Coarctation: the search for the Holy Grail

Comparative Analysis of Surgical and Endovascular Approaches for Isolated Aortic Coarctation Repair across Age Groups: Outcomes and Long-Term Efficacy

Background: Aortic coarctation, a condition characterized by localized narrowing of the aorta, can be managed with either surgical or endovascular techniques. This study aims to compare these approaches concerning long-term outcomes, particularly re-coarctation rates and late arterial hypertension. Methods: We retrospectively analyzed data from patients with native, isolated aortic coarctation treated by surgical or endovascular methods between 2015 and 2024. Clinical and demographic data were collected from electronic health records. Blood pressure was measured using oscillometric devices, and transthoracic echocardiography (TTE) was performed by an experienced sonographer. The primary endpoint was to identify which treatment predicted re-coarctation during follow-up, while the secondary endpoint assessed the incidence of late arterial hypertension. Results: Sixty-nine patients were included, with a mean age of 18.14 ± 8.18 years (median 16 years; range 8 to 37 years) and a median follow-up of 3 years (range 6 months to 8 years). Of these, 67 (97.1%) underwent elective repairs. Repair techniques included endovascular treatment (24.6%), surgical end-to-end anastomosis (47.8%), and surgical patchplasty (27.5%). The endovascular group was significantly older (29.82 ± 5.9 years vs. 14.33 ± 4.25 years, p = 0.056) and had shorter procedure durations and hospital stays. One-year freedom from reintervention was significantly higher in the surgical group (98.7%) compared to the endovascular group (88.23%) (p < 0.001). Conclusions: Both techniques effectively treat aortic coarctation, but surgical repair offers better long-term outcomes, while endovascular repair provides shorter recovery times. These findings should inform the choice of treatment modality based on patient-specific factors and clinical priorities.

Impact of complex congenital heart disease on the prevalence of arterial hypertension after aortic coarctation repair

OBJECTIVES

This study was designed to evaluate the difference in the prevalence of long-term arterial hypertension among patients with corrected aortic coarctation according to the existence of associated cardiac congenital lesions.

METHODS

We identified 235 patients who had undergone surgery for aortic coarctation and classified them into 2 groups: patients with isolated coarctation of the aorta (CoA) and patients with aortic coarctation associated with complex congenital heart disease. Data were retrospectively analysed.

RESULTS

There were 148 subjects with isolated CoA and 87 with complex CoA (CoA-c). Patients were defined as hypertensive if they required antihypertensive treatment and/or when blood pressure was above 95th percentile. Patients with isolated aortic coarctation were significantly younger than patients with CoA-c (P < 0.001) and a markedly higher prevalence of arterial hypertension (44% vs 24%) was documented in the isolated coarctation group. The difference in the prevalence of hypertension in the 2 groups was still significant after correcting for differences in age (P < 0.001), confirming that the prevalence of arterial hypertension in patients with CoA-c was half of that of patients with isolated CoA.

CONCLUSIONS

We conclude that complex congenital heart disease in patients who have undergone surgical correction for aortic coarctation results in a significantly lower prevalence of late-onset hypertension. Reduced systemic flow and pressure before surgery in patients with CoA-c might be associated with a lower rate of arterial hypertension.

Primary surgical repair of coarctation of the aorta in adolescents and adults: intermediate results and consequences of hypertension

OBJECTIVES

Coarctation of the aorta is known to present with hypertension in older patients; we reviewed our experience and assessed the outcome of hypertension following surgical correction.

METHODS

From April 2004 to date, 43 patients above the age of 12 underwent coarctation of the aorta repair. The mean age was 20.4 + 9.7 years (maximum 56 years); 21 (48.8%) were older than 18 years and 28 (65.1%) were men. Thirty (69.8%) patients had hypertension. Fourteen (32.6%) had a bicuspid aortic valve; 11 (25.6%) had patent ductus arteriosus; 6 (14%) had myxomatous mitral valve; 4 (9.3%) had ascending aortic aneurysms; and 2 (4.7%) had descending aneurysms.

RESULTS

Surgical correction included resection and interposition of a tube graft in 31 (72.1%), an end-to-end anastomosis in 6 (14%) and patch aortoplasty in 3 (7%). Three (7%) patients required an extra-anatomical bypass: 1 had a long segment coarctation of the aorta, and 2 had a Bentall procedure with an ascending-to-descending aortic bypass. Staged procedures were done for concomitant disease in 4 (9.3%). There was 1 death: a 56-year-old woman died of refractory ventricular fibrillation during surgery. Thirty (69.8%) patients were discharged with antihypertensive medication. At a follow-up of 2.8 ± 2.2 years (maximum 9.2 years), the number of hypertensive patients decreased (17/36; 47.2%) (P = 0.042). Univariable predictors for persistence of hypertension revealed the use of an interpositional tube graft for repair (odds ratio 13.855, confidence interval 0.000-0.001; P = 0.001) as an indicator, whereas there were no independent predictors for persistence of hypertension.

CONCLUSIONS

Surgical intervention is warranted irrespective of age and helps correct and control hypertension better; however, significant numbers of patients still require antihypertensive medication and regular monitoring. Intervention using an interposition tube graft may affect the prevalence of hypertension.

Long-Term Outcomes of Coarctation Repair Through Left Thoracotomy

BACKGROUND

Optimal surgical approach for repair of coarctation of the aorta (CoA) remains controversial. This study aimed to evaluate reintervention rates and its predictors by using a strategy of resection with extended end-to-end anastomosis (REEEA) through left thoracotomy.

METHODS

A retrospective analysis was performed for all patients who underwent isolated CoA repair or simultaneous repair of CoA and ventricular septal defect repair by REEEA between January 2000 and December 2015 at Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. Patients with complex congenital heart disease were excluded. Transverse arch hypoplasia was defined as echocardiographic z-score lower than -2 or by documentation in medical or operative reports. Reintervention was defined as the need for balloon angioplasty or reoperation. Hypertension was defined as antihypertensive medication use or blood pressure greater than or equal to the 95th percentile.

RESULTS

A total of 251 patients with median age at repair of 14.6 days met inclusion criteria. Repair was by left thoracotomy in 226 (90%). Follow-up data were available for 186 of 251 patients, with median follow-up time of 5.4 years (range, 0.2 to 15.3 years); 169 (91%) of these patients underwent thoracotomy. There were no early deaths or early reoperations. A proximal transverse arch z-score lower than -4.1 or a distal transverse arch z-score of less than -2.8 was predictive of repair through sternotomy. Only 4 (2%) patients required reintervention (2 patients had balloon angioplasties, 2 had reoperations). Transverse arch hypoplasia was a risk factor for reintervention (p = 0.048), but surgical approach was not (p = 0.35). Late hypertension was identified in only 33 of 186 (18%) patients.

CONCLUSIONS

Repair of CoA, even with associated transverse arch hypoplasia, by REEEA through left thoracotomy has a low mortality, low reintervention rate, and low incidence of late hypertension.

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.

Mid-term results, and therapeutic management, for patients suffering hypertension after surgical repair of aortic coarctation

We designed our study to investigate the efficacy of a new therapeutic approach to late onset hypertension in patients after surgical repair of aortic coarctation. Several studies have shown a higher incidence of hypertension during daily activities, and during exercise, in patients after surgical correction of coarctation. To the best of our knowledge, however, no data exists concerning haemodynamics, the response of arterial pressures, and the effects of medications for lowering blood pressure during exercise or during daily activities.We studied 128 patients, aged 15.6 +/- 4.3 years, to determine the response of blood pressure as we administered treatment in the attempt to achieve a normotensive state. We excluded patient with associated cardiac abnormalities, apart from those with bicuspid aortic valves. We evaluated blood pressure at rest in both the right arm and leg to establish presence of any gradient, as well as the blood pressure in the arm during exercise testing, and by 24-hour ambulatory monitoring.Atenolol was prescribed for those with elevated values of blood pressure but with a normal increment of heart rate during exercise. We prescribed Candesartan for those with elevated levels of blood pressure but with reduced increments of heart rate, specifically maximal heart rates of less than 85% of their predicted value. Both drugs were used when one alone was not effective. We found that, in young patients, candesartan provided better control of blood pressure with no side-effects, especially as demonstrated using 24-hour ambulatory monitoring, while atenolol was less effective, with more side-effects. Our experience suggests that both drugs should be used in patients who are non-responsive to monotherapy.

Coarctation of the aorta: a case presentation

Coarctation is a constriction or narrowing of the aorta and presents most commonly within the first two weeks of life. This article reviews a case study of an infant diagnosed with coarctation of the aorta on day 8 of life. It includes an overview of the etiology, clinical presentation, and management plus an account of the infant's transport to a regional pediatric intensive care unit (PICU).

Muscle-Sparing Extrapleural Approach for the Repair of Aortic Coarctation

BACKGROUND

This paper describes a muscle-sparing, extrapleural approach to repair aortic coarctation, and evaluates the results with established standards.

METHODS

Forty consecutive patients with aortic coarctation (median age, 8 days; weight, 3.3 kg) were approached with a less invasive technique consisting of a short posterior thoracotomy, with only minimal (24 patients) or no (16 patients) division of thoracic wall muscles and a subperiosteal-extrapleural approach. Extended resection of the coarctation with enlargement of the distal aortic arch was performed in all patients. The median cross-clamp and operative times were 22 and 90 minutes, respectively.

RESULTS

The repair was possible in all patients without needing conversion. There was no intraoperative or postoperative related complication. Two patients died early of low cardiac output as a result of ventricular fibroelastosis and respiratory failure. One patient died late of unrelated cause. The perioperative mean gradients across the neoarch were less than 5 mm Hg in all but 3 patients with proximal (2 patients) or mid arch (1) stenosis. The median ventilation time, intensive care unit stay, and hospital stay in isolated coarctation repairs was 2, 4.5, and 11 days, respectively. One patient had a recurrent stenosis at the site of surgical repair. Two patients underwent successful balloon dilatation, and 2 had surgical enlargement plasty of the proximal aortic arch at the time of intracardiac repair. None of the patients required chronic antihypertensive medication. At 29 months, freedom from reintervention on the isthmus and arch plus isthmus was 97.1% and 89.7%, respectively.

CONCLUSIONS

A muscle-sparing, extrapleural approach for the repair of aortic coarctation is possible and provides results similar to conventional techniques. The approach reduces postoperative morbidity related to division of thoracic wall muscles and handling of the lung, restores a normal intercostal space, and produces superior cosmetic results, while at the same time leading to early and permanent relief of proximal hypertension.

The influence of different surgical procedures on hypertension after repair of coarctation

We measured resting and exercise haemodynamics, as well as 24-hour ambulatory blood pressure, so as to study the influence on development of hypertension in children after repair of coarctation by either construction of a subclavian flap or end-to-end anastamosis. The patients in both groups were studied a mean time of 13 years after surgery. Thus, we divided 43 children who had undergone surgical repair of coarctation, and who were not on antihypertensive therapy, into a group of 22 patients who had undergone subclavian flap repair, with a mean age of 14 plus or minus 2.6 years, and another group of 21 patients undergoing end-to-end anastomosis, with a mean age of 13.5 plus or minus 3.9 years. We examined blood pressure at rest and during exercise, along with the measurement of cardiac output using impedance cardiography, and during 24-hour ambulatory monitoring. We recorded systolic and diastolic blood pressures, pulse pressure, cardiac output and total peripheral vascular resistance at rest and at peak exercise. During ambulatory monitoring, we measured mean pressures over 24 hours, in daytime and nighttime, 24-hour pulse pressure, and 24-hour mean arterial pressure. Student's t test was used to judge significance, accepting this when p was less than 0.05. The group repaired using the subclavian flap showed significantly disadvantageous differences for diastolic blood pressure at rest, systolic blood pressure at peak exercise and for 24-hour systolic and diastolic blood pressure, 24-hour mean arterial pressure, and daytime and nighttime systolic blood pressure during ambulatory monitoring. Our findings suggest that, after repair using the subclavian flap in comparison to end-to-end anastomosis, patients show a higher incidence of late hypertension, both during exercise and ambulatory monitoring. The data indicate different residual aortic stiffnesses, these being lower after end-to-end anastomosis, which may be due to the greater resection of the abnormal aortic tissue when coarctation is repaired using the latter technique.

Surgery for complex coarctation of the aorta

The application of improved surgical techniques to correct coarctation in the neonate and infant may in the longterm reduce the incidence of recoarctation in the adult. In addition, in many cases, catheter-based intervention offers an alternative to reoperation and the role of catheter-based intervention is likely to be extended with the introduction of improved technology. However, surgery is likely to be required in coarctation and recoarctation in the adult in some cases, particularly those with hypoplasia of the aortic arch, aneurysms of the ascending aorta and those with intracardiac pathology. Operation for primary coarctation in the adult can be performed through a left thoracotomy without significant postoperative morbidity. However, this is not the case with recoarctation where reoperation through a left thoracotomy has resulted in a high incidence of postoperative complications including residual coarctation, false aneurysm and recurrent laryngeal nerve palsy. Repair through a median sternotomy offers an alternative surgical approach to recoarctation which avoids these complications and allows concomitant procedures for problems associated with arteriopathy, aortic valve disease and other associated intracardiac anomalies. The approach to coarctation and recoarctation in the adult should be tailored to individual patients and made after careful discussion with interventional cardiologists.