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Kreuzer M, Sames-Dolzer E, Klapper M, Tulzer A, Mair R, Seeber F, Gierlinger G, Saric D, Mair R. The anatomic repair of recurrent aortic arch obstruction in children and adolescents. JTCVS OPEN 2024; 19:215-222. [PMID: 39015463 PMCID: PMC11247212 DOI: 10.1016/j.xjon.2024.04.007] [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: 01/15/2024] [Revised: 03/22/2024] [Accepted: 04/09/2024] [Indexed: 07/18/2024]
Abstract
Objective Surgery for recurrent aortic arch obstruction is highly challenging and publications are rare. The aim of this retrospective, single-center study was to evaluate mortality, complications, and reintervention rate after an anatomic repair. Methods Between 1999 and 2022, in total 946 operations on the aortic arch were performed at the Children's Heart Center Linz. In 39 cases, the indication was a recurrent or residual aortic arch obstruction or coarctation in a patient aged 18 years or younger. This is our study cohort. The aorta was reconstructed by a direct anastomosis/autograft in 20 patients, patch in 17 patients, and interposition graft in 2 adolescents. In 32 procedures, cardiopulmonary bypass with whole body perfusion was employed, in 4, antegrade cerebral perfusion was employed, in 2, a left heart bypass was employed, and in 1 no cardiopulmonary bypass was used. Results Median (Q1, Q3) age at operation was 253 days (100, 2198 days), weight 7.5 kg (4.5, 17.8 kg). Median cardiopulmonary bypass time was 177 minutes (115, 219 minutes), crossclamp time 73 minutes (49, 102 minutes). Three infants died during the hospital stay: 1 with Williams syndrome, 1 with hypoplastic left heart syndrome, and 1 with heterotaxia. There was no death due to an arch complication. The main complications were 1 neurologic injury after postoperative resuscitation (Williams syndrome) and 1 permanent recurrent laryngeal nerve paralysis. During the follow-up period of median 8.1 years (2.6, 12 years) 1 re-reintervention on the aortic arch was necessary. Conclusions Sophisticated reoperations on the aortic arch could be performed safely. In children, the growth potential of all segments of the aorta could be sustainably preserved by avoiding interposition or extra-anatomic bypass grafts.
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Affiliation(s)
- Michaela Kreuzer
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Eva Sames-Dolzer
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Melanie Klapper
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
| | - Andreas Tulzer
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Department of Pediatric Cardiology, Kepler University Hospital, Linz, Austria
| | - Roland Mair
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
| | - Fabian Seeber
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
| | - Gregor Gierlinger
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Dalibor Saric
- Department of Pediatric Cardiology, Klinički Bolnički Centar Zagreb, Zagreb, Croatia
| | - Rudolf Mair
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
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Hui C, Ren Q, Zhuang J, Chen J, Li X, Cui H, Cen J, Xu G, Wen S. Bronchus compression is a predictor for reobstruction in coarctation with hypoplastic arch repair. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad186. [PMID: 37991842 PMCID: PMC10681811 DOI: 10.1093/icvts/ivad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/13/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVES The surgical treatment of coarctation of aorta with hypoplastic aortic arch (CoA/HAA) was challenging to achieve long-lasting arch patency. We reviewed early and late outcomes in our centre and identified predictors for arch reobstruction. METHODS A retrospective analysis of medical records was performed to identify CoA/HAA patients who underwent primary arch reconstruction via median sternotomy between 2011 and 2020. Preoperative aortic arch geometry was analysed with cardiac computed tomographic angiography. Bedside flexible fibre-optic bronchoscopy was routinely performed after surgery in intensive care unit. RESULTS There were 104 consecutive patients (median age 39.5 days) who underwent extended end-to-end anastomosis, extended end-to-side anastomosis and autograft patch augmentation. Early mortality was 3.8% and overall survival was 94.1% [95% confidence interval (CI) 89.6-98.8%] at 1, 3 and 5 years. Reobstruction-free survival was 85.1% (95% CI 78.4-92.3%) at 1 year, 80.6% (95% CI 73.1-88.9%) at 3 years and 77.4% (95% CI 69.2-86.6%) at 5 years. Preoperative aortic arch geometric parameters were not important factors for reobstruction. Nineteen patients (18.3%) were detected with left main bronchus compression (LMBC) on flexible fibre-optic bronchoscopy. Cardiopulmonary bypass time [P < 0.001, hazard ratio (95% CI): 1.02 (1.01-1.03)] and postoperative LMBC [P = 0.034, hazard ratio (95% CI): 2.99 (1.09-8.23)] were independent predictive factors on multivariable Cox regression analysis of reobstruction-free survival. CONCLUSIONS Aortic arch can be satisfactorily repaired by extended end-to-end anastomosis, extended end-to-side anastomosis and autograft patch augmentation via median sternotomy in CoA/HAA. Cardiopulmonary bypass time and postoperative LMBC detected by flexible fibre-optic bronchoscopy are significant predictors for long-term arch reobstruction.
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Affiliation(s)
- Chengyi Hui
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Qiushi Ren
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Department of Cardiac Surgery, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Department of Cardiac Surgery, School of Medicine, South China University of Technology, Guangzhou, China
| | - Jimei Chen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Xiaohua Li
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Hujun Cui
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jianzheng Cen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Gang Xu
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
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Xiao HJ, Zhan AL, Huang QW, Huang RG, Lin WH. Evaluation of the aorta in infants with simple or complex coarctation of the aorta using CT angiography. Front Cardiovasc Med 2023; 9:1034334. [PMID: 36698954 PMCID: PMC9868234 DOI: 10.3389/fcvm.2022.1034334] [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: 09/01/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Objective To assess aortic dilatation and determine its related factors in infants with coarctation of the aorta (CoA) by using computed tomography angiography (CTA). Methods The clinical data of 55 infantile patients with CoA diagnosed by CTA were analyzed retrospectively. Aortic diameters were measured at six different levels and standardized as Z scores based on the square root of body surface area. The results of simple and complex CoA were compared. Univariate and multivariate logistic regression were used to analyze the effects of sex, age, hypertension, degree of coarctation, CoA type, bicuspid aortic valve (BAV), and other factors related to aortic dilatation. Results In total, 52 infant patients with CoA were analyzed, including 22 cases of simple CoA and 30 cases of complex CoA. The ascending aorta of the infants in the simple CoA group and the complex CoA group were dilated to different degrees, but the difference was not statistically significant (50.00% vs. 73.33%, P = 0.084, and 2.05 ± 0.40 vs. 2.22 ± 0.43 P = 0.143). The infants in the complex CoA group had more aortic arch hypoplasia than those in the simple CoA group (33.33% vs. 9.09%, P = 0.042). Compared to the ventricular septal defect (VSD) group, the Z score of the ascending aorta in the CoA group was significantly higher than that in the VSD group (P = 0.023 and P = 0.000). A logistic retrospective analysis found that an increased degree of coarctation (CDR value) was an independent predictor of ascending aortic dilatation (adjusted OR = 0.002; P = 0.034). Conclusion Infants with simple or complex CoA are at risk of ascending aortic dilatation, and the factors of ascending aortic dilatation depend on the degree of coarctation. The risk of aortic dilatation in infants with CoA can be identified by CTA.
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Truba IP, Golovenko OS, Dziuryi IV. Restenosis Rate and Reinterventions after Aortic Arch Repair in Infants. UKRAINIAN JOURNAL OF CARDIOVASCULAR SURGERY 2022. [DOI: 10.30702/ujcvs/22.30(04)/tg056-5965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The aim. This study aims to determine the reintervention rate in infantsundergoing aortic arch repair and to analyze risk factors and evaluate the results of reinterventions.
Materials and methods. This retrospective study examines 445 infants with aortic arch hypoplasia who under-went aortic arch reconstruction between 2011 and 2019. The study included only patients with two-ventricle physiology and subsequent two-ventricle repair. Techniques for primary repair included extended end-to-end anastomosis (n = 348), end-to-side anastomosis (n = 611), autologous pericardial patch repair (n = 16).
Results. The overall mortality in the entire study group was 3.3 %. Follow-up period ranged from 1 month to 9.4 years (mean 2.8 ± 2.5 years). Restenosis at the site of aortic arch repair was identiϐied in 47 (10.5 %) patients. Of these, 12 patients underwent surgical reconstruction of the aortic arch, 27 patients underwent balloon angioplasty, and in 8 patients both methods were used. Freedom from reintervention was 89.4 % at 1-year follow-up and 87.5 % at 4-year follow-up. The most determining factorsfor restenosis were related to hypoplastic proximal aortic arch and body weight less than 2.5 kg.
Conclusions. Surgical treatment of aortic arch hypoplasia in newborns and infants is effective and shows good immediate and long-term results. Anatomical correction of reobstruction at the level of the aortic arch is safe with both endovacular and surgical methods with low mortality and incidence of repeated interventions. Identified risk factors for mortality and recurrent aortic arch interventions help to improve the treatment of aortic arch hypoplasia in patients under 1 year of age.
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Nucera M, Glöckler M, Widenka H, Friess JO, Siepe M, Kadner A. Hybrid Approach for Correction of Recurrent Aortic Arch Obstruction After Repair of Interrupted Aortic Arch-A Case Report. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100088. [PMID: 37288062 PMCID: PMC10242564 DOI: 10.1016/j.shj.2022.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 06/09/2023]
Affiliation(s)
- Maria Nucera
- Department of Cardiac Surgery, Center for Congenital Heart Disease, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Glöckler
- Department of Cardiology, Center for Congenital Heart Disease, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hannah Widenka
- Department of Cardiac Surgery, Center for Congenital Heart Disease, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan-Oliver Friess
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, Center for Congenital Heart Disease, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department of Cardiac Surgery, Center for Congenital Heart Disease, Bern University Hospital, University of Bern, Bern, Switzerland
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Agasthi P, Pujari SH, Tseng A, Graziano JN, Marcotte F, Majdalany D, Mookadam F, Hagler DJ, Arsanjani R. Management of adults with coarctation of aorta. World J Cardiol 2020; 12:167-191. [PMID: 32547712 PMCID: PMC7284000 DOI: 10.4330/wjc.v12.i5.167] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Andrew Tseng
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Joseph N Graziano
- Division of Cardiology, Phoenix Children's Hospital, Children's Heart Center, Phoenix, AZ 85016, United States
| | - Francois Marcotte
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - David Majdalany
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
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Abstract
PURPOSE OF REVIEW Aortic coarctation is a common congenital abnormality causing significant morbidity and mortality if not corrected. Re-coarctation or restenosis of the aorta following treatment is a relatively common long-term problem and the optimal therapy has not been elucidated. In this review, we identify the challenges associated with and the optimal management for recurrent aortic coarctation and the most appropriate therapy for different patient cohorts. RECENT FINDINGS Open surgery provides a durable long-term aortic repair, however, given the complex nature of the procedure, has a somewhat higher rate of serious complications. Endovascular repair, although less invasive and relatively safe, has limitations in treated complex anatomy and is more likely to require repeat intervention. Open surgical repair is more appropriate for infants that have not been intervened on and endovascular therapy should be reserved for older children and adults and those that require repeat intervention.
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8
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Beckmann E, Jassar AS. Coarctation repair-redo challenges in the adults: what to do? J Vis Surg 2018; 4:76. [PMID: 29780722 DOI: 10.21037/jovs.2018.04.07] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/02/2018] [Indexed: 01/06/2023]
Abstract
Aortic coarctation is one of the most common congenital cardiac pathologies. Repair of native aortic coarctation is nowadays a common and safe procedure. However, late complications, including re-coarctation and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both endovascular and conventional open repair play important roles in the treatment of late complications after previous coarctation repair. This article will review the incidence of late complications after coarctation repair and will discuss the treatment options for redo coarctation repair in adult patients.
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Affiliation(s)
- Erik Beckmann
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Arminder S Jassar
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Wong JSY, Lee MGY, Brink J, Konstantinov IE, Brizard CP, d'Udekem Y. Are more extensive procedures warranted at the time of aortic arch reoperation? Eur J Cardiothorac Surg 2017; 52:1132-1138. [PMID: 28575303 DOI: 10.1093/ejcts/ezx166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/03/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine the early and late outcomes of patients undergoing aortic arch reoperations. METHODS The follow-up of 70 patients undergoing a second arch operation (excluding univentricular physiology) between 1979 and 2015 was reviewed. Median age at initial arch operation and second operation was 9 days (interquartile range: 5-35) and 10 months (interquartile range: 3-64), respectively. The most common indication for initial arch operation was coarctation in 79% (55/70). The most common indication for a second arch operation was arch reobstruction in 90% (63/70). RESULTS There were 2 hospital deaths (2/70, 3%) and 3 early third arch operations (3/70, 4%). Late follow-up was available in 94% (64/68) of hospital survivors. After a mean of 9 ± 7 years, there were 5 late deaths (5/64, 8%). Fifteen-year survival was 90% (95% confidence interval: 75-96). Arch reobstruction (echocardiogram gradient >25 mmHg/third operation for reobstruction) was present in 28% (18/64) and 16% (10/64) required a third arch operation. Fifteen-year freedom from arch reobstruction and third arch operation was 63% (95% confidence interval: 43-78) and 74% (95% confidence interval: 52-87), respectively. On multivariable analysis, hypoplastic arch at initial arch repair (P = 0.03) and interposition graft at second arch operation (P < 0.0001) were risk factors for third arch operation. CONCLUSIONS Patients undergoing a second arch operation have significant rates of arch reobstruction and reoperation. The high rates of arch reobstruction and third arch operation warrant more extensive procedures at the time of second arch operation, especially in patients with a hypoplastic arch. Regular long-term monitoring after arch reoperation is mandatory.
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Affiliation(s)
- Jeremy S Y Wong
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Melissa G Y Lee
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Heart Research Group, Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Johann Brink
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Heart Research Group, Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Heart Research Group, Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Heart Research Group, Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Australia
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10
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Jepson B, Sivanandam S. Multimodality imaging in prenatal diagnosis and management of aortic arch anomalies. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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11
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Herzog S, Dave H, Schweiger M, Hübler M, Quandt D, Kretschmar O, Knirsch W. Effectiveness of Balloon Angioplasty in Children With Recurrent Aortic Coarctation Depends on the Type of Aortic Arch Pathology. J Interv Cardiol 2016; 29:414-23. [PMID: 27358058 DOI: 10.1111/joic.12307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The aim of this study was to evaluate the effectiveness of balloon angioplasty (BAP) for recurrent aortic coarctation (ReCoA) in infants comparing simple and complex type of aortic arch pathology (Norwood I procedure). BACKGROUND ReCoA is a known complication after cardiovascular surgery for coarctation of the aortic arch. METHODS AND RESULTS In a single center case study, we analyzed 20 infants undergoing BAP for ReCoA comparing simple (n = 10) and complex type of aortic arch pathology (n = 10). At catherization diameter of ReCoA stenosis was 3.2 ± 0.7 mm (mean ± SD) with short localized (11/20) or long hypoplastic stenosis (9/20) before and 4.8 ± 1.2 mm after BAP (P < 0.001). Invasive systolic pressure gradient was reduced from 27.5 ± 16.2 mmHg before to 5.1 ± 6.6 mmHg after BAP (P < 0.001), comparable in simple and complex type of ReCoA. At day 1 after catherization noninvasive systolic arterial blood pressure gradient was reduced from 20.2 ± 23.1 to 6.7 ± 9.9 mmHg (P < 0.001), respectively, calculated continuous wave Doppler echo gradient from 36.3 ± 22 to 16.8 ± 9.6 mmHg (P < 0.01). Complications were aortic arch dissection (1/20), discrete aortic arch aneurysm formation (1/20), pericardial effusion (1/20), and peripheral arterial thrombosis (4/20). At a mid-term follow up of 9.5 months (1-40) after BAP, 3 infants needed early surgical reintervention due to secondary ReCoA, all with long hypoplastic aortic arch segments, but simple type of aortic arch pathology. CONCLUSIONS At mid-term follow up, BAP remains an effective catheter intervention for ReCoA for infants with localized ReCoA, but not with long hypoplastic aortic arch segments, even in simple type of aortic arch pathology.
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Affiliation(s)
- Stefanie Herzog
- Division of Paediatric Cardiology, Paediatric Heart Center, University Children's Hospital Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zürich, Switzerland
| | - Hitendu Dave
- Children's Research Center, University Children's Hospital Zürich, Switzerland.,Division of Congenital Cardiovascular Surgery, Paediatric Heart Center, University Children's Hospital Zürich, Switzerland
| | - Martin Schweiger
- Children's Research Center, University Children's Hospital Zürich, Switzerland.,Division of Congenital Cardiovascular Surgery, Paediatric Heart Center, University Children's Hospital Zürich, Switzerland
| | - Michael Hübler
- Children's Research Center, University Children's Hospital Zürich, Switzerland.,Division of Congenital Cardiovascular Surgery, Paediatric Heart Center, University Children's Hospital Zürich, Switzerland
| | - Daniel Quandt
- Division of Paediatric Cardiology, Paediatric Heart Center, University Children's Hospital Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zürich, Switzerland
| | - Oliver Kretschmar
- Division of Paediatric Cardiology, Paediatric Heart Center, University Children's Hospital Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zürich, Switzerland
| | - Walter Knirsch
- Division of Paediatric Cardiology, Paediatric Heart Center, University Children's Hospital Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zürich, Switzerland
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12
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Saxena A. Recurrent coarctation: interventional techniques and results. World J Pediatr Congenit Heart Surg 2015; 6:257-65. [PMID: 25870345 DOI: 10.1177/2150135114566099] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Anita Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
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13
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Goldberg JF. Long-term Follow-up of "Simple" Lesions--Atrial Septal Defect, Ventricular Septal Defect, and Coarctation of the Aorta. CONGENIT HEART DIS 2015; 10:466-74. [PMID: 26365715 DOI: 10.1111/chd.12298] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2015] [Indexed: 01/10/2023]
Abstract
Surgery for congenital heart disease has advanced significantly in the past 50 years, such that repair of "simple" lesions, such as atrial septal defect, ventricular septal defect, and coarctation of the aorta carries minimal risk, with mortality risk much less than 1%. It was once thought successful repair of these lesions was definitively corrective. There is mounting evidence, however, that there are long-term complications after these repairs, prompting the need for continued follow-up. This review describes the current understanding of diagnosis, treatment, and long-term outcomes for these patients, with the goal of advocating for lifelong surveillance. As the perioperative care of these repairs has evolved significantly over time, so must the way in which we study these patients in the long-term.
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Affiliation(s)
- Jason F Goldberg
- Section of Pediatric Cardiology, Baylor College of Medicine, Houston, Tex, USA
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14
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Mery CM, Khan MS, Guzmán-Pruneda FA, Verm R, Umakanthan R, Watrin CH, Adachi I, Heinle JS, McKenzie ED, Fraser CD. Contemporary Results of Surgical Repair of Recurrent Aortic Arch Obstruction. Ann Thorac Surg 2014; 98:133-40; discussion 140-1. [DOI: 10.1016/j.athoracsur.2014.01.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/10/2014] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
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15
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Tong F, Li ZQ, Li L, Chong M, Zhu YB, Su JW, Liu YL. The Follow-up Surgical Results of Coarctation of the Aorta Procedures in a Cohort of Chinese Children from a Single Institution. Heart Lung Circ 2014; 23:339-46. [DOI: 10.1016/j.hlc.2013.10.060] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 09/23/2013] [Accepted: 10/10/2013] [Indexed: 10/26/2022]
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16
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Bernabei M, Margaryan R, Arcieri L, Bianchi G, Pak V, Murzi B. Aortic arch reconstruction in newborns with an autologous pericardial patch: contemporary results. Interact Cardiovasc Thorac Surg 2012; 16:282-5. [PMID: 23223671 DOI: 10.1093/icvts/ivs510] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The incidence of recurrent aortic arch obstruction after Norwood procedure and other types of aortic arch reconstruction in newborns remains high. Biological and synthetic materials are used to enlarge the aorta. We report our experience using autologous pericardium to reconstruct the aortic arch in patients with hypoplastic left heart syndrome, aortic arch interruption and hypoplastic aortic arch. METHODS A retrospective analysis of 39 consecutively operated patients evaluated after an initial Norwood and other types aortic arch repair was performed. The presence of recurrent arch obstruction (mean gradient ≥ 20 mmHg) and its management were noted. The mean weight of our patients was 3.2 ± 0.7 kg. RESULTS The mean age at primary surgical correction was 7.4 ± 6.8 (range 1-35 days). All patients were discharged without a significant residual gradient at the aortic arch except 4 who had a peak gradient of ≥ 30 mmHg. The overall incidence of recurrent arch obstruction was 28.2% (11 patients). Four (12.1%) patients had a distal obstruction, 1 (3%) had proximal obstruction and 1 had a mid-transverse arch obstruction. All patients underwent aortic arch reintervention consisting of balloon dilatation, and only after unsuccessful dilatation, 3 underwent surgical patch aortoplasties. CONCLUSIONS The use of autologous pericardium in aortic arch reconstruction procedure is effective and associated with an acceptable incidence of recurrent arch obstruction. Its availability and characteristics make it an attractive alternative to other materials.
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Affiliation(s)
- Massimo Bernabei
- Department of Congenital Heart Disease, Ospedale Del Cuore Fondazione G. Monasterio, Massa, Italy
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17
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Said SM, Dearani JA, Burkhart HM, Schaff HV. Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction. ACTA ACUST UNITED AC 2012. [DOI: 10.1053/j.optechstcvs.2012.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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18
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Abstract
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.
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Affiliation(s)
- D R Turner
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
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19
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Brown JW, Ruzmetov M, Hoyer MH, Rodefeld MD, Turrentine MW. Recurrent coarctation: is surgical repair of recurrent coarctation of the aorta safe and effective? Ann Thorac Surg 2010; 88:1923-30; discussion 1930-1. [PMID: 19932264 DOI: 10.1016/j.athoracsur.2009.07.024] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2008] [Revised: 07/13/2009] [Accepted: 07/15/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND Persistence or recurrence of stenosis is a complication of coarctation repair and is associated with major long-term morbidity. The rate of recurrence varies significantly, depending on the age of the patient, technique at initial repair, and the arch anatomy. We reviewed our experience with surgical repair of recurrent coarctation of the aorta and compared it with our institutional experience with balloon aortoplasty. METHODS We retrospectively reviewed our experience with 1,012 patients undergoing initial repair of coarctation between 1960 and 2008. During that time, 103 patients (10%) required reintervention. Median age at reintervention was 6.5 years (range, 2 weeks to 44 years) and median weight was 12 kg (range, 1.9 to 94 kg). Fifty-nine patients with recoarctation had surgical repair, and 44 patients were treated with balloon aortoplasty with or without stent placement. RESULTS Ninety-five percent of patients have been followed up (median time, 14.2 years; range, 2 months to 42 years). There were 5 late deaths. Actuarial survival was 98% at 15 and 40 years in patients with surgical reintervention, and it was 91% (p = 0.001) at 15 years in patients with balloon aortoplasty reintervention. A second redo coarctation of the aorta reintervention was performed in 12 patients: 8 patients after percutaneous intervention (nonsurgical) and 4 patients after surgical recoarctation repair. The median interval between first and second reintervention was 3.5 years (range, 1 month to 14 years). One patient who had two dilations underwent a third and fourth reintervention: patch enlargement and pseudoaneurysm resection. Freedom from reintervention in the surgical group was 96% at 15 years and 94% at 40 years, which was compared with actuarial freedom from reintervention for patients with percutaneous intervention (balloon/stent) at 15 years (82%; p < 0.001). CONCLUSIONS Our study demonstrates that surgical repair of recurrent coarctation of the aorta can be performed safely and with excellent results. The recurrence after surgical reintervention is low, and most patients to date have not required further intervention. Balloon aortoplasty as an alternative method of managing recoarctation is efficient and less invasive than surgery; however, well-described complications may occur. Recurrence rates with angioplasty are significantly higher than with surgery.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, James W. Riley Hospital for Children, Indianapolis, Indiana 46202-5123, USA.
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20
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Brown JW, Rodefeld MD, Ruzmetov M. Transverse aortic arch obstruction: when to go from the front. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2009; 12:66-69. [PMID: 19349017 DOI: 10.1053/j.pcsu.2009.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Transverse aortic arch hypoplasia involving some or all segments of the arch (tubular hypoplasia) may exist in association with intra-cardiac anomalies of varying severity. Surgical repair of the distal transverse aortic arch and isthmus are adequately managed by an extended end-to-end coarctation repair in most infants via a left thoracotomy. The surgical management and timing of proximal aortic arch obstruction is controversial but almost always requires an approach via sternotomy using cardiopulmonary bypass.
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Affiliation(s)
- John W Brown
- Section of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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21
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Maddali MM, Valliattu J, al Delamie T, Zacharias S. Selection of Monitoring Site and Outcome after Neonatal Coarctation Repair. Asian Cardiovasc Thorac Ann 2008; 16:236-9. [DOI: 10.1177/021849230801600312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To assess whether simultaneous invasive arterial pressure monitoring of right upper and lower limbs in neonatal aortic coarctation with or without arch hypoplasia has an impact on surgical decision-making and outcome, data of 140 newborns who underwent emergency surgical repair over 15 years were analyzed retrospectively. The 36 who had simultaneous right arm and lower limb arterial pressure monitored intraoperatively were assigned to group 1. The other 104 who had blood pressure monitored invasively at a single site (either upper or lower limb) were allocated to group 2. In group 1, a residual gradient across the repaired segment was detected intraoperatively in 13% of patients, and corrected at the same sitting. In group 2, 6% needed subsequent balloon angioplasty. In all babies with arch hypoplasia in group 1, the proximal aortic cross clamp was readjusted at least once to avoid compromise of carotid blood flow. Simultaneous right upper and lower limb invasive pressure monitoring has an impact on the overall outcome in these sick neonates.
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Affiliation(s)
| | - John Valliattu
- Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
| | - Taha al Delamie
- Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
| | - Sunny Zacharias
- Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
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22
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Implantation of stents for treatment of recurrent and native coarctation in children weighing less than 20 kilograms. Cardiol Young 2007; 17:617-22. [PMID: 17977467 DOI: 10.1017/s1047951107001448] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We report our experience with implantation of stents for treatment of recurrent and native aortic coarctation in children weighing less than 20 kilograms. We treated 9 such patients between March, 2003, and January, 2006. In 2 patients, the coarctation had not previously been treated, while in 7 it had recurred after surgery. The patients had a median weight of 14 kilograms, with a range from 5.5 to 19 kilograms. Balloon dilation was needed in 1 patient before the stent was implanted. We used Palmaz Genesis XD stents in 7 patients, these having lengths from 19 to 29 millimetres, 1 Palmaz Genesis 124P stent, and 1 peripheral JoStent with a diameter of 6 to 12 millimetres. Implantation was effective in all patients. Immediately after implantation, the mean peak systolic gradient decreased from 30 millimetres of mercury, the range having been 15 to 50 mm, to 3 millimetres of mercury, with the final range from zero to 10 mm. There were no complications, with no observations of aneurysms, dissections, or dislocated stents. In 1 patient, the peripheral pulse was weak secondary to arterial access, but treatment with Heparin led to complete resolution. It was necessary to re-dilate the stent in another patient, while 2 others are scheduled for redilation because of growth-related restenosis. Our findings suggest that implantation of stents can produce excellent relief of the gradient produced by recurrent or native coarctation. The process is safe and effective in patients weighing less than 20 kilograms.
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Abstract
Disease of the aortic arch is a common component of congenital heart disease requiring surgical treatment in the neonate. While sometimes found in isolation, aortic arch disease must be placed into the larger context of frequently associated pathology. This review describes the anatomic variations of neonatal aortic arch pathology, surgical approaches and techniques, and expected outcomes.
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Affiliation(s)
- Frank A Pigula
- Department of Cardiac Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
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24
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Rhodes AB, O'Donnell SD, Gillespie DL, Rasmussen TE, Johnson CA, Fox CJ, Burklow TR, Hagler DJ. The endovascular management of recurrent aortic hypoplasia and coarctation in a 15-year-old male. J Vasc Surg 2005; 41:531-4. [PMID: 15838490 DOI: 10.1016/j.jvs.2004.09.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 15-year-old male complained of easy fatigability, leg weakness, and pain on exertion with episodes of syncope while playing baseball. His past medical history was significant for aortic coarctation associated with a congenital bovine hypoplastic aortic arch. A recent arteriogram revealed innominate and left common carotid artery stenosis as well as recurrent coarctation. He had previously undergone three Dacron patch aortoplasties. At the age of 7, he underwent a fourth operation for recurrent coarctation and because of extensive scar tissue in the region of his prior procedures, a left subclavian artery-to-descending aortic bypass was performed. An endovascular repair to deal with the recent recurrence was performed because of prior surgical difficulties. Percutaneous balloon-expandable stents were placed in the aortic coarctation, innominate, and the left common carotid arteries. Postprocedure, ankle brachial indices were >1 and the patient remains asymptomatic after 1 year.
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Affiliation(s)
- Andrew B Rhodes
- Vascular Surgery Clinic Ward 64, Walter Reed Army Medical Center, 6900 Georgia Avenue NW, Washington, DC 20307-5001, USA
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Bhat AH, Sahn DJ. Congenital heart disease never goes away, even when it has been 'treated': the adult with congenital heart disease. Curr Opin Pediatr 2004; 16:500-7. [PMID: 15367842 DOI: 10.1097/01.mop.0000140996.24408.1a] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW As the specialties of pediatrics and pediatric cardiology continue to forge ahead with better diagnoses, medical care, and surgical results, an expanding population of patients with congenital heart disease (CHD) outgrows the pediatric age group, yet does not quite graduate to routine adult cardiology or general medicine. The adult with congenital heart disease (ACHD) faces medical, surgical, and psychosocial issues that are unique to this population and must be addressed as such. This review attempts to discuss and highlight some of the important advances and controversies brought up in the past year, in the care and management of these patients. RECENT FINDINGS The past five to 10 years have seen dynamic interest in understanding sequelae of corrected, uncorrected, or palliated congenital heart disease. The search for the ideal surgery, optimal prosthesis, and a smooth transition to adult care continues and is reflected in the vast amount of academic work and publications in this field. Of particular interest, conduit reoperations and single ventricle pathway modifications are still an art and a science in evolution. SUMMARY While all are agreed that there is a pressing need to focus on the delivery of care to the adult with congenital heart disease, this essentially requires a clearer understanding of late sequelae of CHD. The sheer heterogeneity of anatomy, age, surgery, and institutional management protocols can make it difficult to develop clear guidelines. This review attempts to give an up-to-date perspective on some of the new findings related to the more common lesions and problems faced in this group.
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Affiliation(s)
- Aarti Hejmadi Bhat
- The Clinical Care Center for Congenital Heart Disease, Oregon Health & Science University, Portland, Oregon 97239-3098, USA
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