Acute results of balloon angioplasty of native coarctation versus recurrent aortic obstruction are equivalent. Valvuloplasty and Angioplasty of Congenital Anomalies (VACA) Registry Investigators

Restenosis Rate and Reinterventions after Aortic Arch Repair in Infants

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.

Isolated Coarctation of the Aorta: Current Concepts and Perspectives

Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal diagnosis, high survival and improved understanding of long-term complication. Isolated CoA has heterogenous presentations, complex etiologic mechanisms, and progressive pathophysiologic changes that influence outcome. End-to-end or extended end-to-end anastomosis are the favored surgical approaches for isolated CoA in infants and transcatheter intervention is favored for children and adults. Primary stent placement is the procedure of choice in larger children and adults. Most adults with treated isolated CoA thrive, have normal daily activities, and undergo successful childbirth. Fetal echocardiography is the cornerstone of prenatal counseling and genetic testing is recommended. Advanced 3D imaging identifies aortic complications and myocardial dysfunction and guides individualized therapies including re-intervention. Adult CHD program enrollment is recommended. Longer follow-up data are needed to determine the frequency and severity of aneurysm formation, myocardial dysfunction, and whether childhood lifestyle modifications reduce late-onset complications.

Midterm safety and outcome of balloon angioplasty of native aortic coarctation in neonates and young infants and initial experience of prepartial dilatation using high-pressure noncompliant balloon

Background:

Balloon angioplasty (BA) for aortic coarctation in neonates and infants remains controversial due to high recurrence rate and vascular complications.

Aim:

This study aimed to determine the safety and outcome of percutaneous treatment of coarctation in neonates and infants and to share the initial experience of strategy of prepartial dilatation with high-pressure noncomplaint balloon before final targeted dilatation using low-pressure compliant balloon.

Materials and Methods:

Retrospective analysis of records of all neonates and infants aged <6 months who underwent BA either using only low-pressure balloon (Group A) or those with prepartial dilatation using high-pressure noncomplaint balloon followed by low-pressure compliant balloon (Group B) between July 2017 and February 2020 was performed. Demographic, clinical, echocardiographic, interventional, and follow-up data were collected for all.

Results:

A total of 51 patients (41.2% neonates) were included in the study. Median age was 1 month 14 days (60.8% girls) and mean weight was 3.6 ± 1.5 kg. The mean peak trans-coarctation gradient was 53 ± 12 (34–80) mmHg. The final pressure gradient dropped to <10 mmHg in all cases of Group B and only in 26.3% (5) patients of Group A (P < 0.001). Recoarctation rate was 25.5% (13) overall and was significantly higher in Group A patients (P < 0.001), in those with borderline/mildly hypoplastic arch (P = 0.04) and in those with postprocedure gradient between 10 and 20 mmHg (P = 0.02). Median time to re-coarctation was significantly delayed in Group B (P < 0.001). There were no major complications or mortality in either group.

Conclusions:

BA in neonates and young infants has an excellent short and mid-term safety and efficacy. The recoarctation rate is significantly reduced as well as delayed with prepartial dilatation using high-pressure noncompliant balloon.

Percutaneous Implantation of Adult Sized Stents for Coarctation of the Aorta in Children ≤20 kg: A 12-Year Experience

BACKGROUND

Stent implantation (SI) is more effective than balloon angioplasty for the treatment of coarctation of the aorta (CoA). Due to technical factors, balloon angioplasty is more commonly performed in small patients. We sought to evaluate outcomes of percutaneous adult sized SI for the treatment of CoA in small patients.

METHODS

A single-center retrospective review of all patients ≤20 kg who underwent percutaneous adult sized SI for native or recurrent CoA from 2004 to 2015 was performed.

RESULTS

Thirty-nine patients (20 patients ≤10 kg) were identified, with 28 (71.8%) having recurrent CoA and 22 (56.4%) previously failed balloon angioplasty. At the time of SI, the median (range) patient age and weight were 1.1 (0.3-7.9) years and 10 (5.5-20.4) kg, respectively. SI resulted in significant improvements in the median gradient (26 mm Hg [interquartile range (IQR), 18-42] to 0 mm Hg [IQR, 0-2]; P< 0.05) and median minimum diameter (3.6 mm [IQR, 2.4-4.8] to 7.7 mm [IQR, 6.5-9.4]; P<0.05). Seven patients (18%) had procedural adverse events. Twenty-seven (69%) patients underwent elective reintervention at a median time of 49.3 (IQR, 26.5-63.2) months from SI, with 8 (21%) stents requiring repeat SI for stent fracture. Over a median follow-up of 67.2 (IQR, 33.8-116.1) months, 25 patients (69%) were without hypertension or blood pressure gradient. Three (11%) patients developed femoral arterial occlusion.

CONCLUSIONS

Adult sized SI is an alternative to surgical intervention for small patients with CoA. SI carries a risk of access-related complications, which may improve with the development of lower profile stents with adult sized maximum diameters.

Endovascular stent implantation for aortic coarctation: parameters affecting clinical outcomes

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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 Interventions in Adult Congenital Heart Disease

This article provides a detailed review of the current practices and future directions of transcatheter interventions in adults with congenital heart disease. This includes indications for intervention, risks, and potential complications, as well as a review of available devices and their performance.

The Challenges of Redo Aortic Coarctation Repair in Adults

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

Native aortic coarctation in neonates and infants: Immediate and midterm outcomes with balloon angioplasty and surgery

Background

Native aortic coarctation in young infants can be treated surgically or with balloon angioplasty, although the latter approach remains controversial. We sought to compare midterm outcomes of balloon and surgical coarctoplasty at our center and to review the current practices in literature.

Methods

The study design was a retrospective record review. Patients with coarctation aged <1 year who underwent balloon or surgical coarctoplasty at our center (January 2010-January 2016) with >6-month post-procedure follow-up were studied. Patients with significant arch hypoplasia or interruption, long-segment coarctation, and associated intracardiac lesions were excluded from the study. Clinical, echocardiographic, and procedural details were recorded at initial presentation and follow-up. Need for reintervention was noted.

Results

Out of a total of 75 patients, 28 underwent balloon (Group A) and 47 underwent surgical coarctoplasty (Group B). There were two deaths in Group B (mortality 4.2%) and none in Group A. In neonates, 63.6% of Group A and 17.4% of Group B patients required reintervention (P = 0.007). Beyond the neonatal age, 29.4% of Group A and 41.6% of Group B patients required reintervention (not statistically significant). On univariate analysis, residual coarctation on predischarge echocardiogram was the only significant predictor of reintervention (P = 0.04). On Kaplan-Meier analysis, with neonatal presentation, freedom from reintervention in Group B was significantly higher than Group A (P = 0.028).

Conclusion

In neonates with native aortic coarctation, surgery unequivocally yields better immediate and midterm results and is the preferred treatment modality. In older infants, balloon coarctoplasty has good early and midterm outcomes with acceptable reintervention rates and should be considered a viable alternative to surgery, especially in critical patients with high surgical risk.

Balloon Dilatation and Stenting for Aortic Coarctation: A Systematic Review and Meta-Analysis

BACKGROUND

There is no systematic assessment of available evidence on effectiveness and comparative effectiveness of balloon dilatation and stenting for aortic coarctation.

METHODS AND RESULTS

We systematically searched 4 online databases to identify and select relevant studies of balloon dilatation and stenting for aortic coarctation based on a priori criteria (PROSPERO 2014:CRD42014014418). We quantitatively synthesized results for each intervention from single-arm studies and obtained pooled estimates for relative effectiveness from pairwise and network meta-analysis of comparative studies. Our primary analysis included 15 stenting (423 participants) and 12 balloon dilatation studies (361 participants), including patients ≥10 years of age. Post-treatment blood pressure gradient reduction to ≤20 and ≤10 mm Hg was achieved in 89.5% (95% confidence interval, 83.7-95.3) and 66.5% (44.1-88.9%) of patients undergoing balloon dilatation, and in 99.5% (97.5-100.0%) and 93.8% (88.5-99.1%) of patients undergoing stenting, respectively. Odds of achieving ≤20 mm Hg were lower with balloon dilatation as compared with stenting (odds ratio, 0.105 [0.010-0.886]). Thirty-day survival rates were comparable. Numerically more patients undergoing balloon dilatation experienced severe complications during admission (6.4% [2.6-10.2%]) compared with stenting (2.6% [0.5-4.7%]). This was supported by meta-analysis of head-to-head studies (odds ratio, 9.617 [2.654-34.845]) and network meta-analysis (odds ratio, 16.23, 95% credible interval: 4.27-62.77) in a secondary analysis in patients ≥1 month of age, including 57 stenting (3397 participants) and 62 balloon dilatation studies (4331 participants).

CONCLUSIONS

Despite the limitations of the evidence base consisting predominantly of single-arm studies, our review indicates that stenting achieves superior immediate relief of a relevant pressure gradient compared with balloon dilatation.

Case Report: An Innovative Endovascular Technique for Repair of Descending Thoracic Aortic Aneurysm following an Open Coarctation Repair

It was once postulated that open surgical repair of coarctation of the aorta during childhood patients was cured. However, long-term follow-up has been significant for late problems such as an aneurysm. The incidence of such aneurysm after open surgical coarctation repair is 11-24%. If such an aneurysm is left untreated, patients are at a high risk of morbidity and mortality. Prior to the endovascular era, patients would require a redo open repair which in itself is a highly morbid operation. Currently, thoracic endovascular aortic repair (TEVAR) has been reported as a feasible and safe alternative to open surgical reprocedures in this context. However, TEVAR might be challenging due to the proximity of the pathology to supraaortic vessels and the ongoing presence of the coarctation. We are reporting a unique case of a 48-year-old male undergoing TEVAR due to aortic aneurysm after previous surgical coarctation treatment and successful closure of the coarctation with a vascular plug device.

Early and Midterm Results Following Interventional Coarctoplasty: Evaluation of Variables that Can Affect the Results

Background and Objectives

Stent coarctoplasty has been approved as the treatment of choice for adult patients with coarctation of the aorta. We have evaluated the early and midterm clinical and procedural results after interventional coarctoplasty. Also, variables that can affect these results were evaluated.

Subjects and Methods

Gathering clinical, angiographic and procedural data, we evaluated the pre-specified outcomes, including procedural success, complications, the incidence of hypertension after coarctoplasty etc., after the procedure. The effect of pre-specified variables including aortic arch shape, coarctation type and etc. on the procedural result was evaluated.

Results

Between February 2005 through March 2014, 133 stent coarctoplasty procedures were performed. Median age was 23.5 years old (interquartile range [IQR]:19-28), and 105 (71.9%) were male. Nearly all of the patients were undergone stent coarctoplasty, mostly with cheatham platinum (CP) stents. There was no association between aortic arch morphology and acute procedural complications. Balloon length more than 40 mm (p=0.028), aorta diameter at the site of Coarctation larger than 2.35 mm (p=0.008) was associated with higher rate of restenosis during follow-up. Comparison between the prevalence of hypertension (HTN) before and after coarctoplasty showed a significant reduction in the prevalence of HTN (117 [91.4%] vs. 95 [74.2%] p<0.001).

Conclusion

Stent coarctoplasty is a low-risk procedure with favorable early and delayed outcomes. Most mortality is related to the patient's comorbid conditions and not to the procedure.

Percutaneous angioplasty used to manage native and recurrent coarctation of the aorta in infants younger than 1 year: immediate and midterm results

Balloon angioplasty (BAP) used to manage native coarctation of the aorta (CoAo) in infants remains controversial. This study aimed to compare short- and midterm results of BAP between native CoAo (NaCo) and postsurgical recoarctations (ReCo) in infants younger than 1 year. This retrospective study compared the clinical, echocardiographic, hemodynamic, and angiographic data for infants who underwent BAP between July 2003 and September 2012. The 12 NaCo and 13 ReCo patients in this study underwent BAP at 4.61 ± 3.69 and 4.88 ± 3.07 months (p = 0.84) and weighed 5.49 ± 2.57 and 6.10 ± 2.11 kg (p = 0.52), respectively. Their respective heights were 60.58 ± 10.58 and 61.15 ± 6.74 cm (p = 0.87). All the ReCo patients had their initial surgery before the age of 3 months. The minimal CoAo diameter was 2.81 ± 0.96 mm in the NaCo group and 2.86 ± 1.0 mm in the ReCo group (p = 0.90). The relative gradient reduction was 62.79 ± 32.43 % in the NaCo group and 73.37 ± 20.78 % in the ReCo group (p = 0.33). The in situ complication rate (pseudoaneurysm) was 8.33 % in the NaCo group and 7.69 % in the ReCo group (p = 0.74). During the early follow-up evaluation, five NaCo patients (41.66 %) presented with recoarctation requiring BAP reintervention within 1.75 ± 1.41 months (all had their initial BAP before 3 months of age) compared with 1 ReCo patient (7.69 %) (p = 0.165). The mean follow-up period was 3.09 ± 2.69 years for the NaCo patients and 3.6 ± 3.18 years for the ReCo patients (p = 0.69), during which the blood pressure gradient was 12.33 ± 9.67 for the NaCo patients and 7.80 ± 8.78 for the ReCo patients (p = 0.17), with corresponding Doppler peak instantaneous gradients of 21.29 ± 11.19 and 16.20 ± 10.23 (p = 0.24). The resultant diameter ratio between the minimal isthmus diameter and the aortic diameter at the diaphragmatic level was 0.81 ± 0.15 in the NaCo group and 0.85 ± 0.12 in the ReCo group (p = 0.53). The immediate and midterm results of BAP for the NaCo and ReCo infants were comparable. Accordingly, BAP seems to be an acceptable alternative to surgery for infants older than 3 months.

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.

State of the art catheter interventions in adults with congenital heart disease

Catheter interventions in adults with congenital heart disease have rapidly advanced. Transcatheter valve repair and replacement techniques have been added to the existing spectrum of well-established procedures. This review summarizes current transcatheter management strategies for congenital cardiac anomalies seen in the adult population.

Coarctation-associated aneurysms: a localized disease or diffuse aortopathy

BACKGROUND

We evaluated the occurrence and treatment of aortic aneurysms in coarctation patients.

METHODS

During 1962 to 2011, 943 cases of coarctation were repaired. Aortic aneurysms were identified in 55 patients (5.8%). Forty-eight had prior coarctation repair (median 23 years earlier, interquartile range 18 to 26 years). Forty-two aneurysms were found in the descending thoracic aorta (76.4%), 18 in the ascending aorta (32.7%), 8 in the left subclavian artery (14.5%), and 1 each (1.8%) in the abdominal aorta, iliac artery, and innominate artery. Twenty-three patients (41.8%) had multiple aneurysms. Twenty-five patients (45.4%) had a bicuspid aortic valve.

RESULTS

Fifty-three patients' aneurysms were treated surgically. Thirty-five (66.0%) had descending thoracic aortic repair, of whom 11 had aorto-left subclavian bypass. Aortic cross-clamping alone was used in 23 patients, left heart bypass in 4, and circulatory arrest in 8. Eleven patients underwent endovascular repair (20.8%). Proximal aortic aneurysms were repaired in 7 patients (13.2%); 1 had simultaneous antegrade endostent delivery. Four patients had ascending-to-descending aortic bypass (7.3%). Concomitant valve-sparing root repair was performed in 2 patients, Bentall in 4, aortic valve replacement in 3, and coronary artery bypass in 1. One 30-day death occurred (1.9%). Three patients (5.7%) had transient neurologic deficits, 2 (3.8%) required tracheostomy, and 11 (20.8%) had vocal cord paralysis.

CONCLUSIONS

Coarctation is a marker for aortic aneurysm formation in adults and merits long-term surveillance. Anatomic complexity and associated conditions can complicate the surgical repair. Various open, extra-anatomic, and endovascular techniques may be used.

[Treatment of native coarctation in adults]

Aortic coarctation is the reflection of a wider vasculopathy affecting the precoarctation arterial tree. Patients should be screened for associated heart disease and anomalies of supra-aortic arch vessels. Treatment options include surgical repair or balloon angioplasty with or without stent-graft implantation. Both treatment options can be complicated by recoarctation or aortic aneurysms and warrant lifelong surveillance. In adults, anatomic correction of coarctation has fewer effects on arterial pressure than in infants. Thus, systemic hypertension may persist in up to half of treated patients. Recoarctation or unrecognized aortic arch hypoplasia should nevertheless be eliminated.

Congenital Heart Defects in Adults : A Field Guide for Cardiologists

Advances in cardiology and cardiac surgery allow a large proportion of patients with congenital heart defects to survive into adulthood. These patients frequently develop complications characteristic of the defect or its treatment. Consequently, adult cardiologists participating in the care of these patients need a working knowledge of the more common defects. Occasionally, patients with congenital heart defects such as atrial septal defect, Ebstein anomaly or physiologically corrected transposition of the great arteries present for the first time in adulthood. More often patients previously treated in pediatric cardiology centers have transitioned to adult congenital heart disease centers for ongoing care. Some of the more important defects in this category are tetralogy of Fallot, transposition of the great arteries, functionally single ventricle defects, and coarctation. Through this field guide, we provide an overview of the anatomy of selected defects commonly seen in an adult congenital practice using pathology specimens and clinical imaging studies. In addition, we describe the physiology, clinical presentation to the adult cardiologist, possible complications, treatment options, and outcomes.

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.

Effectiveness and safety of balloon dilation of native aortic coarctation in premature neonates weighing < or = 2,500 grams

Six neonates weighing < or = 2,500 g with native coarctation of the aorta underwent balloon dilation. Of the 6 neonates, 4 were female and 2 were male, with a mean age of 14 days (range 9 to 20) and a mean weight of 1,900 g (range 790 to 2,500). The procedure was acutely successful in all 6 patients; the peak gradient decreased from 38 + or - 19 mm Hg to 11 + or - 3 mm Hg. The diameter increased from 1.5 + or - 0.6 mm to 3.6 + or - 0.7 mm. Of the 6 patients, 3 had required no additional intervention at a mean of 42 months after the initial dilation, and 3 had developed restenosis a mean of 2.4 months after the initial dilation and underwent successful redilation. Of the latter 3 patients, 2 developed restenosis and underwent surgical repair 37 and 68 days after the second dilation, and 1 of these patients developed recoarctation after surgery that was treated successfully with balloon dilation 54 days after the end-to-end repair. In conclusion, premature neonates weighing < or = 2,500 g with coarctation of the aorta appear to respond acutely to balloon dilation. Some patients will have a successful long-term result after a single balloon dilation procedure. However, restenosis is common and tends to develop rapidly.

Recurrent coarctation: is surgical repair of recurrent coarctation of the aorta safe and effective?

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.

Stent implantation for coarctation of the aorta in children <30 kg

OBJECTIVES

Our aim was to determine key characteristics of stents commonly implanted in the aorta through bench testing and to describe our technique and acute results in patients weighing <30 kg.

BACKGROUND

Despite the increasing use of stents for interventional treatment for coarctation of the aorta (CoA) in larger patients, use of large stents is controversial in small children.

METHODS

Methods included bench testing of large stents, and retrospective review of all patients over 1 year of age who had stent implantation for treatment of CoA. Patients were divided into 2 groups based on weight. Paired comparisons were made before and after stent implantation, and group outcomes were compared.

RESULTS

Sixty patients comprised the entire sample, with 22 patients assigned to group I (<30 kg) and 38 patients assigned to group II (>or=30 kg). The mean minimum diameters of the CoA (group I 5.0 to 10.7 mm; group II 8.0 to 15.0 mm) and the ratio of the coarctation diameter to the descending aorta diameter measured at the level of the diaphragm (CoA/DAo ratio) (group I 0.4 to 0.93; group II 0.46 to 0.94) increased significantly in both groups (all p < 0.05). The mean systolic gradient decreased significantly in both groups (group I 23.0 to 2.0 mm Hg; group II 24.0 to 2.8 mm Hg; both p = 0.001). No difference was found between the groups in the CoA/DAo ratio, residual systolic gradients, or the decrease in systolic gradient after stent implantation. There were no significant complications in patients under 30 kg.

CONCLUSIONS

As in larger patients, use of large stents for treatment of CoA in small children is effective and safe in the short term. In these patients, stent redilations will be required, and follow-up is ongoing.

The role of stents in the treatment of congenital heart disease: Current status and future perspectives

Intravascular or intracardiac stenoses occur in many forms of congenital heart disease (CHD). Therefore, the implantation of stents has become an accepted interventional procedure for stenotic lesions in pediatric cardiology. Furthermore, stents are know to be used to exclude vessel aneurysm or to ensure patency of existing or newly created intracardiac communications. With the further refinement of the first generation of devices, a variety of "modern" stents with different design characteristics have evolved. Despite the tremendous technical improvement over the last 20 years, the "ideal stent" has not yet been developed. Therefore, the pediatric interventionalist has to decide which stent is suitable for each lesion. On this basis, currently available stents are discussed in regard to their advantages and disadvantages for common application in CHD. New concepts and designs developed to overcome some of the existing problems, like the failure of adaptation to somatic growth, are presented. Thus, in the future, biodegradable or growth stents might replace the currently used generation of stents. This might truly lead to widening indications for the use of stents in the treatment of CHD.

An unexpected finding late after repair of coarctation of the aorta

We describe a late complication in a 75-year-old man 50 years after repair of a coarctation of the aorta (CoA). Two years after an aortic valve replacement, mitral valve repair and radiofrequency MAZE the patient presented with dyspnoea and right-sided heart failure, based on a large pseudoaneurysm of the descending aorta, compressing the main bronchus and possibly temporarily the pulmonary arterial system. After sealing the aneurysm with an endovascular stent the patient recovered uneventfully. Recommendations are made for follow-up in patients after repair of CoA. (Neth Heart J 2008;16:260-3.).

Long-term (up to 20 years) results of percutaneous balloon angioplasty of recurrent aortic coarctation without use of stents

AIMS

To assess the efficacy, safety, and long-term results of the balloon angioplasty of recoarctation.

METHODS AND RESULTS

The angioplasty was performed in 99 consecutive patients aged 36 days to 32.6 years (median 268 days). Recoarctation to descending aorta diameter ratio increased from 0.44 (0.35/0.50) to 0.66 (0.57/0.77), P < 0.001. Systolic gradient was reduced from 34.0 (26.0/44.75) to 15.0 (8.25/27.0) mmHg, P < 0.001. In seven patients (7.1%) the procedure was ineffective. One patient (1%) with heart failure died within 24 h after a successful angioplasty and in another (1%) an intimal abruption necessitated surgical revision. The follow-up ranged up to 20.7 years (median 8.1 years). Actuarial probability of survival 20.7 years after the procedure was 0.91, and of reintervention-free survival was 0.44. Older age at the angioplasty was associated with a higher incidence of reinterventions (hazard ratio 1.057; 95% confidence interval 1.012-1.103; P = 0.010). The type of surgery and the recoarctation anatomy did not influence the outcome. In 69 patients aneurysm formation was studied by high-sensitive methods with only one positive finding per 462 patient-years.

CONCLUSION

Angioplasty is safe and effective regardless of the type of surgery used and the recoarctation anatomy. Older age at the angioplasty is associated with a higher incidence of reinterventions.

Adult congenital heart disease: a 2008 overview

INTRODUCTION

During the past decades, health care of patients born with congenital heart disease (CHD) has improved substantially, leading to a growing population of adult survivors.

SOURCE OF DATA

Using the recently published and relevant data on adult CHD (ACHD), we reviewed the most common congenital heart defects and discussed important related issues.

AREAS OF AGREEMENT

Adults with CHD most often require specialized medical or surgical care in a tertiary centre. However, this population also need local follow-up; general practitioners and other specialists therefore have to face the complexity of their disease. AREAS OF CONTROVERSIES: Management of pregnancy, non-cardiac surgery, arrhythmias and endocarditis prophylaxis may be challenging in patients with CHD and should be adapted to their condition.

GROWING POINTS

The present article summarizes key clinical information on ACHD for the benefit of physicians who are not specialized in this field. Areas timely for developing research Research efforts and education strategies are greatly needed in order to optimize the care of patients with ACHD.

Implantation of stents for treatment of recurrent and native coarctation in children weighing less than 20 kilograms

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.

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.

The adult with repaired coarctation of the aorta

Coarctation of the aorta is a common congenital lesion that may often be repaired or intervened upon early in life. The management of patients with this disorder revolves around the concept that although the coarctation may be treated, what remains is a diffuse systemic cardiovascular disorder. Careful clinical care and investigation is required to reduce morbidity from recurrent disease and residual lesions. The natural and modified history of the disorder is reviewed. This article focuses on the clinical care of adults with repaired coarctation and includes a review of clinical goals and investigation as well as indications for reintervention.

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.

Long-term results (up to 18 years) of balloon angioplasty on systemic hypertension in adolescent and adult patients with coarctation of the aorta

BACKGROUND

Little is known regarding the long-term follow-up results of balloon angioplasty (BA) for patients with aortic coarctation (AC) on systemic hypertension.

HYPOTHESIS

To define the long-term effect of BA of AC on systemic hypertension in adolescent and adult patients.

METHODS

Follow-up data of 53 patients (36 male), mean age 24 +/- 9 years, undergoing BA for discrete AC at median interval of 11.8 years (range, 4-18 years), including cardiac catheterization, magnetic resonance imaging (MRI), and echocardiography. Patients were divided into two groups at 1 year after BA on the basis of absence (group A: 40 patients) or presence (group B: 11 patients) of persistent hypertension and need for medication.

RESULTS

Fifty-one patients had baseline hypertension, BA produced an immediate reduction in peak AC gradient from 66 +/- 23 mmHg to 10.8 +/- 7 mmHg (p < 0.0001). The immediate systolic blood pressure (SBP) decreased from 165 +/- 17 mmHg (95% CI: 159 to 171) to 125 +/- 10 mmHg (95% CI: 122 to 131) (p < 0.001) in 40 patients (group A) and from 184 +/- 19 mmHg (95% CI: 169 to 198) to 142 +/- 22 mmHg (95% CI: 124 to 156) (p<0.001) in 11 patients (group B). At 1-year follow-up, SBP decreased further to 115 +/- 10 in group A (95% CI 111-119) and 134 +/- 19 in group B (95% CI 122-142) (p<0.001). The blood pressure had normalized without medication in group A (165 +/- 17 to 115 +/- 10 mmHg).

CONCLUSION

Long-term results of BA for discrete AC are excellent and should be considered as the first option for treatment of this disease. No paradoxical hypertension occurred post angioplasty, and normalization of blood pressure without medication occurred in 78% of the patients after BA.

Surgery is the best treatment for primary coarctation in the majority of cases

Today, the availability of competing techniques for coarctation repair, including numerous surgical approaches as well as interventional ones, raises important questions about indications, risks and criteria for procedural success. Surgical treatment of coarctation is an extremely well tolerated procedure with excellent long-term efficacy due to an 88 to 96% 5 years freedom from re-intervention in patients operated on within the first months of life. If compared with surgery, balloon angioplasty features a higher risk for aneurysm formation, aortic rupture and a lower degree of success, with potentially important residual pressure gradient in up to 20.7% of patients. Stents are believed to overcome the problems of simple dilation, but concerns remain about the materials and the potential of re-expandibility in view of the growth of the treated aorta. Moreover, serious complications, including death, have been reported by stent implantation as well, similar to aneurysms or dissections (4.3%), balloon rupture with stent migration or cerebral vascular injury (9%). There is no evidence to date for the superiority of any interventional approach to surgical treatment of primary coarctation. The favorable long-term surgical results outweigh the proposed short-term benefits of angioplasty and stenting, which should be restricted to well selected cases.

Endovascular stenting for aortic coarctation

Surgery had been the traditional treatment for native coarctation of the aorta, one of the most common cardiovascular congenital malformations. As a less invasive mode of treatment, balloon angioplasty has emerged as an alternative to surgery but has not gained universal acceptance due to its rates of restenosis secondary to vessel recoil and concerns over aortic wall injury resulting in aneurysm formation. To overcome these problems, endovascular stents were introduced in the management of this condition. The early- and intermediate-term results are encouraging, with low rates of restenosis and complications. In this article, the authors review the current evidence on coarctation stenting and discuss future trends in this area.

Covered Cheatham-platinum stents for aortic coarctation: early and intermediate-term results

OBJECTIVES

This study sought to evaluate the use of covered Cheatham-platinum (CP) stents in the treatment of aortic coarctation (CoA).

BACKGROUND

Aortic aneurysms and stent fractures have been encountered after surgical and transcatheter treatment for CoA. Covered stents have previously been used in the treatment of abdominal and thoracic aneurysms in adults. We implanted covered CP stents as a rescue treatment in patients with CoA aneurysms or previous stent-related complications and in patients at risk of developing complications because of complex CoA anatomy or advanced age.

METHODS

Thirty-three covered CP stents were implanted in 30 patients; 16 patients had had previous procedures. The remaining patients had complex or near-atretic CoA.

RESULTS

The mean patient age and weight were 28 (+/-17.5) years (range 8 to 65 years), and 62 (+/-13) kg (range 28 to 86 kg), respectively. The systolic gradient across the CoA decreased from a mean (+/-SD) of 36 +/- 20 mm Hg before to a mean of 4 +/- 4 mm Hg after the procedure (p < 0.0001), and the diameter of the CoA increased from 6.4 +/- 3.8 mm to 17.1 +/- 3.1 mm (p < 0.0001). The follow-up period was up to 40 months (mean, 11 months). All stents were patent and in good position on computed tomography or magnetic resonance imaging performed three to six months later. In 43% of the patients antihypertensive medication was either decreased or stopped.

CONCLUSIONS

Covered CP stents may be used as the therapy of choice in patients with complications after CoA repairs, whereas they provide a safe alternative to conventional stenting in patients with severe and complex CoA lesions or advanced age.