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Ye L, Castaldi B, Cattapan I, Pozza A, Fumanelli J, Di Salvo G. Hypertension in aortic coarctation. Front Cardiovasc Med 2025; 12:1505269. [PMID: 40260103 PMCID: PMC12009809 DOI: 10.3389/fcvm.2025.1505269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2024] [Accepted: 03/19/2025] [Indexed: 04/23/2025] Open
Abstract
Aortic coarctation (AoC) is a common congenital heart defect, affecting 5%-8% of patients with structural congenital anomalies. Despite advances in surgical and percutaneous interventions, hypertension remains a significant complication in AoC patients, even after successful repair. Chronic hypertension develops in 20%-70% of patients and is a leading cause of long-term cardiovascular morbidity. In these patients, hypertension is associated to renin-angiotensin system activation, residual aortic arch abnormalities, and impaired aortic elasticity. Additionally, exercise-induced hypertension and masked hypertension contribute to adverse outcomes. Management of hypertension in AoC patients requires both perioperative and long-term care. Early after correction, intravenous antihypertensive agents, such as sodium nitroprusside, esmolol, and labetalol, are commonly used to stabilize blood pressure and reduce the risk of complications like cerebral hemorrhage. Oral beta-blockers, ACE inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) are most commonly used for chronic hypertension. In this review, we discussed about diagnostic workup and therapeutical strategies for hypertension in AoC patients.
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Affiliation(s)
| | - Biagio Castaldi
- Pediatric Cardiology Unit, Department of Women’s and Children’s Health, University Hospital of Padua, Padua, Italy
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Recco DP, Kizilski SB, Dafflisio GJ, Ghosh RM, Kittichokechai P, Gauvreau K, Piekarski B, Prakash A, Hoganson DM. Postoperative aortic isthmus size after arch reconstruction with patch augmentation predicts arch reintervention. J Thorac Cardiovasc Surg 2025; 169:964-973.e4. [PMID: 39326728 DOI: 10.1016/j.jtcvs.2024.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2024] [Revised: 09/16/2024] [Accepted: 09/17/2024] [Indexed: 09/28/2024]
Abstract
BACKGROUND Rates of reintervention (RI) after patch-augmented reconstruction for hypoplastic aortic arch (HAA) remain moderately high. We analyzed mid-term outcomes of aortic arch reconstruction to define modifiable reintervention risk factors. METHODS Excluding Damus-Kaye-Stansel anastomoses and previous arch repair, 338 patients underwent arch reconstruction between 2000 and 2021 at median age of 6 days (interquartile range [IQR], 4-13 days) and a median weight of 3.2 kg (IQR, 2.8-3.7 kg). Surgical technique was patch augmentation with coarctectomy with or without interdigitation in 269 patients (80%), isolated patch aortoplasty in 41 (12%), and other reconstruction in 28 (8%). Risk factors for reintervention were assessed using competing risk models. RESULTS At median follow-up of 3.9 years (IQR, 1.1-8.0 years), 35 patients (10.4%) required reintervention (endovascular, n = 30; surgical, n = 12; both, n = 7). The 10-year cumulative incidence of death/transplant was 10% (95% confidence interval [CI], 4%-20%), and that of and reintervention was 13% (95% CI, 8%-20%). On univariate analysis, isolated patch aortoplasty (P = .002), aortic homograft patch material (P = .006), and postoperative aortic size z-score ≤-2 for each segment were associated with greater risk of reintervention: ascending aorta (P = .006), proximal (P = .001) and distal (P = .005) transverse arches, and aortic isthmus (P < .001). On multivariable analysis, aortic homograft (hazard ratio [HR], 6.29; 95% CI, 1.94-20.5; P = .002) and postoperative isthmus z-score ≤-2 (HR, 10.5; 95% CI, 5.15-21.5; P < .001) remained significant. Patients with a repaired isthmus z-score ≤-2 had a 72.8% (95% CI, 44.6-94.4%) cumulative incidence of reintervention at 10 years, versus 6.8% (95% CI, 4.1%-11.4%) in those with a z-score >-2. CONCLUSIONS Aortic undersizing during patch-augmented reconstruction of HAA results in a >10% rate of reintervention at mid-term follow-up. Achieving adequate postoperative arch size is critical for preventing reintervention, with aortic isthmus size of utmost importance.
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Affiliation(s)
- Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Shannen B Kizilski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | | | - Reena M Ghosh
- Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Pakaparn Kittichokechai
- Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Breanna Piekarski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Ashwin Prakash
- Harvard Medical School, Boston, Mass; Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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3
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Fricke K, Christierson L, Heiberg E, Sjöberg P, Hedström E, Steiner K, Weismann CG, Töger J, Liuba P. Three-dimensional aortic arch geometry and blood flow in neonates after surgical repair for aortic coarctation. Front Cardiovasc Med 2025; 11:1518070. [PMID: 39834739 PMCID: PMC11743609 DOI: 10.3389/fcvm.2024.1518070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2024] [Accepted: 12/05/2024] [Indexed: 01/22/2025] Open
Abstract
Background Recurrent coarctation of the aorta (re-CoA) is a well-known although not fully understood complication after surgical repair, typically occurring in 10%-20% of cases within months after discharge. Objectives To (1) characterize geometry of the aortic arch and blood flow from pre-discharge magnetic resonance imaging (MRI) in neonates after CoA repair; and (2) compare these measures between patients that developed re-CoA within 12 months after repair and patients who did not. Methods Neonates needing CoA repair, without associated major congenital heart defects, were included. Transthoracic echocardiography (echo) and 4D phase-contrast MRI were performed prior to discharge after CoA repair to assess 3D arch geometry, flow velocity and flow pattern in the distal aortic arch corresponding to the area at risk for re-CoA. Arch geometry was assessed by measuring angles of the aortic arch and its branches using 3D patient-specific geometries segmented from MRI. Continuous data are presented as median and interquartile range. Results The median age at CoA surgery was 9 days. Four out of the included 28 patients (14%) developed re-CoA within the first 12 months after surgery. Re-CoA was associated with repair technique (lateral thoracotomy 100% vs. 33%, p = 0.02), higher postoperative isthmic flow velocity by echocardiography (1.9 [0. 9] m/s vs. 1.25 [0.5] m/s, p = 0.04) and postoperative crenel aortic arch (100% vs. 21%, p = 0.007) with a larger distance between the first and last branching points (12.6 [3.1] mm vs. 7.3 [7.0] mm; p = 0.01). A smaller angle between the ascending aorta and the brachiocephalic artery (89 [58]° vs. 122 [37]°, p = 0.05) and between the proximal aortic arch and the left carotid artery (75° vs. 97 [37]°, p = 0.04), with a more pronounced caliber change between the ascending aorta and the proximal (1.85 vs. 0.86 [0.76]; p = 0.03) and distal aortic arch (2.19 [2.42] vs. 1.01 [0.94]; p = 0.03) were observed in re-CoA patients. Patients who developed re-CoA had more left-handed helical flow in systole (p = 0.045), more right-handed helical flow in diastole (p = 0.02), and less vortical flow (p = 0.05). Conclusion Subtle changes in aortic arch geometry and flow pattern early after neonatal CoA repair may contribute to the risk of re-CoA.
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Affiliation(s)
- Katrin Fricke
- Pediatric Cardiology, Pediatric Heart Center, Skåne University Hospital, Lund, Sweden
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Lea Christierson
- Pediatric Cardiology, Pediatric Heart Center, Skåne University Hospital, Lund, Sweden
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Biomedical Engineering, Lund University, Lund, Sweden
| | - Einar Heiberg
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Pia Sjöberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Lund, Sweden
| | - Erik Hedström
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Clinical Physiology, Skåne University Hospital, Lund, Sweden
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Skåne University Hospital, Lund, Sweden
| | - Kristoffer Steiner
- Department of Women`s and Children`s Health, Karolinska Institute, Stockholm, Sweden
| | - Constance G. Weismann
- Pediatric Cardiology, Pediatric Heart Center, Skåne University Hospital, Lund, Sweden
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig-Maximilian University, Munich, Germany
| | - Johannes Töger
- Department of Biomedical Engineering, Lund University, Lund, Sweden
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Petru Liuba
- Pediatric Cardiology, Pediatric Heart Center, Skåne University Hospital, Lund, Sweden
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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Stukov Y, Jacobs JP, Sharaf OM, Peek GJ, Pitkin AD, Cruz Beltrán SC, Lopez-Colon D, Nixon CS, Bleiweis MS. 15-Year Analysis of Surgical Approaches and Outcomes for Coarctation in 132 Neonates and Infants. Pediatr Cardiol 2025; 46:173-180. [PMID: 38557773 DOI: 10.1007/s00246-023-03360-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/19/2023] [Indexed: 04/04/2024]
Abstract
A variety of surgical approaches exist to treat aortic coarctation in neonates and infants. Our institutional approach is designed to match the surgical approach to the individual anatomy of the patient. The objective of this study is to evaluate operative characteristics and outcomes of all neonates and infants who underwent surgical repair of coarctation of the aorta or hypoplastic aortic arch at University of Florida from 2006 to 2021, inclusive, either in isolation or with concomitant repair of atrial septal defect (ASD) and/or ventricular septal defect (VSD). A retrospective review was performed of 132 patients aged 0-1 year who underwent surgical repair of aortic coarctation or hypoplastic aortic arch between 2006 and 2021, inclusive, either in isolation or with concomitant repair of ASD and/or VSD. Patients were divided into two groups based on the surgical approach: Group 1 = Median Sternotomy and Group 2 = Left Lateral Thoracotomy. Continuous variables are presented as median (minimum-maximum); categorical variables are presented as N (%). The most common operative technique in Group 1 was end-to-side reconstruction with ligation of the aortic isthmus. The most common operative technique in Group 2 was extended end-to-end repair. Operative Mortality was one patient (1/132 = 0.76%). Transcatheter intervention for recurrent coarctation was performed in seven patients (7/132 = 5.3%). Surgical re-intervention for recurrent coarctation was performed in three patients (3/132 = 2.3%). From these data, one can conclude that a strategy of matching the surgical approach to the anatomy of neonates and infants who underwent surgical repair of aortic coarctation or hypoplastic aortic arch, either in isolation or with concomitant repair of ASD and/or VSD, is associated with less than 1% Operative Mortality and less than 3% recurrent coarctation requiring reoperation.
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Affiliation(s)
- Yuriy Stukov
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Omar M Sharaf
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Giles J Peek
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Andrew D Pitkin
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Susana C Cruz Beltrán
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Dalia Lopez-Colon
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Connie S Nixon
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA
| | - Mark S Bleiweis
- Congenital Heart Center, University of Florida, 1600 Archer Road, Gainesville, FL, 32608, USA.
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Chiu P, Gearhart A, Gikandi A, Marathe S, Holland M, Goto S, Ghelani SJ, Kaza AK. Sternotomy or thoracotomy for neonatal repair of coarctation of the aorta with aortic arch hypoplasia. JTCVS OPEN 2024; 22:386-394. [PMID: 39780815 PMCID: PMC11704562 DOI: 10.1016/j.xjon.2024.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 09/16/2024] [Accepted: 09/18/2024] [Indexed: 01/11/2025]
Abstract
Objective For neonatal repair of coarctation of the aorta, patients may either undergo thoracotomy with extended end-to-end anastomosis or sternotomy for aortic arch reconstruction with cardiopulmonary bypass. The objective of this study was to evaluate the comparative effectiveness of the 2 approaches in patients with arch hypoplasia. Methods This is a single-center retrospective cohort study from July 2005 through May 2022 of patients who underwent neonatal repair for isolated coarctation of the aorta with additional arch hypoplasia. Inverse probability of treatment weighting is a statistical method for creating comparable pseudopopulations and was used to account for baseline differences in population. The primary outcome was aortic reintervention, and secondary outcomes were vocal cord dysfunction, length of stay, chylothorax, and phrenic nerve palsy. Results There were 130 patients who met inclusion criteria. After weighting, the interaction between distal transverse arch size and operative approach (sternotomy vs thoracotomy) was statistically significant, P < .05 for interaction. Among patients with a distal arch z-score <-3.5, patients undergoing thoracotomy with extended end-to-end anastomosis had an increased hazard for reintervention. Sternotomy was associated with an increased length of stay in the intensive care unit by 4.7 days, P < .001, and odds of vocal cord dysfunction were also greater, odds ratio 7.1 (95% confidence interval, 1.66 to 41.26; P = .01). Conclusions Among patients with a distal arch z-score smaller than -3.5, the hazard of reintervention was increased for patients undergoing thoracotomy with extended end-to-end anastomosis. However, length of stay and risk of vocal cord paresis was reduced in patients undergoing thoracotomy.
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Affiliation(s)
- Peter Chiu
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Mass
| | - Addison Gearhart
- Department of Cardiology, Boston Children’s Hospital, Boston, Mass
| | - Ajami Gikandi
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Mass
| | - Supreet Marathe
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Mass
| | - Margaret Holland
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Mass
| | - Shinichi Goto
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Mass
| | - Sunil J. Ghelani
- Department of Cardiology, Boston Children’s Hospital, Boston, Mass
| | - Aditya K. Kaza
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, Mass
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Turaev B, Abralov K, Ibragimov N. Deciphering risk elements: exploring precursors to recoarctation in individuals with aortic coarctation. KARDIOCHIRURGIA I TORAKOCHIRURGIA POLSKA = POLISH JOURNAL OF CARDIO-THORACIC SURGERY 2024; 21:211-217. [PMID: 39781436 PMCID: PMC11704758 DOI: 10.5114/kitp.2024.145904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 10/18/2024] [Indexed: 01/12/2025]
Abstract
Introduction Coarctation of the aorta (CoA) patients often experience recoarctation, the reoccurrence of aortic narrowing, presenting a considerable clinical challenge. Aim This study aims to investigate the triggers or contributing factors associated with the development of recoarctation (reCoA) following the initial repair of CoA. Material and methods The retrospective cohort study includes information about 120 patients, who underwent 4 different types of surgical repairs of coarctation of the aorta through left thoracotomy in the period 2012-2022. Recoarctation was evaluated using the pressure gradient on the coarctation site measured by echocardiography (echoCG). A threshold of more than 20 mm Hg was employed to define recoarctation. All statistical analysis was performed using SPSS and Jamovi applications. Results The study revealed that 30 (25%) patients experienced early recoarctation, while 52 (43.7%) patients encountered late recoarctation. Among the 28 (23.3%) patients who had arch hypoplasia, 12 experienced early recoarctation, and 22 exhibited late recoarctation. Correlation tests demonstrated a strong negative correlation of the z-score of the arch size with both early recoarctation (r = -0.229, p = 0.013) and late recoarctation (r = -0.421, p < 0.001). Resection and end-to-end anastomosis (EEA) displayed the highest proportions of early (59%) and late (77%) recoarctation. Conclusions Aortic arch hypoplasia emerges as a significant risk factor for both early and late recoarctation. Additionally, while all coarctation repair methods carry some risk of recoarctation, resection and end-to-end anastomosis and prosthetic patch aortoplasty may pose a higher risk compared to extended end-to-end anastomosis.
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Affiliation(s)
- Bobur Turaev
- Tashkent Pediatric Medical Institute Hospital, Tashkent, Uzbekistan
| | - Khakimjon Abralov
- The Republican Specialized Scientific and Practical Medical Center for Surgery named after Academician V. Vakhidov, Tashkent, Uzbekistan
| | - Nodir Ibragimov
- Tashkent Pediatric Medical Institute Hospital, Tashkent, Uzbekistan
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Türkmen H, Uysal F, Genç A, Bostan ÖM, Şenkaya Siğnak I. Evaluation of Children with Aortic Coarctation: A Single-Center Experience. Turk Arch Pediatr 2024; 59:480-487. [PMID: 39440413 PMCID: PMC11391242 DOI: 10.5152/turkarchpediatr.2024.24050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/26/2024] [Indexed: 10/25/2024]
Abstract
Coarctation of the aorta (CoA) accounts for 3.5% of all congenital heart diseases in children. The clinical manifestations range from heart failure to asymptomatic hypertension. Treatment options include surgical repair, balloon angioplasty, and stenting. We aimed to investigate the long-term results of surgery and balloon angioplasty to identify the possible risk factors for recoarctation and predictors associated with early success in treatment modalities. The data of 138 children who underwent examinations at a tertiary center between 2015 and 2020 with the diagnosis of CoA were evaluated. The basic demographic characteristics, clinical and echocardiographic findings, results, and treatment methods of the patients were evaluated retrospectively. The mean follow-up period was 75.1 months (range of 1-223). As initial treatment, 75 patients (60.5%) underwent balloon angioplasty, 44 (35.5%) underwent surgery, and 5 (4%) underwent stenting. The early success rate of balloon angioplasty and surgery was 72.5% and 79.5%, respectively. Recoarctation occurred in 47.6% of patients following the first therapy. The median reintervention-free survival time was 138 months for all patients and was significantly higher in the surgery group (P = .025). The recoarctation rate was slightly lower in the surgery group than in those who underwent balloon angioplasty, but it was not statistically significant. None of the clinical and echocardiographic findings were found to be associated with recoarctation or early success. The rate of recoarctation is still high in long-term follow-up after aortic coarctation treatment, and clinical and echocardiographic findings are insufficient to predict the chance of early success and the risk of recoarctation.
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Affiliation(s)
- Hasan Türkmen
- Department of Pediatric Cardiology, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Fahrettin Uysal
- Department of Pediatric Cardiology, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Abdüsselam Genç
- Department of Pediatric Cardiology, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Özlem M. Bostan
- Department of Pediatric Cardiology, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
| | - Işık Şenkaya Siğnak
- Department of Pediatric Cardiovascular Surgery, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
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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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Landsem L, Brown N, Cox R, Ross F. Perioperative and Anesthetic Considerations in Shone's Complex. Semin Cardiothorac Vasc Anesth 2024; 28:28-37. [PMID: 38134942 DOI: 10.1177/10892532231223840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.
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Affiliation(s)
- Leah Landsem
- Division of Paediatric Cardiac Anesthesiology, Department of Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Nicholas Brown
- Department of Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Ryan Cox
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
| | - Faith Ross
- Division of Paediatric Cardiac Anesthesiology, Department of Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
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10
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Winder MM, Ware A, Husain A, Griffiths E, Swink JM, Ou Z, Eckhauser A. Interdigitating Technique for Repair of Aortic Arch Obstruction to Reduce Reintervention Rates. Ann Thorac Surg 2024; 117:387-394. [PMID: 37414382 PMCID: PMC10764635 DOI: 10.1016/j.athoracsur.2023.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/08/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND The incidence of reintervention for aortic arch obstruction is 5% to 14% after coarctation or hypoplastic aortic arch repair and 25% after the Norwood procedure. Institutional practice review indicated higher than reported reintervention rates. Our aim was to assess the impact of an interdigitating reconstruction technique on reintervention rates for recurrent aortic arch obstruction. METHODS Children (<18 years) were included if they had undergone aortic arch reconstruction by sternotomy or the Norwood procedure. Three surgeons participated in the intervention with staggered rollout dates between June 2017 and January 2019, with the study ending December 2020 and review for reinterventions ending February 2022. Preintervention cohorts represented patients who underwent aortic arch reconstructions with patch augmentation, and postintervention cohorts represented patients who underwent an interdigitating reconstruction technique. Reinterventions by cardiac catheterization or operation were measured within 1 year of initial operation. Wilcoxon rank sum and χ2 tests were used to compare preintervention and postintervention cohorts. RESULTS Overall, 237 patients were included for participation in this study, with 84 patients in the preintervention cohort and 153 in the postintervention cohort. Patients undergoing the Norwood procedure represented 30% (n = 25) of the retrospective cohort and 35% (n = 53) of the intervention cohort. Overall reinterventions were significantly decreased after the study intervention from 31% (n = 26/84) to 13% (n = 20/153; P < .001). Reintervention rates were decreased for each intervention cohort: aortic arch hypoplasia (24% [n = 14/59] vs 10% [n = 10/100]; P = .019) and Norwood procedure (48% [n = 12/25] vs 19% [n = 10/53]; P = .008). CONCLUSIONS The interdigitating reconstruction technique for obstructive aortic arch lesions was successfully implemented and is associated with a decrease in reinterventions.
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Affiliation(s)
- Melissa M Winder
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah; Heart Center, Primary Children's Hospital, Salt Lake City, Utah.
| | - Adam Ware
- Division of Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Adil Husain
- Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Eric Griffiths
- Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Aaron Eckhauser
- Section of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
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Fogaça da Mata M, Anjos R, Lemos M, Nelumba T, Cordeiro S, Rato J, Teixeira A, Abecasis M. Prenatal diagnosis of coarctation: Impact on early and late cardiovascular outcome. Int J Cardiol 2024; 396:131430. [PMID: 37827282 DOI: 10.1016/j.ijcard.2023.131430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/02/2023] [Accepted: 10/08/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Prenatal diagnosis (PND) of aortic coarctation (AoCo) has been associated with a significant improvement in early results, but there is limited information on the long-term cardiovascular outcome. METHODS We studied 103 patients with simple AoCo, operated in the neonatal period, with a median follow-up of 8,5 years (2 to 23,7 years), with 47% followed for over 10 years. PND was made in 35%. The primary aim was to determine the short and long-term cardiovascular impact of PND of AoCo. RESULTS Neonates with PND had less preoperative neonatal complications, with only 2,8% incidence of a composite preoperative severe morbidity course, compared to 28% in the postnatal group. PND patients underwent surgery 8 days earlier and had a shorter length of stay in ICU. PND did not impact the incidence of post-operative complications. On the long-term, prevalence of hypertension, left ventricular hypertrophy and rate of recoarctation were not influenced by PND. The PND group had mean 24 h diastolic BP 9 mmHg lower and mean daytime diastolic BP 11 mmHg lower. In the final multivariable model, PND was the single independent variable correlating with daytime diastolic BP. CONCLUSION PND of AoCo effectively leads to a better pre-operative course with less pre-operative morbidity. We found no significant differences in immediate post-operative cardiovascular outcomes. A better initial course of patients with PND does not have a major long-term impact on cardiovascular outcomes, nevertheless, at late follow-up PND patients had lower diastolic BP values on ambulatory monitoring, which may have an impact on long-term cardiovascular risk.
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Affiliation(s)
- Miguel Fogaça da Mata
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal.
| | - Rui Anjos
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Mariana Lemos
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Tchitchamene Nelumba
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Susana Cordeiro
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - João Rato
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Ana Teixeira
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
| | - Miguel Abecasis
- Pediatric Cardiac Surgery Department, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal
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Pergola V, Avesani M, Reffo E, Da Pozzo S, Cavaliere A, Padalino M, Vida V, Motta R, Di Salvo G. Unveiling the gothic aortic arch and cardiac mechanics: insights from young patients after arterial switch operation for d-transposition of the great arteries. Monaldi Arch Chest Dis 2023; 94. [PMID: 37768214 DOI: 10.4081/monaldi.2023.2712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The arterial switch operation (ASO) has become the standard surgical treatment for patients with d-transposition of the great arteries. While ASO has significantly improved survival rates, a subset of patients develop a unique anatomical anomaly known as the gothic aortic arch (GAA). Understanding cardiac mechanics in this population is crucial, as altered mechanics can have profound consequences for cardiac function and exercise capacity. The GAA has been associated with changes in ventricular function, hemodynamics, and exercise capacity. Studies have shown a correlation between the GAA and decreased ascending aorta distensibility, loss of systolic wave amplitude across the aortic arch, and adverse cardiovascular outcomes. Various imaging techniques, including echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography, play a crucial role in assessing cardiac mechanics and evaluating the GAA anomaly. Despite significant advancements, gaps in knowledge regarding the prognostic implications and underlying mechanisms of the GAA anomaly remain. This review aims to explore the implications of the GAA anomaly on cardiac mechanics and its impact on clinical outcomes in young patients after ASO. Advancements in imaging techniques, such as computational modeling, offer promising avenues to enhance our understanding of cardiac mechanics and improve clinical management.
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Affiliation(s)
- Valeria Pergola
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua.
| | - Martina Avesani
- Pediatric Cardiology Unit, Department of Woman's and Child's Health, University Hospital of Padua, University of Padua.
| | - Elena Reffo
- Pediatric Cardiology Unit, Department of Woman's and Child's Health, University Hospital of Padua, University of Padua.
| | | | | | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua.
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua.
| | - Raffaella Motta
- Radiology Unit, Department of Cardiac, Thoracic and Vascular Sciences, and Public Health, University of Padua.
| | - Giovanni Di Salvo
- Pediatric Cardiology Unit, Department of Woman's and Child's Health, University Hospital of Padua, University of Padua.
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