Surgical versus balloon therapy for aortic coarctation in infants < or = 3 months old

Effect of coarctation of aorta anatomy and balloon profile on the outcome of balloon angioplasty in infantile coarctation

OBJECTIVE

Coarctation of the Aorta (CoA) is a relatively common cardiovascular disorder. The present study aimed to evaluate the effect of COA anatomy and high versus low-pressure balloons on the outcome of balloon angioplasty among neonates and infants.

METHODS

In this retrospective study, the neonates and infants undergoing balloon angioplasty at Namazi hospital were enrolled. After balloon angioplasty, immediate data results were promptly recorded.Moreover, midterm echocardiographic information was collected via electronic cardiac records of pediatric wards and clinical and echocardiographic data at least 12 months after balloon angioplasty. Finally, data were analyzed using SPSS-20.

RESULTS

In this study, 42 infants were included. The median age at the time of balloon angioplasty was 1.55 (range 0.1-12) months and 66.7% of the patients were male. The mean pressure gradient of coarctation was 38.49 ± 24.97 mmHg, which decreased to 7.61 ± 8.00 mmHg (P < 0.001). A high-pressure balloon was used in 27, and a low-pressure balloon was used in 15 patients. COA's pressure gradient changed 30.89 ± 18.06 in the high-pressure group and 24.53 ± 20.79 in the low-pressure balloon group (P = 0.282). In the high-pressure balloon group, 14.81% and in the low-pressure group, 33.33% had recoarctation and need second balloon angioplasty (p < 0.021). The infant with discrete coarctation had a higher decrease in gradient and lower recoarctation.

CONCLUSION

Recoarctation rate was lower in the high-pressure balloon. The infant with discrete COA had a better response to the balloon with more decrease in gradient and lower recoarctation rate. Therefore, the stenotic segment anatomy needs to be considered in the selection of treatment methods.

Balloon Angioplasty for Native Aortic Coarctation in 3- to 12-Month-Old Infants

BACKGROUND

Balloon angioplasty for native coarctation of the aorta (CoA) is successful in children and adults but in neonates results in frequent restenosis. The efficacy of balloon angioplasty for native CoA during infancy beyond the neonatal period was examined in infants aged 3 to 12 months of age.

METHODS

A retrospective review of 68 infants who underwent balloon angioplasty for native CoA. 95% CI are in parentheses.

RESULTS

Procedural age was (mean±SD) 6±3.4 months and weight was 7±1.8 kg. Balloon angioplasty produced a large decrease in both the noninvasive arm-to-leg blood pressure gradient (41.2±18.7 to 5.6±9.6 mm Hg) and the invasive peak systolic pressure gradient (34±12 to 11±9 mm Hg). Balloon angioplasty increased the CoA diameter from 2.7±1 mm to 4.6±1.2 mm. One patient was lost to follow-up. A catheter reintervention was required in 11.8% and surgery in 10.3%. The hazard of reintervention was highest early. Median freedom from reintervention was 89% (95% CI, 80%-96%) at 1 year, 83% (95% CI, 73%-92%) at 5 years, and 81% (95% CI, 69%-90%) at 10 years. Femoral artery thrombosis was documented in 6 (9%) infants without any long-term consequence. One patient developed a small aortic aneurysm late and has not required treatment. A robust estimate of the frequency of aortic aneurysms remains to be determined as the majority of subjects have not had cross-sectional imaging.

CONCLUSIONS

Balloon angioplasty of native CoA is effective and safe in infants aged 3 to 12 months with outcomes comparable to those in older children and adults. Catheter reinterventions can avoid the need for surgery in most patients.

Transcatheter cardiac interventions in neonates with congenital heart disease: A single centre experience

Objective

Percutaneous cardiac catheterization has been used as a diagnostic tool and as a therapeutic option in neonates with congenital heart disease (CHD). This study aimed to evaluate the procedural and short-term follow-up data of newborns who underwent cardiac catheterization procedures.

Methods

This retrospective study reviewed demographic, diagnostic and clinical data from the medical records of newborns who underwent percutaneous transcatheter interventions to treat CHD.

Results

Forty-six newborns were included in the study. The median gestational week and weight were 35.0 weeks and 2723 g, respectively. The median time to the procedure was 7.6 days. Aortic and pulmonary balloon valvuloplasty, ductal stenting, atrial balloon/blade septostomy and coronary fistula embolization procedures were used. The overall success rate was 73.9% (34 of 46 patients) with a complication rate of 28.3% (13 of 46 patients). Eleven patients (23.9%) underwent reinterventions after initial catheterization. Five patients (10.9%) died in the first 48 h after their procedures.

Conclusions

Interventional cardiological procedures applied during the neonatal period provide alternative life-saving methods to surgery, especially in developing countries where surgical outcomes are poor and newborn mortality rates are high.

The Journey of an Indian Pediatric Cardiologist : Dr. K. C. Chaudhuri Lifetime Achievement Award/Oration at AIIMS, New Delhi, September 2017

The life journey of an Indian pediatric cardiologist, who bestowed considerable attention to the development of new knowledge and train/teach physicians around the world while providing care of patients with heart disease over a 45-y period, is reviewed. This appraisal focuses particular attention on the scientific contributions to the literature. These include spontaneous closure of physiologically advantageous ventricular septal defects, various issues related to a congenital heart defect namely, tricuspid atresia and transcatheter and, interventional pediatric cardiac procedures.

Therapeutic Utilities of Pediatric Cardiac Catheterization

In an era when less invasive techniques are favored, therapeutic cardiac catheterization constantly evolves and widens its spectrum of usage in the pediatric population. The advent of sophisticated devices and well-designed equipment has made the management of many congenital cardiac lesions more efficient and safer, while providing more comfort to the patient. Nowadays, a large variety of heart diseases are managed with transcatheter techniques, such as patent foramen ovale, atrial and ventricular septal defects, valve stenosis, patent ductus arteriosus, aortic coarctation, pulmonary artery and vein stenosis and arteriovenous malformations. Moreover, hybrid procedures and catheter ablation have opened new paths in the treatment of complex cardiac lesions and arrhythmias, respectively. In this article, the main therapeutic utilities of cardiac catheterization in children are discussed.

Recurrent coarctation: interventional techniques and results

Coarctation of the aorta (CoA) accounts for 5% to 8% of all congenital heart defects. With all forms of interventions for native CoA, repeat intervention may be required due to restenosis and/or aneurysm formation. Restenosis rates vary from 5% to 24% and are higher in infants and children and in those with arch hypoplasia. Although repeat surgery can be done for recurrent CoA, guidelines from a number of professional societies have recommended balloon angioplasty with or without stenting as the preferred intervention for patients with isolated recoarctation. For infants and young children with recurrent coarctation, balloon angioplasty has been shown to be safe and effective with low incidence of complications. However, the rates of restenosis and reinterventions are high with balloon angioplasty alone. Endovascular stent placement is indicated, either electively in adults or as a bailout procedure in those who develop a complication such as dissection or intimal tear after balloon angioplasty. Conventionally bare metal stents are used; these can be dilated later if required. Covered stents, introduced more recently, are best reserved for those who have aneurysm at the site of previous repair or who develop a complication such as aortic wall perforation or tear. Stents produce complete abolition of gradients across the coarct segment in a majority of cases with good opening of the lumen on angiography. The long-term results are better than that of balloon angioplasty alone, with very low rates of restenosis. However, endovascular stenting is a technically demanding procedure and can be associated with serious complications rarely.

Percutaneous balloon angioplasty for severe native aortic coarctation in young infants less than 6 months: medium- to long-term follow-up

Background:

Although balloon angioplasty (BA) has been performed for more than 20 years, its use as a treatment for native coarctation of the aorta (CoA) during childhood, especially in young infants, remains controversial. This study aimed to assess the effects and potential role of percutaneous transcatheter BA for native CoA as an alternative therapy to surgical repair in young infants.

Methods:

The 37 patients aged from 6 days to 6 months with severe CoA in congestive heart failure or circulatory shock were admitted for BA. Patient's weight ranged from 2.4 to 6.1 kg. All 37 patients were experiencing cardiac dysfunction, and eight patients were in cardiac shock with severe metabolic acidosis. Eleven patients had an isolated CoA, whereas the others had a CoA associated with other cardiac malformations. Cardiac catheterization and aortic angiography were performed under general anesthesia with intubation. Transfemoral arterial approaches were used for the BA. The size of the balloon ranged from 3 mm × 20 mm to 8 mm × 20 mm, and a coronary artery balloon catheter was preferred over a regular peripheral vascular balloon catheter.

Results:

The femoral artery was successfully punctured in all but one patient, with that patient undergoing a carotid artery puncture. The systolic peak pressure gradient (PG) across the coarctation was 41.0 ± 16.0 mmHg (range 13–76 mmHg). The mean diameter of the narrowest coarctation site was 1.7 ± 0.6 mm (range 0.5–2.8 mm). All patients had successful dilation; the PG significantly decreased to 13.0 ± 11.0 mmHg (range 0–40 mmHg), and the diameter of coarctation significantly improved to 3.8 ± 0.9 mm (range 2.5–5.3 mm). No intraoperative complications occurred for any patients. However, in one case that underwent a carotid artery puncture, a giant aneurysm formed at the puncture site and required surgical repair. The following observations were made during the follow-up period from 6-month to 7-year: (1) The PG across the coarctation measured by echocardiography further decreased or remained stable in 31 cases. The remaining six patients, whose PGs gradually increased, required a second dilation. No patient required further surgery because of a CoA; (2) in two cases, an aortic aneurysm was found with an angiogram performed immediately postdilatation and disappeared at 18 and 12 months of age, respectively; (3) tricuspid regurgitation and pulmonary hypertension improved in all patients; (4) all patients were doing well and were asymptomatic.

Conclusions:

Percutaneous BA is a relatively safe and effective treatment for severe native CoA in young infants, and should be considered a valid alternative to surgery because of its good outcome and less trauma and fewer complications than surgery.

Severe coarctation of the aorta in a 900 g donor of twin-twin transfusion newborn with successful repeated transcatheter angioplasty: a case report

We present a case of severe aortic coarctation in a donor of twin-twin transfusion syndrome. Patients underwent two angioplasty procedures at age 7 and 47 days, weighing 900 and 1500 g, respectively. Umbilical artery approach was used in the first procedure, and femoral artery approach was used in the second. Follow-up at the age of 13 months showed no recurrence of coarctation.

Coarctation of the aorta: management, indications for intervention, and advances in care

OPINION STATEMENT

Coarctation of the aorta (CoAo) accounts for 9 % of congenital heart defects. Balloon angioplasty has been the conventional endovascular treatment of choice for both native and recurrent coarctation in adults. Recent advancement in stent technology with the development of the covered stents has enhanced the scope for percutaneous management of both native CoAo and post-surgical CoAo. Stent implantation provides better hemodynamic results with larger acute diameter gain and better long-term hemodynamic benefit. Stenting also decreases the incidence of aneurysm formation. The development of biodegradable stents may revolutionize the percutaneous management of coarctation, as the degradation of the stent scaffold within 6 months of implantation will further decrease the incidence of restenosis. In the future stenting may suffice and obviate the need for open repair. Until then, surgical repair of CoAo is the preferred method in both infants and complicated lesions, leaving stenting to adults with focal and uncomplicated disease.

Endovascular management of coarctation of the aorta

Untreated thoracic aortic coarctation leads to early death predominantly because of hypertension and its cardiovascular sequelae. Surgical treatment has been available for > 50 years and has improved hypertension and survival. More recently, endovascular techniques have offered a minimally invasive alternative to traditional open repair. Early and intermediate results suggest angioplasty and stenting have an important role in the management of aortic coarctation, particularly in adults and older children.

Uncommon congenital and acquired aortic diseases: role of multidetector CT angiography

State-of-the-art multidetector computed tomographic (CT) technology has replaced invasive angiography for evaluation of patients suspected to have aortic disease. Although most aortic disease is associated with atherosclerosis (ie, aneurysms and dissection), the spectrum of aortic disease is vast and includes various congenital and acquired entities. Radiologists should also be familiar with uncommon aortic diseases, which are divided into those that are congenital in origin and acquired disorders, and with their findings at multidetector CT. The first group includes patent ductus arteriosus, aortic hypoplasia, aortic coarctation, interrupted aortic arch, aortopulmonary window, common arterial trunk, supravalvular aortic stenosis, and vascular rings. The acquired disorders include aortic dissection due to extension of a coronary artery dissection, Marfan syndrome, large-vessel vasculitis such as Takayasu arteritis, and mycotic aneurysms. Finally, specific conditions associated with therapeutic maneuvers--such as recoarctation, stent-graft rupture, and endoleaks--can also be assessed with multidetector CT. Multidetector CT is an alternative tool helpful in establishing the primary diagnosis, defining anatomic landmarks and their relationships, and identifying associated cardiovascular anomalies. It is also an adjunct in the evaluation of complications during follow-up.

Balloon angioplasty for native coarctation of the aorta in neonates and infants with congestive heart failure

BACKGROUND

Balloon angioplasty (BA) is an alternative to surgical repair for coarctation of the aorta (CoA) in children. However, its role in the treatment of native CoA in neonates and infants remains controversial. The purpose of this study was to report the midterm outcomes of BA for native CoA in neonates and infants with congestive heart failure (CHF).

METHODS

Between July 2000 and March 2007, 18 neonates and infants with native CoA and CHF who underwent BA were enrolled. Patients without recoarctation were designated as group A, while those with recoarctation or CHF were designated as group B. The clinical presentations, laboratory data, and outcomes were compared between groups.

RESULTS

There were 10 patients in group A and eight in group B. The mean age was 2.8 +/- 3.1 months (range, 0.7-11 months). Mean body weight was 4.0 +/- 1.9 kg (range, 2.1-8.0kg). CHF improved markedly in all patients immediately after BA, with a reduction in systolic pressure gradient from 36.4 +/- 12.0 to 5.6 +/- 6.0 mmHg (p < 0.001). The recoarctation rate was 44% (8/18). The risk factors for restenosis were post-BA systolic pressure gradient >10 mmHg (p = 0.007) and CoA diameter <3 mm (p = 0.013).

CONCLUSIONS

The outcomes of BA for native CoA in neonates and infants with CHF remain poor. The incidence of recoarctation is high in neonates and patients whose post-BA systolic pressure gradient is >10 mmHg or whose CoA diameter is <3 mm.

Percutaneous treatment of neonatal aortic coarctation presenting with severe left ventricular dysfunction as a bridge to surgery

BACKGROUND

Neonatal aortic coarctation presenting with multiorgan failure is a life threatening condition.

OBJECTIVE

Our aim was to investigate whether emergency balloon dilation improved the prognosis of neonates with aortic coarctation who present with multiorgan failure.

METHODS

We studied all neonates referred over a period of 6 years with aortic coarctation and left ventricular dysfunction, with or without multiorgan failure. During the first half of the period, from January, 2001 to December, 2003, patients were treated surgically after regression of the multiorgan failure. During the second half, from January, 2004, to January, 2007, patients not responding to medical management were referred for balloon dilation of the coarcted segment.

RESULTS

Among 113 and 181 neonates, respectively, treated during the 2 periods, 40 and 36 had left ventricular dysfunction (p less than 0.01), and 11 and 23 had multiorgan failure (p less than 0.01). Prior to 2004, 6 deaths occurred before surgery. After 2004, 3 out of 14 patients (21%) treated by balloon angioplasty died in consequence of the procedure.During the period of the study, the global mortality of patients with left ventricular dysfunction diminished from 17.5 to 13.8%, this difference not being statistically significant. Mortality due to multiorgan failure, however, diminished from 54 to 13% (p less than 0.01). Multiorgan failure was reversed under medical treatment in 45% of patients, but in 87% under the regime of medical combined with interventional treatment (p less than 0.01).

CONCLUSIONS

To the best of our knowledge, this is the first series of neonates with aortic coarctation and multiorgan failure receiving a palliative treatment by balloon dilation. Although the prognosis of this condition remains severe, emergency balloon dilation can diminish mortality, providing a bridge to surgery in severely ill patients.

Safety and efficacy of low-profile balloons in native coarctation and recoarctation balloon angioplasty for infants

Background Traditionally, high-profile/high-pressure balloons have been used for angioplasties, whereas low-profile/low-pressure balloons have been used for valvuloplasties. High-profile balloons require larger introducing sheaths, which can be a limiting factor for percutaneous catheter interventions in infants. This report aims to report the author's experience with the efficacy of low-profile balloons using smaller introducing sheaths for coarctation balloon angioplasty in infants. Methods From April 2004 to April 2008, 15 infants, representing both native coarctation and recoarctation indications, underwent coarctation balloon angioplasty and were retrospectively reviewed. The arterial access was achieved using 4-Fr (Cook) introducing sheaths and Tyshak (NuMED, Hallenweg-Netherlands) balloons 5 to 8 mm in diameter for coarctation angioplasty in the study group. Results In this study, 15 infants (7 with native coarctation and 8 with postoperative recoarctation) underwent balloon angioplasty. These infants ranged in age from 2 to 9 months (median, 4 months) and in weight from 3.5 to 10.8 kg (median, 5.7 kg). The peak-to-peak coarctation gradient was reduced from 46.2 +/- 28 mmHg before angioplasty to 10 +/- 8 mmHg afterward (p = 0.001). The angiographic diameter of the coarctation segment was increased from 2.4 +/- 1.0 mm before angioplasty to 5 +/- 0.8 mm afterward (p = 0.001). There were no immediate major or minor complications. During a follow-up period up to 48 months, only one patient from the native coarctation group experienced recoarctation and underwent successful reballooning, and none of the patients experienced aneurysms. Conclusion This study shows that the use of low-profile/low-pressure balloons is an effective treatment for infants. Furthermore, low-profile balloons required smaller introducing sheaths, which provides a clear advantage of minimizing vascular complications with coarctation ballooning in younger infants.

Balloon angioplasty of native coarctation and comparison of patients younger and older than 3 months

BACKGROUND

There is a high incidence of restenosis and aneurysm formation after balloon angioplasty for discrete native coarctation in neonates and young infants, and so the techniques remains controversial in this group of patients because its clinical validity, particularly in comparison with surgery, has not been well established.

METHODS AND RESULTS

From January 1999 to October 2005, group A (17 patients [8 males, 9 females] <3 months old ranging from 0.2 to 2.9 months, with a body weight of 2.5-5.5 kg) and group B (11 patients [5 males, 6 females] >3 months old ranging from 5.5 months to 6.4 years, with a body weight of 7.8-21 kg) with discrete native coarctation who underwent balloon angioplasty and were included in this study. There were 13 (76%) successes in group A, and 10 (90%) successes in group B for the initial balloon angioplasty. There was no significant difference in success rate between groups A and B (p>0.05). There were 9 (69%) cases of restenosis patients in group A, and 2 (20%) in group B, a significant difference between the 2 groups (p<0.05). In group A, 1 patient showed aneurysm formation after angioplasty, 1 (5.8%) showed femoral artery obstruction and 2 (11%) showed reduced pulses.

CONCLUSIONS

Balloon angioplasty of discrete native coarctation is effective in patients both younger and older than 3 months. However, thea rates of restenosis, aneurysm formation, and approach artery injury are higher in patients younger than 3 months old when compared with patients aged over 3 months. These complications should be considered when performing balloon angioplasty in patients less than 3 months of age.

Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients > or = 1 year old. The Quebec Native Coarctation of the Aorta study

BACKGROUND

The objectives of this study were to compare, in the current era, the immediate results, complications, and midterm outcomes obtained by surgical repair versus transcatheter treatment of coarctation of the aorta (CoA).

METHODS

The study was of retrospective nature and included 80 consecutive patients > or = 1 year old (mean age 12 +/- 10 years) treated for an isolated CoA in 4 university centers in Quebec between 1998 and 2004. Fifty patients underwent aortic angioplasty, with stent implantation in 19, and 30 had surgical repair. Immediate results, procedural complications, clinical events, and the incidence of aortic aneurysm at follow-up were compared between groups.

RESULTS

There were no differences between the 2 groups in clinical baseline characteristics. Percentage reduction in peak systolic pressure gradient across the coarctation was similar between the 2 groups (angioplasty 72% +/- 23% vs surgery 75% +/- 18%, P = .55). Procedure-related complications occurred more frequently after surgical repair compared with angioplasty (50% vs 18%, P = .005), and median hospitalization time was longer in the surgical than in the angioplasty group (7 vs 1 day, P < .001). At 38 +/- 21 months' follow-up, no patient in the surgical group and 16 patients in the angioplasty group had at least 1 aortic reintervention (0% vs 32%, P < .0001). The presence of an aortic aneurysm was diagnosed more frequently in the angioplasty group compared with the surgical group (24% vs 0%, P = .01).

CONCLUSION

Aortic angioplasty provided comparable immediate hemodynamic results to surgery, with reduced morbidity and hospitalization length for the treatment of CoA in patients > or = 1 year old. However, angioplasty was associated with a higher rate of reintervention and aneurysm formation at a mean follow-up of 3 years.

Intraluminal aortoplasty vs. surgical aortic resection in congenital aortic coarctation. A clinical random study in pediatric patients

BACKGROUND

Our objective was to compare results of two therapeutic modalities to treat congenital aortic coarctation: intraluminal aortoplasty without endoluminal stent installation (patients in group A) vs. surgical aortic resection (patients in group B). Trans-coarctation gradient pressure was evaluated prior to and immediately after treatment. Re-coarctation, aneurysm formation, in-hospital morbidity and mortality, and complications related to treatment were also evaluated.

METHODS

A clinical, randomized, multicenter study was performed in pediatric patients with congenital aortic coarctation. Immediate and mid- to late therapeutic results were evaluated. With regard to statistics, we evaluated event variations by Kaplan-Meier model, nonparametric Wilcoxon test, Mann-Whitney U test, two-tailed Student t and chi-square tests, and Fisher analysis. Significance was considered relevant when p<0.05.

RESULTS

There were no differences in demographic variables, procedure failure, complications, mortality, or aortic aneurysm between groups A and B, respectively. Intraluminal angioplasty and surgical aortic resection were similarly effective in reducing trans-coarctation pressure gradient, as well as arterial systemic pressure. However, differences were found between groups A and B at follow-up. Group A showed higher re-coarctation (50 vs. 21%). Absence of peripheral arterial pulses in limbs was higher in group A (50 vs. 21%), as well as persistence of arterial hypertension (49 vs. 19%); these differences were significant (p<0.05). On the other hand, complications observed after surgical aortic resection were more serious than post-angioplasty complications, but these differences were not statistically significant.

CONCLUSIONS

Although re-coarctation and persistency of arterial hypertension were less frequent after surgical aortic resection, complications observed with this procedure are more serious than complications related to angioplasty, although these differences are not statistically significant.

Balloon dilatation and stent implantation for vascular stenosis

BACKGROUND

Previous results show that the success rate of balloon angioplasty for pulmonary artery stenosis is low. Mortality and morbidity are significant in balloon angioplasty for coarctation of the aorta.

METHODS

A review of the experience of balloon angioplasty for pulmonary artery stenosis and coarctation of the aorta at our institution was performed. A review of scientific reports of balloon angioplasty for these lesions was investigated.

RESULTS

Review of our results indicates that balloon angioplasty for pulmonary artery stenosis can be performed with a high success rate (80-90%), (i) by performing it at an appropriate time, (ii) by using high-pressure balloons, (iii) by using stents, and (iv) by using intravascular ultrasound (IVUS). Major complications occurred in 3% at our institution in balloon angioplasty for pulmonary artery stenosis. Incomplete dilation has been noted in 10-25% of patients of coarctation of the aorta. Aortic aneurysm has been reported in 2-7% of patients. Re-stenosis and/or hypertension also occur. The re-stenosis rate may be decreased if the aorta is dilated until signs of intimal tear are observed. Systemic hypertension may be noted in the long term after balloon angioplasty of coarctation of the aorta, even in patients with fairly good anatomical repair. The mechanisms for hypertension are not clear, but residual stenosis, even mild, may result in upper body hypertension.

CONCLUSIONS

Although there are significant limitations in the procedures, balloon angioplasty is effective in the management of pulmonary artery stenosis and coarctation of the aorta.

Balloon angioplasty of native aortic coarctation in infants 3 months of age and younger

The use of balloon dilation to treat native aortic coarctation is controversial, particularly in infants. Between January 1991 and September 1996, 12 patients < or = 3 months of age with native coarctation of the aorta (CoA) underwent balloon angioplasty (BA). All 12 lesions were dilated successfully with a mean reduction in peak systolic gradient from 49.3 +/- 16.5 mm Hg to 6.8 +/- 4.0 mm Hg (p < 0.001) and a mean increase in minimum CoA diameter from 2.4 +/- 0.6 mm to 5.5 +/- 1.3 mm (p < 0.001). Intimal flaps or tears were detected immediately after BA in 4 (33%) of 12 patients by angiography and in 8 (89%) of 9 patients by intravascular ultrasonography. No deaths or major complications related to the BA occurred. One patient had documented asymptomatic femoral artery obstruction, and one patient with hydrops fetalis and congenital pleural effusions died with gram-negative sepsis 1 week after the procedure. Follow-up was available for 10 patients (1 was lost to follow-up) between 2 months and 4.1 years (mean 2.4 +/- 1.3 years) after BA. No patient had an aortic aneurysm. Restenosis occurred in 5 (50%) of 10 patients, requiring reintervention a mean of 2.6 +/- 2.1 months after BA. One patient underwent surgical repair. Repeat BAs were performed in the other four patients; three were successful, and one with partial gradient relief required surgical repair. Five patients have not required reintervention a mean of 2.9 +/- 1.0 years after the initial BA. Among these five patients, follow-up intravascular ultrasound performed in three patients a mean of 2.0 +/- 1.9 years after BA showed favorable endovascular remodeling. There was a tendency for early reintervention in patients < 1 month of age and coexistence of a patent ductus arteriosus at the time of BA. In conclusion, selected infants < or = 3 months of age with discrete native CoA may be treated initially with balloon dilation. Most patients who have restenosis respond successfully to repeat BA.

Successful balloon dilation of an abdominal coarctation of the aorta in patient with presumed Takayasu's aortitis

An 11-year-old male with a severe abdominal aortic coarctation, presumably secondary to aortitis, underwent successful percutaneous balloon dilation that resulted in near-complete relief of the obstruction. Intravascular ultrasound imaging showed a major endovascular tear immediately following dilation and satisfactorily excluded significant branch (superior mesenteric) artery compromise. Arterial remodeling was demonstrated with persistence of the gradient relief over a 12-month follow-up period.

Interventional cardiac catheterization therapy for combined coarctation of the aorta and patent ductus arteriosus: successful outcome in two infants

We report two infants each with coarctation of the aorta and small patent ductus arteriosus who had balloon angioplasty therapy for aortic obstruction at 3-6 months of age followed by anterograde placement of a single Gianturco coil to close the ductus at a separate catheterization. One infant developed recoarctation that resolved with repeat angioplasty prior to closure of the ductus. Follow-up evaluations have demonstrated a trivial aortic gradient, no aortic aneurysm, and no residual shunt.

Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children

OBJECTIVES

To evaluate the usefulness of balloon angioplasty for relief of native aortic coarctation, we reviewed our experience with this procedure, with special emphasis on follow-up results.

BACKGROUND

Controversy exists with regard to the role of balloon angioplasty in the treatment of native aortic coarctation.

METHODS

During an 8.7-year period ending September 1993, 67 neonates, infants and children underwent balloon angioplasty for native aortic coarctation. A retrospective review of this experience with emphasis on long-term follow-up forms the basis of this study.

RESULTS

Balloon angioplasty produced a reduction in the peak-to-peak coarctation gradient from 46 +/- 17 (mean +/- SD) to 11 +/- 9 mm Hg (p < 0.001). No patient required immediate surgical intervention. At intermediate-term follow-up (14 +/- 11 months), catheterization (58 patients) and blood pressure (2 patients) data revealed a residual gradient of 16 +/- 15 mm Hg (p > 0.1). When individual results were scrutinized, 15 (25%) of 60 had recoarctation, defined as peak gradient > 20 mm Hg. Recoarctation was higher (p < 0.01) in neonates (5 [83%] of 6) and infants (7 [39%] of 18) than in children (3 [8%] of 36), respectively. Two infants in our early experience had surgical resection with excellent results. Three patients had no discrete narrowing but had normal arm blood pressure and had no intervention. The remaining 10 patients had repeat balloon angioplasty with reduction in peak gradient from 52 +/- 13 to 9 +/= 8 mm Hg (p < 0.001). Reexamination 31 +/- 18 months after repeat angioplasty revealed a residual gradient of 3 to 19 mm Hg (mean 11 +/- 6). Three (5%) of 58 patients who underwent follow-up angiography developed an aneurysm. Detailed evaluation of the femoral artery performed in 51 (88%) of 58 patients at follow-up catheterization revealed patency of the femoral artery in 44 (86%) of 51 patients. Femoral artery occlusion, complete in three (6%) and partial in four (8%), was observed, but all had excellent collateral flow. Blood pressure, echocardiography-Doppler ultrasound and repeat angiographic or magnetic resonance imaging data 5 to 9 years after angioplasty revealed no new aneurysms and minimal (2%) late recoarctation.

CONCLUSIONS

On the basis of these data, it is concluded that balloon angioplasty is safe and effective in the treatment of native aortic coarctation; significant incidence of recoarctation is seen in neonates and infants; repeat balloon angioplasty for recoarctation is feasible and effective; and the time has come to consider balloon angioplasty as a therapeutic procedure of choice for the treatment of native aortic coarctation.

Balloon angioplasty for native coarctation of the aorta

Balloon angioplasty of native coarctations of the aorta is one of the most controversial facets of the pediatric interventional cardiologist's practice. We have evaluated the history and experimental rationale of this technology. Presently accepted techniques are outlined and controversies intrinsic in performance of this procedure are discussed. Acute, short-term, and long-term results are reviewed with particular emphasis on differences in success of the procedure as related to patient age. Common and significant complications are discussed and in some cases compared to analogous surgical complications. Newer technologies and approaches to interventional therapy for coarctation of the aorta are also discussed.

Balloon angioplasty for postoperative recurrent coarctation of the aorta

Surgical repair for recurrent or residual postoperative coarctation of the aorta is associated with some morbidity, mortality, and an incidence of recurrent coarctation that may be as high as 20%. Balloon angioplasty for recurrent or residual postoperative coarctation has become the standard treatment of choice for this condition. In this article, we review the protocol we use, and the acute and long-term results of this procedure. Since 1983, over 400 patients have undergone balloon angioplasty for recurrent coarctation with excellent immediate relief of the gradient and improvement in the diameter. On long-term follow-up, the majority of these patients enjoyed a lasting beneficial effect of the balloon angioplasty. We discuss the future use of stents for selected patients who are not amenable or failed balloon angioplasty of recurrent or residual postoperative coarctation.