimal complications. This subset of patients are likely to continue on antihypertensive medications despite resolution of stenosis.

Left Ventricular Remodeling After Transcatheter Versus Surgical Therapy in Adults With Coarctation of Aorta

OBJECTIVES

The purpose of this retrospective cohort study was to compare remodeling of left ventricular (LV) structure and function after transcatheter stent therapy with remodeling of LV structure and function after surgical therapy for COA.

BACKGROUND

Transcatheter stent therapy is as effective as surgery in producing acute hemodynamic improvement in patients with coarctation of aorta (COA). However, LV remodeling after transcatheter COA intervention has not been systematically investigated.

METHODS

LV remodeling was assessed at 1, 3, and 5 years post-intervention by using LV mass index (LVMI), LV end-diastolic dimension, LV ejection fraction, LV global longitudinal strain (LVGLS), LV mitral annular tissue Doppler early velocity (LVe'), and ratio of mitral inflow pulsed wave Doppler early velocity and e' (E/e') ratio.

RESULTS

There were 44 patients in the transcatheter group and 128 patients in the surgical group. Compared to the surgical group, the transcatheter group had less regression of LVMI (-4.6; 95% confidence interval [CI]: -5.5 to -3.7 vs. -7.3; 95% CI: -8.4 to -6.6 g/m2; p < 0.001), less improvement in LVGLS (2.1; 95% CI: 1.8 to 2.4 vs. 2.9; 95% CI: 2.6 to 3.2%; p = 0.024), and in e' (1.0 ; 95% CI: 0.7 to 1.2 vs. 1.5 ; 95% CI: 1.3 to 1.7 cm/s; p = 0.009) at 5 years post-intervention. Exploratory analysis showed a correlation between change in LVMI and LVGLS, and between change in LVMI and mitral annular tissue Doppler early velocity (e'), and this correlations were independent of the type of intervention received.

CONCLUSIONS

Transcatheter stent therapy was associated with less remodeling of LV structure and function during mid-term follow-up. As transcatheter stent therapy becomes more widely used in the adult COA population, there is a need for ongoing clinical monitoring to determine if these observed differences in LV remodeling translate to differences in clinical outcomes.

Immediate results of percutaneous management of coarctation of the aorta: A 7-year single-centre experience

BACKGROUND

Coarctation of the aorta (CoA) is often treated percutaneously. The aim of this study was to describe the immediate results of percutaneous management of native aortic coarctation (NaCoA) and recoarctation of the aorta (ReCoA) at our institution.

METHODS

We identified all patients with NaCoA or ReCoA who underwent percutaneous dilatation by either balloon angioplasty (BAP) or endovascular stent implantation (ESI) between 2011 and 2017. Success was defined as a residual peak-to-peak gradient (PPG) <20 mmHg or a ≥50% reduction in the gradient if the pre-intervention PPG was <20 mmHg.

RESULTS

63 patients (median age 6.8 years, interquartile range [IQR] 0.4-14.2) were identified. Among 11 patients with NaCoA, 7 underwent BAP and 4 had ESI, and among 52 patients with ReCoA, 42 underwent BAP and 10 had ESI. In patients with NaCoA, BAP was successful in 71%, with median PPG decreasing from 32 mmHg (IQR 25-46) to 17 mmHg (IQR 4-23) (p = .02), and ESI was successful in 100%, with median PPG decreasing from 20 mmHg (IQR 14.5-40) to 2 mmHg (IQR 0-6) (p < .01). In patients with ReCoA, BAP was successful in 69%, with median PPG decreasing from 20 mmHg (IQR 16-31.3) to 9 mmHg (IQR 0-14.3) (p < .001), and ESI was successful in 100%, with median PPG decreasing from 18 mmHg (IQR 11.5-22.8) to 0 mmHg (IQR 0-3.5) (p < .01). ESI was more successful than BAP (p = .01). There was only one complication.

CONCLUSIONS

Percutaneous management of CoA is safe and effective in both NaCoA and ReCoA. Stent implantation is more effective than BAP.

Management of adults with coarctation of aorta

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.

Registries, Risk Calculators, and Risk-Adjusted Outcomes: Current Usage, Limitations, and Future Prospects

Small study sizes are a limiting factor in assessing outcome measures in pediatric cardiology. It is even more difficult to assess the outcomes of congenital catheterizations where the sample sizes are even smaller, particularly on a individual institutional level. The creation of multicenter registries is a method by which investigators can pool data to better assess quality and outcome measures of these procedures. No registry is perfect with several being available today, each with its own strengths and weaknesses. In addition, there are a multitude of methods currently used to assess quality and outcomes from the data contained in these registries, each having its own limitations as well. Nonetheless, multicenter registrities remain one of the best available options to improve the quality of care for pediatric interventional cardiac catheterization. Below, we provide an overview of the current state of quality assessment/improvement in pediatric interventional cardiology including a review of the available registrities and the metrics used to measure quality of care and outcomes.

Extra-anatomic aortic bypass with aortic-, mitral-, and tricuspid surgery in a 53-year old: A single-stage approach for complex coarctation associated with triple valve pathology

Coarctation is rare in patients over 50 years of age; however, if present, it can be associated with complex intracardiac pathologies and represent a formidable surgical challenge. Herein, we report a single‐stage approach for surgical repair of coarctation associated with aortic, mitral, and tricuspid valve pathology using an ascending‐to‐descending aortic bypass with posterior pericardial access.

Coarctation: A Review

Coarctation of the aorta occurs in 0.04% of the population, and accounts for approximately 10% of lesions in adults with congenital heart disease. It can occur as an isolated lesion or as a part of a complex defect, and is most commonly associated with bicuspid aortic valve, ventricular septal defect, and mitral valve abnormalities. Since the first surgical repair in 1944, the available treatment options have expanded greatly. Perhaps one of the most important advances in the management of coarctation of the aorta has been the development of transcatheter therapy for both native and especially recurrent coarctation of the aorta. Late complications, even after apparently successful treatment, are not uncommon. For this reason, lifelong follow-up is vital.

The Challenges of Redo Aortic Coarctation Repair in Adults

PURPOSE OF REVIEW

Aortic coarctation is a common congenital abnormality causing significant morbidity and mortality if not corrected. Re-coarctation or restenosis of the aorta following treatment is a relatively common long-term problem and the optimal therapy has not been elucidated. In this review, we identify the challenges associated with and the optimal management for recurrent aortic coarctation and the most appropriate therapy for different patient cohorts.

RECENT FINDINGS

Open surgery provides a durable long-term aortic repair, however, given the complex nature of the procedure, has a somewhat higher rate of serious complications. Endovascular repair, although less invasive and relatively safe, has limitations in treated complex anatomy and is more likely to require repeat intervention. Open surgical repair is more appropriate for infants that have not been intervened on and endovascular therapy should be reserved for older children and adults and those that require repeat intervention.

Self-Expandable Stents in Vascular Stenosis of Moderate to Large-Sized Vessels in Congenital Heart Disease: Early and Intermediate-Term Results

Background and Objectives

Vascular stenosis after surgical repair frequently occurs in congenital heart disease. Although conventional balloon dilation is a useful option for stenotic lesions, restenosis may occur. Consequently, balloon expandable stents have been used; however, there are a limited number of balloon expandable stents in our country. Here, we report the early and intermediate-term outcomes of self-expandable stents in vascular stenosis of moderate to large-sized vessels in congenital heart disease.

Methods

Twelve self-expandable stents were implanted in 9 patients between February 2012 and January 2019. The median age and weight were 12 years (range, 4–39 years) and 38 kg (range, 19–69 kg), respectively. The patients were followed-up for a median duration of 43 months (range, 1–83 months) after stent implantation.

Results

Nine self-expandable stents were implanted in the pulmonary artery, 2 stents in the right ventricle to the pulmonary artery conduit, and 1 stent in the coarctation. The narrowest diameter of the stented vessel increased from 5.7±3.2 mm to 12.6±3.4 mm (p<0.05). The mean pressure gradient across the stenotic lesion decreased from 23.0±28.2 mmHg to 3.2±3.6 mmHg (p<0.05). Distal migration of the stent occurred in 1 patient, and significant neointimal ingrowth was noted in 1 patient.

Conclusions

The self-expandable stent may be a useful option to relieve vascular stenosis in moderate to large-sized vessels with acceptable intermediate-term outcomes.

Aortic rupture during endovascular repair of a postoperative coarctation pseudoaneurysm in an adult: Emergency lifesaving stent graft implantation

We present a case with aortic rupture during an operation of thoracic endovascular aortic repair of an anastomotic pseudoaneurysm. This happened after the use of a low-pressure remodeling balloon inside the covered part of the deployed endografts. It was successfully treated with a second more centrally in the aortic arch-implanted endograft with full coverage of the left subclavian artery orifice. This patient had a history of surgically operated aortic coarctation.

Management of Coarctation of The Aorta in Adult Patients: State of The Art

Coarctation of the aorta (CoA) is a common form of congenital heart disease. Adult patients with CoA may be asymptomatic or may present with hypertension. Over the last few years, endovascular management of adult patients with CoA emerged as the preferred strategy. Stent implantation, though technically challenging, offers the best and most lasting therapy. In this paper, we will review technical considerations and outcome of patients undergoing stent implantation for CoA.

Adult Congenital Interventions in Heart Failure

Congenital heart disease (CHD) is the most common birth defect, occurring in approximately 0.8% to 1.0% of neonates. Advances in medical and surgical therapies for children with CHD have resulted in a growing population of patients reaching adulthood, with survival rates exceeding 85%. Many of these patients, especially if managed inappropriately, face the prospect of future complications including heart failure and premature death. For adults with uncorrected or previously palliated CHD, percutaneous therapies have become the primary treatment for many forms of CHD. In this article, we discuss the role of transcatheter interventions in the treatment of adults with CHD.

Stent Angioplasty for Critical Native Aortic Coarctation in Three Infants: Up to 15-Year Follow-Up Without Surgical Intervention and Review of the Literature

Management of neonatal native coarctation is debated till now. Surgical therapy remains an option but may be unwarranted in critically sick infants with complex lesions. Balloon dilatation has been employed but with early re-stenosis. Stent angioplasty has also been used but as a bridge towards definitive surgical therapy. Four critically sick infants with complex coarctation and additional co-morbidity factors underwent primary stent therapy as surgical intervention was denied. One patient had died earlier due to reasons unrelated to the procedure. Three survivors underwent multiple dilatations of primary stents as indicated. One of the three survivors did not require any further dilatation after the age of 5 years and remained stable till the time of reporting. High-pressure Cheatham Platinum stents were implanted inside the primary stents in two infants, who developed re-stenosis due to somatic growth. These stents were further balloon dilated at high atmospheric pressure. Femoral arteries in both of them were blocked but were re-canalized after balloon dilatation in one and stent angioplasty in the other. After a follow-up of about 15 years, all of them have been doing fine with acceptable Doppler gradients. They were normotensive and on no cardiac medications. It can be concluded that, though surgical repair remains a standard of care, stent angioplasty in selected infants with complex lesions is feasible and effective. Multiple dilatations can be performed without added risk of stent migration. Bio-absorbable and growth stents hold a promise for future use in such situations.

Coronary subclavian steal syndrome-is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery?

Subclavian artery stenosis (SAS) resulting in coronary subclavian steal syndrome (CSSS) is a common but under recognized pathology following coronary artery bypass surgery (CABG). Patients with SAS may be asymptomatic due to the sub-clinical diversion of blood flow from the myocardium and retrograde blood flow during catheter angiography in the left internal mammary artery (LIMA) may be the first suggestion of CSSS. The management of SAS, causing CSSS, may rarely require acute assessment and intervention. However, full anatomical assessment of the stenosis morphology may be limited on fluoroscopy. Correction of SAS may be essential to achieve effective reperfusion therapy.

Current Transcatheter Approaches for the Treatment of Aortic Coarctation in Children and Adults

Coarctation of the aorta is a common congenital heart defect and can present at any age. Infants may carry a fetal diagnosis, or are generally diagnosed after auscultation of a murmur, although rarely present in shock. Those that escape early childhood detection typically present in adolescence and adulthood, generally with upper-extremity hypertension. Percutaneous therapies have evolved to include balloon angioplasty and stent placement, and generally are the preferred first-line therapy for most adolescent/adult patients. Percutaneous interventions are now viable options in younger and smaller patients. The advent of bioresorbable stents may provide further expansion of treatment options to very small patients.

Self-Expanding Versus Balloon-Expandable Stents in Patients With Isthmic Coarctation of the Aorta

Endovascular stent implantation has become the treatment of choice for the management of patients with native coarctation of the aorta (CoA). The aim of this study was to compare the outcomes of self-expandable stenting (SES) with balloon-expandable stenting (BES) in the treatment of native CoA. In this single-center retrospective study, all patients who underwent SES or BES for the management of native CoA were enrolled. Patients were followed up for a median period of 35 (inter-quartile range 15 to 71) months. The primary outcome of interest was a composite end point consisted of death, surgical repair, re-stenting, re-ballooning, and hospital admission for hypertension crisis. The CoA diameter has changed from 3.2 ± 2.1 to 14.2 ± 4.0 mm in the BES group and from 4.6 ± 2.6 to 12.2 ± 3.7 mm in the SES group (both p <0.001). The procedure was successful with residual pressure gradient <20 mm Hg in 99.0% and 98.6% of patients in the BES and SES groups, respectively. Major adverse events occurred in 6 (8.7%) in the SES groups and 14 (20.3%) in the BES group (p = 0.053). Kaplan-Meier curve showed no difference between the 2 groups in terms of survival from major adverse events (p = 0.10), but when groups were matched for the propensity of stenting methods, SES was associated with lower major adverse events (p = 0.01). In conclusion, the SES and BES methods were safe and durable in our cohort with low rates of adverse events. After adjustment for the propensity of treatment with each stenting method, SES was associated with better outcomes. Regardless of the outcome of each method, it should be noted that the taken approach should be tailored to the patient's anatomy.