Endovascular treatment of aortic coarctation using covered balloon-expandable stents-a systematic review and meta-analysis

Objectives

Balloon dilation followed by balloon-expandable stent implantation is an effective treatment for improving hemodynamic status in patients with coarctation of the aorta (CoA). However, limited evidence exists regarding the safety and efficacy of covered balloon-expandable stents (CBSs) in a large cohort. In this meta-analysis, we aimed to evaluate the overall success rates, hemodynamic and anatomical benefits, complications, and mid-term results of CBSs in treating CoA.

Methods

The PubMed, Embase, and Cochrane Library databases were systemically searched for studies reporting outcomes of CBSs in treating CoA. Single-group rate meta-analyses were performed to calculate estimated pooled procedural success rates, the incidence of complications, and re-coarctation rates. A meta-analysis using standardized mean differences was conducted to compare pre- and postoperative trans-coarctation pressure gradients (PGs), coarctation diameter, and overall changes in systolic blood pressure (SBP). Subgroup analyses were performed to identify potential sources of heterogeneity.

Results

The final analysis included 12 studies with a total of 411 patients. The estimated pooled procedural success rate was 100% [95% confidence interval (CI): 98%-100%, I2 = 0, P = 0.78]. Significant decreases in trans-coarctation PGs and SBP were observed. The pooled incidences of stent-related, aortic, and access site complications were 2% (95% CI: 0%-5%, I 2 = 30.4%, P = 0.15), 2% (95% CI: 0%-4%, I 2 = 0%, P = 0.76), and 3% (95% CI: 1%-7%, I 2 = 52.9%, P = 0.02), respectively. Subgroup analyses showed that implantation of BeGraft stents was related to a significantly higher incidence of access site complications.

Conclusion

Covered balloon-expandable stent implantation in treating CoA is safe and effective with high procedural success rates, an acceptable incidence of complications, and a low incidence of re-coarctation.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, PROSPERO (CRD42023430356).

Coarctation of the Aorta and Late-Onset Sepsis With Supraventricular Tachycardia: A Clinical Case Review

We report a case of an 11-day-old male infant who presented to our hospital with complaints of breathing difficulty and cough for two days prior to admission. The child had a seizure post-admission which was controlled with phenobarbitone. The child was connected to a mechanical ventilator. The baby also had persistent tachycardia, which upon doing an electrocardiogram (ECG) led to a diagnosis of supraventricular tachycardia (SVT). Additional investigations revealed the existence of late-onset sepsis (LOS), which was treated with appropriate antibiotics. In view of weak femoral pulses with normal brachial pulses, a diagnosis of coarctation of the aorta (CoA) was entertained. The diagnosis was confirmed by an echocardiogram, and the baby was transferred to a higher-level medical center for surgical correction. Regrettably, the baby succumbed to heart failure and shock on the 12th day of life. This case highlights the infrequency of CoA accompanied by SVT. The case delves into the challenges of diagnosing the condition, the necessary medical interventions, and the unforeseen complications that must be considered to reduce mortality in such circumstances.

Surgically induced aortic coarctation in a neonatal porcine model allows for longitudinal assessment of cardiovascular changes

Noncritical aortic coarctation (COA) typically presents beyond early childhood with hypertension. Correction of COA does not ensure a return to normal cardiovascular health, but the mechanisms are poorly understood. Therefore, we developed a porcine COA model to study the secondary cardiovascular changes. Eight male neonatal piglets (4 sham, 4 COA) underwent left posterolateral thoracotomy with descending aorta (DAO) mobilization. COA was created via a 1-cm longitudinal DAO incision with suture closure, plication, and placement and an 8-mm external band. All animals had cardiac catheterization at 6 (11-13 kg), 12 (26-31 kg), and 20 (67-70 kg) wk of age. Aortic luminal diameters were similar along the thoracic aorta, except for the COA region [6.4 mm COA vs. 17.3 mm sham at 20 wk (P < 0.001)]. Collateral flow could be seen as early as 6 wk. COA peak systolic pressure gradient was 20 mmHg at 6 wk and persisted through 20 wk increasing to 40 mmHg with dobutamine. Pulse pressures distal to the COA were diminished at 12 and 20 wk. This model addresses many limitations of prior COA models including neonatal creation at an expected anatomic position with intimal injury and vessel sizes similar to humans.NEW & NOTEWORTHY A neonatal model of aortic coarctation was developed in a porcine model using a readily reproducible method of aortic plication and external wrap placement. This model addresses the limitations of existing models including neonatal stenosis creation, appropriate anatomic location of the stenosis, and intimal injury creation and mimics human somatic growth. Pigs met American Heart Association (AHA) criteria for consideration of intervention, and the stenoses were graded as moderate to severe.

One-stop interventional procedure for bicuspid aortic stenosis in a patient with coexisting aortic coarctation: a case report

Introduction

Coarctation of the aorta (CoA) is usually diagnosed and corrected early in life. Most untreated patients with CoA usually die before 50 years of age. Adult patients with concomitant CoA and severe bicuspid aortic stenosis are relatively rare and present complex management challenges without standard guidelines.

Case summary

A 63-year-old female patient with uncontrolled hypertension was admitted due to chest pain and dyspnea upon exertion (NYHA grades III). Echocardiogram showed a severely calcified and stenotic bicuspid aortic valve (BAV). A severe stenotic calcified eccentric aortic coarctation 20 mm distal to the left subclavian artery (LSA) was discovered by computed tomography (CT) angiography. Following consultation with the cardiac team and patient willingness, we performed a one-stop interventional procedure to repair both defects. First, a cheatham-platinum (CP) stent was implanted via the right femoral access, immediately distal to the LSA. Due to the markedly twisted and angled descending aortic arch, we chose to perform transcatheter aortic valve replacement (TAVR) via the left common carotid artery. The patient was discharged and followed up for 1 year without symptoms.

Discussion

Although surgery is still the main treatment for these diseases, it is not suitable for high-risk surgical patient. Transcatheter intervention for patients with severe aortic stenosis complicated with CoA simultaneously is rarely reported. The success of this procedure depends on the patient's vascular condition, the skills of the heart team, and the availability of the technical platform.

Conclusion

Our case report demonstrates the feasibility and efficacy of a one-stop interventional procedure in an adult patient with concurrent severely calcified BAV and CoA via two different vascular approaches. Transcatheter intervention, in contrast to traditional surgical approaches or two-stop interventional procedures, as a minimally invasive and novel method, offers a wider range of therapeutic methods for such diseases.

4D flow MRI derived aortic hemodynamics multi-year follow-up in repaired coarctation with bicuspid aortic valve

PURPOSE

The purpose of this study was to investigate the relationships between hemodynamic parameters and longitudinal changes in aortic dimensions on four-dimensional (4D) flow magnetic resonance imaging (MRI) in patients with bicuspid aortic valve (BAV) and repaired coarctation.

MATERIALS AND METHODS

The study retrospectively included patients with BAV and childhood coarctation repair who had at least two cardiothoracic MRI examinations including 4D flow MRI at baseline and follow-up. Analysis included the calculation of aortic peak velocities, wall shear stress (WSS), pulse wave velocity (PWV), aortic dimensions and annual growth rates. Differences between examinations were assessed using paired t-test or Wilcoxon signed rank test. Relationships between growth rate and 4D flow metrics were assessed using Pearson or Spearman correlation tests.

RESULTS

The cohort included 15 patients (mean age 35 ± 8 [SD] years, 9 men) with a median follow-up time of 3.98 years (Q1: 2.10; Q3: 4.96). There were no significant differences in aortic mean WSS, peak velocities, and PWV between baseline and follow-up values. Greater baseline peak velocities at the site of the coarctation were strongly associated with aortic narrowing (follow-up vs. baseline diameter) at coarctation zone (r = -0.64; P = 0.010) and moderately in descending aorta (r = -0.53; P = 0.042). In addition, increased baseline WSS in the aortic arch was strongly related with narrowing of the coarctation zone at follow-up (r = -0.64, P = 0.011).

CONCLUSION

Measures of aortic hemodynamics and aortic WSS are stable over time in patients with BAV with coarctation repair. Increased peak velocity was associated with a progressive narrowing at the site of the coarctation repair.

Heart team approach for comprehensive management of aortic coarctation in the adult

BACKGROUND

Aortic coarctation in the adult is usually associated with chronic systemic hypertension, which leads to the sequelae of congestive heart failure, vascular dysfunction and decreased lifespan. Open and endovascular treatment modalities both provide excellent procedural outcomes with minimal mortality and morbidity, but a structured algorithm for workup and periprocedural decision making is not well established. We outline our heart team decision making approach along with our institution's experience treating this condition.

METHODS

We retrospectively reviewed twenty-four consecutive adult patients treated for aortic coarctation since 2010 at a single center. Outcomes of interest included mortality, treatment approach, device used and post-procedure hypertension status. We describe our protocol for work-up and intervention decision making. We explain our rationale for recommending treatment and the approach, open or endovascular, using existing literature and our experience.

RESULTS

Procedural success rate was 100%, and there were no 30-day, one-year or five-year mortalities, whether the approach was open or endovascular. At last contact, 32% of patients were normotensive and no longer taking blood pressure medications. Several patients presented with complex problems as a result of commonly described complications of prior open or endovascular repair, and we describe our approach to the management of these difficult cases.

CONCLUSIONS

Even at a high-volume heart and vascular hospital, aortic coarctation is an uncommon presentation in adult patients. Our experience suggests that excellent outcomes are obtained by discussing each patient among a multidisciplinary heart team and developing a work-up and treatment protocol to guide selection of interventional modality.

Coarctation of the Aorta in Adolescence: Significance of Detailed Cardiac Examination in Pediatric Hypertension

ABSTRACT

Although coarctation of the aorta (CoAo) is a congenital anomaly, it can pose a diagnostic challenge in those presenting beyond neonatal period, as some patients can remain asymptomatic until complications of hypertension develop later in life. Careful physical examination can play an important role in timely diagnosis and prevention of complications.We present 2 cases of adolescents with undiagnosed CoAo who both presented with nonspecific headaches and hypertension. Both were initially misdiagnosed as essential hypertension until careful detailed physical examination later detected weak/absent femoral pulses and discrepancy in upper and lower limb blood pressures. These findings raised the clinical suspicion of CoAo, which was confirmed on further investigations.Our cases highlight the importance of considering CoAo in the differential diagnosis of hypertension in adolescents. These cases also stress the significance of detailed cardiac examination including 4-limb blood pressure and femoral pulses in a patient presenting to the emergency department with high blood pressure irrespective of the primary complaint.

Deep Learning Based Centerline-Aggregated Aortic Hemodynamics: An Efficient Alternative to Numerical Modelling of Hemodynamics

Image-based patient-specific modelling of hemodynamics are gaining increased popularity as a diagnosis and outcome prediction solution for a variety of cardiovascular diseases. While their potential to improve diagnostic capabilities and thereby clinical outcome is widely recognized, these methods require considerable computational resources since they are mostly based on conventional numerical methods such as computational fluid dynamics (CFD). As an alternative to the numerical methods, we propose a machine learning (ML) based approach to calculate patient-specific hemodynamic parameters. Compared to CFD based methods, our approach holds the benefit of being able to calculate a patient-specific hemodynamic outcome instantly with little need for computational power. In this proof-of-concept study, we present a deep artificial neural network (ANN) capable of computing hemodynamics for patients with aortic coarctation in a centerline aggregated (i.e. locally averaged) form. Considering the complex relation between vessels shape and hemodynamics on the one hand and the limited availability of suitable clinical data on the other, a sufficient accuracy of the ANN may however not be achieved with available data only. Another key aspect of this study is therefore the successful augmentation of available clinical data. Using a statistical shape model, additional training data was generated which substantially increased the ANNs accuracy, showcasing the ability of ML based methods to perform in-silico modelling tasks previously requiring resource intensive CFD simulations.

RNA sequencing analyses in infants patients with coarctation of the aorta

BACKGROUND

Coarctation of the aorta (CoA) is a serious innate heart disease. Although surgery results are generally good, some complications such as recoarctation and aortic aneurysm or persistent hypertension were serious threats to patient's health. To better understand the pathology of CoA and its underlying molecular mechanism is particularly important for early diagnosis and preventing the occurrence of its complications. However, the mechanisms of CoA remain unclear, especially for infants.

METHODS

RNA sequencing (RNA-seq) was used to identify the differentially expressed genes (DEGs) in vascular tissues of 12 patients with CoA and 10 normal participants form 3- to 34-month-old infants. The characteristic of DEGs were validated by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) and immunochemical staining (IHC) in vessels of patients with CoA and normal infants.

RESULTS

A total of 2491 DEGs with the false discovery rate less than 0.05(> 1.5-fold, P < 0.05 change) were identified, including 443 upregulated genes and 2048 downregulated genes. The Gene Ontology enrichment analysis showed that 26 out of the 2491 DEGs identified were associated with cardiovascular diseases. These 26 genes were mainly associated with extracellular matrix (ECM) and smooth muscle cells (SMCs) differentiation. Three DEGs, that is, CNN1 (calponin), α-actinin1 and myosin heavy chain 11 MYH11, were validated using qRT-PCR and Western blot analysis. In addition, immunochemical staining showed that calponin and MYH11 were highly expressed on the surface and in the deep layers of the thickened intima respectively.

CONCLUSION

This study comprehensively characterized the CoA transcriptome. Migration of extracellular matrix (ECM) and smooth muscle cells (SMCs) to the subendothelial space may be the major characteristic of CoA in infants.

Open anatomical repair for primary coarctation of the aorta in adults

OBJECTIVES

Although endovascular repair has become an alternative treatment for coarctation of the aorta (CoA) in adults, open repair provides concomitant repair of other cardiac complications, including post-stenotic aneurysm, ascending aortic aneurysm, and intracardiac diseases. We evaluated open anatomical repair for CoA repair in adults.

METHODS

Eleven patients (6 men, age range 21-63 years) underwent primary CoA repair. Complicating conditions included post-stenotic aortic aneurysm in the descending aorta in 5 patients (45.5%) and ascending aortic aneurysm in 3 (27.3%). Two patients (18.2%) had a bicuspid aortic valve, and one (9.1%) had a quadricuspid aortic valve. Ventricular septal defect was detected in 1 patient (9.1%). Eight patients (72.7%) underwent descending aorta replacement through a left thoracotomy, comprising partial cardiopulmonary bypass in 4 and deep hypothermic circulatory arrest in 4. Of those, the left subclavian artery was reconstructed in 4 patients. The remaining 3 patients (27.3%) underwent total arch replacement, through a median sternotomy in 1 and using a combination of median sternotomy and thoracotomy in 2.

RESULTS

No in-hospital mortality was observed. No spinal cord ischemia or neurological events were encountered, but 1 patient (9.1%) who underwent CoA repair via median sternotomy and thoracotomy required prolonged ventilatory support for more than 48 h. During the follow-up of 90 months (interquartile range 65-124 months), no patient died or required reintervention for the repaired segment.

CONCLUSIONS

CoA in adults could be anatomically repaired with graft replacement both through the median sternotomy, the left thoracotomy, and the combination of both approaches, according to the complicated aortic or intracardiac lesions.

Analysis of the 2020 European Society of Cardiology (ESC) Guidelines for the Management of Adults With Congenital Heart Disease (ACHD)

Adult congenital heart disease (ACHD) continues to rapidly increase worldwide. With an estimated 1.5 million adults with ACHD in the USA alone, there is a growing need for better education in the management of these complex patients and multiple knowledge gaps exist. This manuscript comprehensively reviewed the recent (2020) updated European Society of Cardiology Guidelines for the management of ACHD created by the Task Force for the management of adult congenital heart disease of the European Society of Cardiology, with perioperative implications for the adult cardiac anesthesiologist and intensivist who may be called upon to manage these complex patients.

Myocardial strain pattern progress in patients with Coarctation of the Aorta undergoing aortic stenting

BACKGROUND AND AIM

Ventricular function evaluation in coarctation of the aorta (CoA) has become more sophisticated and precise with speckle tracking, revealing subclinical changes. However, CoA stenting treatment effects in on myocardial strain are still controversial. This study aimed to estimate the extent to which changes in left ventricular global longitudinal strain (LV GLS) occur in patients with CoA who undergo stenting.

METHODS

The study included 21 patients with CoA (median age: 15 years [8-39]) and 21 healthy individuals matched by age and gender. Clinical and echocardiographic evaluations were performed 1 day before, 6 months, and 1 year after stenting. Correlations between LV GLS and arm-leg gradient, isthmus gradient on echocardiogram, age at intervention, left ventricular mass, and ejection fraction were tested.

RESULTS

Before treatment, patients with CoA had lower LV GLS than the control group (-18.4% ± 1.96 vs -21.5% ± 1.37; P < .01), showing significant increase to -19.4% ± 2.1 at 6 months and -20.7% ± 2.19 at 1 year, P < .001. Only 28.5% (6 patients) had preserved GLS before treatment, improving to 80.9% (17 patients) in 1 year. The only variable correlated with low LV GLS values before treatment was age at intervention (Spearman's index = -0.571; P = .007).

CONCLUSION

Percutaneous therapy showed significant LV GLS improvement 12 months after aortic stenting. Older patients have lower GLS, suggesting that early intervention may have positive effects on preservation of LV systolic function.

Aortic elasticity after aortic coarctation relief: comparison of surgical and interventional therapy by cardiovascular magnetic resonance imaging

Background

Patients after aortic coarctation (CoA) repair show impaired aortic bioelasticity and altered left ventricular (LV) mechanics, predisposing diastolic dysfunction. Our purpose was to assess aortic bioelasticity and LV properties in CoA patients who underwent endovascular stenting or surgery using cardiovascular magnetic resonance (CMR) imaging.

Methods

Fifty CoA patients (20.5 ± 9.5 years) were examined by 3-Tesla CMR. Eighteen patients had previous stent implantation and 32 had surgical repair. We performed volumetric analysis of both ventricles (LV, RV) and left atrium (LA) to measure biventricular volumes, ejection fractions, left atrial (LA) volumes, and functional parameters (LAEF_Passive, LAEF_Contractile, LAEF_Reservoir). Aortic distensibility and pulse wave velocity (PWV) were assessed. Native T1 mapping was applied to examine LV tissue properties. In twelve patients post-contrast T1 mapping was performed.

Results

LV, RV and LA parameters did not differ between the surgical and stent group. There was also no significant difference for aortic distensibility, PWV and T1 relaxation times. Aortic root distensibility correlated negatively with age, BMI, BSA and weight (p < 0.001). Native T1 values correlated negatively with age, weight, BSA and BMI (p < 0.001). Lower post-contrast T1 values were associated with lower aortic arch distensibility and higher aortic arch PWV (p < 0.001).

Conclusions

CoA patients after surgery or stent implantation did not show significant difference of aortic elasticity. Thus, presumably other factors like intrinsic aortic abnormalities might have a greater impact on aortic elasticity than the approach of repair. Interestingly, our data suggest that native T1 values are influenced by demographic characteristics.

Preoperative Physiology, Imaging, and Management of Coarctation of Aorta in Children

Coarctation of the aorta (CoA) is a narrowing of the proximal thoracic aorta typically located at the junction of the aorta with the ductus arteriosus. While it is a simple lesion to understand, considerable variation exists in the anatomy and pathophysiology, leading to varied clinical presentation, management options, and prognosis. On the one hand critical CoA manifests in the neonatal period as a duct-dependent lesion, while less severe forms of obstruction present later in childhood or adulthood as hypertension or incidentally noted precordial murmurs. While transthoracic echocardiography is usually adequate, older children and adults may need more advanced imaging modalities like computed tomography and magnetic resonance imaging prior to intervention. Depending on the type of lesion, management options currently available include surgery and percutaneous balloon angioplasty and stenting. Even after successful interventions, these patients need life-long surveillance for residual aortic obstruction and systemic hypertension with variable long-term clinical outcomes.

The effects of age at correction of aortic coarctation and recurrent obstruction on adolescent patients: MRI evaluation of wall shear stress and pulse wave velocity

Background

Coarctation patients before curative reconstruction are exposed to abnormal flow patterns which potentially could cause wall deterioration. This study evaluated the effect of age at correction on the pulse wave velocity (PWV) and peak wall shear stress (WSS) in adolescent patients with corrected coarctation. Effects of valve morphology and presence of reobstruction were also evaluated.

Methods

Twenty-one patients aged 13.7 ± 2.6 years (mean ± standard deviation) were included (bicuspid aortic valve, n = 14; reobstruction, n = 9). Mean age at correction was 1.0 ± 1.8 years. PWV was determined from two high-temporal through-plane phase-contrast magnetic resonance imaging (MRI) acquisitions, for two segments: ascending aorta plus aortic arch and descending aorta. WSS was determined from four-dimensional flow MRI. Peak WSS over five systolic phases was determined for ascending aorta, aortic arch, and descending aorta.

Results

Patients with tricuspid aortic valve showed a significant correlation between the age at correction and descending aorta PWV (r_s = 0.80, p = 0.010). Significant differences were found between patients without and with reobstruction for peak WSS in the aortic arch (3.9 ± 1.3 Pa versus 6.5 ± 2.2 Pa, respectively; p = 0.003) and descending aorta (5.0 ± 1.3 Pa versus 6.7 ± 1.1 Pa, respectively; p = 0.005).

Conclusions

A prolonged period of abnormal haemodynamic exposure may result in increased aortic wall stiffening. The increased peak WSS as results of a reobstruction possibly promotes different disease progression, which endorse longitudinal follow-up examination of corrected coarctation patients.

Procedural risk factors, incidence and timing of reintervention after treatment for native coarctation of the aorta in children: a population-based study†

OBJECTIVES

The aim of the present study was to evaluate procedural risk factors, incidence and timing of reintervention because of recurrent aortic coarctation in children.

METHODS

The study cohort consisted of 304 patients with isolated coarctation: 251 underwent surgery and 53 were treated percutaneously (40 balloon angioplasty, 13 stent) at the Helsinki Children's Hospital in 2000-2012. Characteristics, intervention and reintervention data were retrospectively collected from clinical records until 2014 (median follow-up 7.9 years). Age- and sex-matched comparisons between the treatment groups were performed in 86 patients (surgery n = 43, percutaneous n = 43).

RESULTS

Forty of the 251 (16%) patients after surgery, 9/40 (23%) patients after balloon angioplasty and 4/13 (31%) patients after stent placement underwent a reintervention after a median time of 3.4, 11.7 and 19.5 months (P < 0.05), respectively. In the surgery group, all reinterventions occurred in children operated on ≤12 months of age and were related to lower body weight and smaller dimensions of the aorta. In the balloon angioplasty group, a higher post-procedure systolic arm-leg blood pressure gradient was associated with reintervention. After stent placement, three-fourths of the reinterventions were performed in a planned postinterventional catheterization. In the age- and sex-matched comparisons (median 5,7 years, range 0,5-17,6), post-procedure blood pressure gradients were higher (mean 10 vs 4 mmHg, P = 0.03), and reinterventions were more common (28%, 95% confidence interval 17-43 vs 2%, 95% confidence interval 0-12) in the percutaneous group compared to the surgery group.

CONCLUSIONS

Reinterventions after surgery in neonates were relatively common. In older children, percutaneous treatment carried a higher risk of reinterventions, which were mainly related to residual coarctation after primary treatment.

Three Stage Hybrid Approach for Congenital Aortic Coarctation and Bicuspid Aortic Valve With Severe Aortic Stenosis in an Adult Patient

Introduction

Report

Discussion

Aortic Coarctation/Arch Hypoplasia Repair: How Small Is Too Small

Aortic coarctation/arch hypoplasia is a relatively common congenital heart disease that leads to severe cardiovascular complications if left untreated. During the modern era, the mortality of the primary surgical repair is very low but the long-term issues, such as recurrent coarctation/arch reobstruction and hypertension, are still significant challenges. The former is related to the surgical repair performed particularly in the management of the smallish distal aortic arch, and for the latter, despite the "successful" repair of the aortic coarctation, the intrinsic vascular anomaly remains a significant long-term morbidity.

Coarctation of Aorta in Children

Coarctation of aorta (CoA) is a discrete narrowing in aorta causing obstruction to the flow of blood. It accounts for 6–8% of all congenital heart diseases. With advances in fetal echocardiography rate of prenatal diagnosis of coarctation of aorta has improved but it still remains a challenging diagnosis to make prenatally. Transthoracic echocardiography is mainstay of making initial diagnosis and routine follow-up. Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) are great advanced imaging tools for two-dimensional and three-dimensional imaging of aortic arch in complex cases. Based on type of coarctation, size of patient, severity of lesion, and associated abnormalities various management options like surgical treatment, transcatheter balloon angioplasty and transcatheter stent implantation are available. There is significant improvement in long-term survival from pre-surgical era to post-surgical era. But, among the postsurgical era patients, the long-term survival has not significantly changed between older and contemporary cohort. Patients with coarctation of aorta need lifelong follow-up event after successful initial intervention.

Endovascular repair of severe aortic coarctation, transcatheter aortic valve replacement for severe aortic stenosis, and percutaneous coronary intervention in an elderly patient with long term follow-up

To the best of our knowledge, there have not been any reports of total transcatheter approach including stenting of severe coarctation of the aorta (CoA), transcatheter aortic valve replacement (TAVR) for concomitant severe aortic valve stenosis, and percutaneous coronary intervention (PCI) to treat significant coronary artery disease in a single patient. We report a 70-year-old female, who presented with uncontrolled hypertension and acute decompensated heart failure (ADHF) and was found to have severe CoA, severe bicuspid aortic valve (BAV) stenosis, and significant proximal left anterior descending (LAD) coronary artery disease. In a multidisciplinary heart team meeting, we decided to perform an endovascular repair of both cardiac and vascular pathologies using a two-stage approach due to the significant comorbidities; mainly uncontrolled hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and severe calcifications of the ascending aorta. The procedures were successfully performed and the patient was asymptomatic 30 months later at follow-up and was without any significant gradients across the coarctation or the aortic valve.

Effect of stent implantation on blood pressure control in adults with coarctation of the aorta

BACKGROUND

Stenting of coarctation of the aorta (CoA) generally results in good angiographic results and a decrease in transcoarctation pressure gradient. However, effect on blood pressure control is less clear. The goal of the current retrospective analysis was to investigate the effects of CoA stenting on blood pressure control.

METHODS

A retrospective analysis was conducted in consecutive adult patients with a CoA who underwent a percutaneous intervention at one of the three participating hospitals. Measurements included office blood pressure, invasive peak-to-peak systolic pressure over the CoA, diameter of the intima lumen at the narrowest part of the CoA and use of medication. The follow-up data were obtained, based on the most recent examination date.

RESULTS

There were 26 native CoA and 17 recurrent CoAs (total n = 43). Seven of them underwent two procedures. Mean peak-to-peak gradient decreased from 27 mmHg to 3 mmHg (p < 0.001), and minimal diameter increased from a mean of 11 mm to 18 mm (p < 0.001). Mean systolic blood pressure decreased from 151 ± 18 mmHg to 135 ± 19 mmHg at first follow-up of 3.8 ± 1.9 months and 137 ± 22 mmHg at latest follow-up of 19.5 ± 10.9 months (p = 0.001 and p = 0.009, compared to baseline, respectively). The total number of hypertensive patients decreased from 74% to 27% at latest follow-up. No significant change in antihypertensive medication was observed.

CONCLUSION

A clinically significant decrease in systolic blood pressure of approximately 16 mmHg was shown after (re)intervention in CoA patients, which sustained at follow-up. This sustained decrease of blood pressure can be expected to lead to less future adverse cardiovascular events.

One-stage ascending-to-abdominal aortic bypass with concomitant aortic valve procedures for aortic coarctation combined with aortic valve pathology in adult patients

OBJECTIVE

This study aims to evaluate the results of one-stage ascending-to-abdominal aortic bypass and aortic valve replacement for concomitant aortic coarctation combined with aortic valve pathology.

METHODS

From June 2009 to March 2017, 28 consecutive adult patients (23 males and five females) with aortic coarctation combined with aortic valve pathology underwent one-stage ascending-to-abdominal aorta bypass and aortic valve replacement or a Bentall procedure. Patients were followed for a mean of 45.5 ± 26.5 months (range 3-96 months).

RESULT

All patients successfully underwent the one-stage procedure. No early deaths were recorded. The mean aortic cross-clamp and cardiopulmonary bypass times were 71 ± 23 and 113 ± 37 mins, respectively. Re-exploration for bleeding was performed on one patient (3.6%). The average post-operative hospital stay was 15.9 ± 4.9 days and the average operation time was 5.2 h. No paraplegia or stroke was observed. The blood pressure gradient of the upper and lower extremities significantly decreased (P < 0.001). Systolic blood pressure decreased from 158 ± 36 mmHg pre-operatively to 121 ± 18 mmHg post-operatively. No deaths or significant gradients between the upper and lower extremities occurred during follow-up. No death and complications of bypass grafts occurred during follow-up.

CONCLUSION

Ascending-to-abdominal aortic bypass and concomitant aortic valve procedures are a suitable therapeutic option for severe aortic coarctation combined with aortic valve pathology in adult patients.

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.

Diagnosis, imaging and clinical management of aortic coarctation

Coarctation of the aorta (CoA ) is a well-known congenital heart disease (CHD) , which is often associated with several other cardiac and vascular anomalies, such as bicuspid aortic valve (BAV), ventricular septal defect, patent ductus arteriosus and aortic arch hypoplasia. Despite echocardiographic screening, prenatal diagnosis of C o A remains difficult. Most patients with CoA present in infancy with absent, delayed or reduced femoral pulses, a supine arm-leg blood pressure gradient (> 20 mm Hg), or a murmur due to rapid blood flow across the CoA or associated lesions (BAV). Transthoracic echocardiography is the primary imaging modality for suspected CoA. However, cardiac magnetic resonance imaging is the preferred advanced imaging modality for non-invasive diagnosis and follow-up of CoA. Adequate and timely diagnosis of CoA is crucial for good prognosis, as early treatment is associated with lower risks of long-term morbidity and mortality. Numerous surgical and transcatheter treatment strategies have been reported for CoA. Surgical resection is the treatment of choice in neonates, infants and young children. In older children (> 25 kg) and adults, transcatheter treatment is the treatment of choice. In the current era, patients with CoA continue to have a reduced life expectancy and an increased risk of cardiovascular sequelae later in life, despite adequate relief of the aortic stenosis. Intensive and adequate follow-up of the left ventricular function, valvular function, blood pressure and the anatomy of the heart and the aorta are , therefore, critical in the management of CoA. This review provides an overview of the current state-of-the-art clinical diagnosis, diagnostic imaging algori thms, treatment and follow-up of patients with CoA.

Intravascular Treatment of Left Subclavian Artery Aneurysm Coexisting with Aortic Coarctation in an Adult Patient

Coexistence of aortic coarctation with aneurysm of subclavian artery is a uncommon situation and may require unusual treatment in patients. A 40-year-old patient diagnosed incidentally with left subclavian artery aneurysm coexisting with aortic coarctation. Patient was initially referred for hybrid treatment. Initially ostium of the left subclavian artery was covered with a stent-graft. Over a 30-month follow-up period aneurysm became thrombosed all the way up to the ostium of internal mammary artery. The patient did not present with neurological symptoms or signs of upper limb ischemia. Taking into consideration good blood supply to the axillary artery via reversed blood flow in the thyreocervical trunk, hence we decided not to proceed with cervicoaxillary bypass grafting. Implantation stent-graft into aorta coarctation with covering axillary artery is proper way of treatment and may need no other surgical procedures.

Coarctation of the Aorta: Strategies for Improving Outcomes

Coarctation of the aorta is a common congenital heart defect through which management has rapidly evolved over the last few decades. The role of transcatheter-based therapies is expanding and seems to be an effective treatment option for coarctation, especially in adults. Patients with prior coarctation repair are at risk of long-term complications related to prior surgeries and associated congenital heart defects, in particular, the risk of restenosis and aortic aneurysm development related to the timing and mode of prior intervention. This article outlines the evaluation and management of adults with unrepaired coarctation and patients after coarctation repair.

[Patient with a Fontan circulation undergoing caesarean section: Anesthesiological management]

Adults suffering from congenital heart diseases (CHD) represent a challenge to anesthesiologists because of the diverse pathologies, complex pathophysiology and special treatment strategies. Due to improved therapeutic options for CHD, patient quality of life and life expectancy is increasing, leaving them as a growing population including pregnant patients with CHD. This article presents the main principles of the pathophysiology and anesthesiological management of pregnant patients living with a Fontan circulation based on a case report, which was complicated by an aortic coarctation and atonic uterine hemorrhage.

Diagnostic Value of Transthoracic Echocardiography in Patients with Coarctation of Aorta: The Chinese Experience in 53 Patients Studied between 2008 and 2012 in One Major Medical Center

Although aortography is well known as the "gold standard" for the diagnosis of coarctation of aorta (CoA), the method is invasive, expensive and not readily accepted by some patients. Ultrasound diagnosis for CoA is non-invasive, inexpensive, readily accepted by every patient, and can be repeated as frequently as necessary. The purpose of this presentation is to evaluate the applicability of transthoracic echocardiography for the diagnosis of CoA. The echocardiographic appearances of 53 patients with CoA who had undergone surgery during a 5-year period from January 2008 to October 2012 were analyzed retrospectively, and the results were compared with findings at surgery. Fifty-three patients with CoA include six with isolated CoA and 47 of CoA associated with other cardiac anomalies. Of the 53 operated patients, 48 were correctly diagnosed preoperatively by echocardiography, while two were misdiagnosed as interrupted aortic arch and the diagnosis were missed in three other patients. Thus the diagnostic accuracy rate was 90.6%, and the misdiagnosis rate was 9.4%. Preoperative echocardiographic evaluation offers very satisfactory anatomic assessment in most patients with CoA. It makes preoperative angiography unnecessary. Thus transthoracic echocardiography should be the first-line method for the diagnosis of coarctation of the aorta.