Long-term, randomized comparison of balloon angioplasty and surgery for native coarctation of the aorta in childhood

Coarctation of the Aorta: Modern Paradigms Across the Lifespan

While coarctation of the aorta varies greatly in both severity and age at presentation, all patients are at increased risk of hypertension both before and after repair. Despite advances in knowledge about genetic etiologies, pathophysiologic mechanisms, and optimal repair strategies, patients with repaired coarctation of the aorta remain at increased risk of acquired cardiovascular disease. The aims of this review are to describe the management of coarctation of the aorta at all ages before and after repair, highlight pathophysiologic mechanisms of hypertension, and review long-term follow-up considerations.

Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author's Experiences and Observations-Part I

Balloon dilatation techniques became available to treat congenital obstructive lesions of the heart in the early/mid-1980s. The purpose of this review is to present the author's experiences and observations on the techniques and outcomes of balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS) and aortic coarctation (AC), both native and postsurgical re-coarctations. Balloon dilatation resulted in a reduction of peak pressure gradient across the obstructive lesion at the time of the procedure as well as at short-term and long-term follow-ups. Complications such as recurrence of stenosis, valvar insufficiency (for PS and AS cases) and aneurysm formation (for AC cases) have been reported, but infrequently. It was recommended that strategies be developed to prevent the reported complications.

Transcatheter Intervention for Coarctation of the Aorta: A Nordic Population-Based Registry With Long-Term Follow-Up

BACKGROUND

Coarctation of the aorta (CoA), a congenital narrowing of the proximal descending thoracic aorta, is a relatively common form of congenital heart disease. Untreated significant CoA has a major impact on morbidity and mortality. In the past 3 decades, transcatheter intervention (TCI) for CoA has evolved as an alternative to surgery.

OBJECTIVES

The authors report on all TCIs for CoA performed from 2000 to 2016 in 4 countries covering 25 million inhabitants, with a mean follow-up duration of 6.9 years.

METHODS

During the study period, 683 interventions were performed on 542 patients.

RESULTS

The procedural success rate was 88%, with 9% considered partly successful. Complications at the intervention site occurred in 3.5% of interventions and at the access site in 3.5%. There was no in-hospital mortality. During follow-up, TCI for CoA reduced the presence of hypertension significantly from 73% to 34%, but despite this, many patients remained hypertensive and in need of continuous antihypertensive treatment. Moreover, 8% to 9% of patients needed aortic and/or aortic valve surgery during follow-up.

CONCLUSIONS

TCI for CoA can be performed with a low risk for complications. Lifetime follow-up after TCI for CoA seems warranted.

Transient Recurrent Laryngeal Nerve Palsy after Interventional Therapy

BACKGROUND

 Hoarseness due to laryngeal nerve injury is a known complication after cardiothoracic surgery involving the aortic arch. However, this complication is only rarely reported after catheter interventions.

RESULTS

 In this article we present the unusual case of a left-sided vocal cord paralysis in four patients after primary stenting of a re-coarctation, re-dilatation of a stented coarctation, a primary stenting of the left pulmonary artery (LPA), and prestenting for percutaneous pulmonary valve implantation with dilation of the LPA. After implanting bare metal stents, it is common practice, whilst contemplating the diameters of the adjacent structures, to optimize the stent diameter in a two-step procedure and dilate the stent until a maximum diameter is achieved and there is no residual gradient after applying this technique. Four of our patients experienced hoarseness after the intervention and a vocal cord paralysis was diagnosed. Angiography revealed no signs of extravasation or dissection. Clinical symptoms improved over the course of the following 6 months; patients with interventions at the aortic arch showed a complete remission, patients with procedures involving the LPA showed only mild regression of the symptoms.

CONCLUSION

 To our knowledge, this complication (Ortner's syndrome, cardiovocal syndrome) after such interventions has rarely been reported before. Although a rare complication, the recognition of these symptoms may support colleagues in managing affected patients. In addition, awareness for hoarseness after interventional therapies and systematic screening for this complication might help to identify patients at risk in the future.

Endovascular Stent Repair of Aortic Coarctation in a Developing Country: A Single-Center Experience

BACKGROUND/PURPOSE

CoA remains one of the most common congenital heart diseases and is associated with significant morbidity and mortality and if untreated. We aim to evaluate the safety, feasibility, and outcomes of endovascular stenting of Coarctation of the aorta (CoA) in a developing country with limited resources and compare it to available benchmarks.

MATERIALS/METHODS

A retrospectively review of all patients who underwent endovascular stent repair of aortic coarctation at our tertiary center since 2009 was done.

RESULTS

18 patients were identified, sixteen had native CoA, while two had recurrent CoA. mean age at the time of procedure was 21.2 ± 9.8 years (range 10-45 years), and 12(66%) patients were males. The mean follow-up duration was 4 ± 2.8 years. Post stenting, the average ascending-to-descending aorta systolic gradient decreased by 42.9 ± 20.4 mmHg (p < 0.001). After the intervention, 13(72.2%) patients achieved normal BP while 5(27.8%) had residual hypertension. Fourteen patients received bare-metal stents, and four had covered stents. Attempted stent implantation was successful in all patients. Our procedural success rate was 94%. On follow-up, no dissections or aneurysmal changes were detected, four patients underwent re-expansion of the stent, one patient with suboptimal stenting result required surgery 6 months after stenting, and two patients had minor post-operative complications.

CONCLUSIONS

Endovascular stenting for de-novo or recurrent CoA in children and adults at a tertiary center in a developing country is feasible and safe with outcomes comparable to developed countries. A multidisciplinary team approach is paramount in achieving good results and low complication rates in limited-resource settings.

Coarctation of the aorta: Prenatal assessment, postnatal management and neonatal outcomes

Coarctation of the aorta (Coa) is a potentially life threatening diagnosis. It occurs in 0.3 per 1000 live births and accounts for 6-8% of all infants with congenital heart defects. Neonates with severe Coa may be completely asymptomatic at birth, as the ductus arteriosus can provide flow to the lower body. Those who are not diagnosed prenatally may be diagnosed only after constriction of the ductus arteriosus, when they present in cardiogenic shock. This group has a higher risk for mortality and morbidity relative to those diagnosed prenatally. Despite the increasing practice of universal pulse oximetry screening, many cases with significant coarctation of the aorta still go undiagnosed in the newborn period. In this article, we present the pathophysiology, diagnosis, presentation, treatment and outcomes of Coa.

Hypertension after coarctation repair-a systematic review

BACKGROUND

Coarctation of the Aorta (CoA) leads to increased morbidity and mortality later in life despite early surgical or percutaneous treatment. Many long-term complications are related to hypertension (HT) which is a common finding late after coarctation repair.

METHODS

A systematic Review was performed including articles published between February 2012 to December 2020. Systematic searches were conducted on PubMed and the Cochrane Controlled Trials Register to look for studies on HT after aortic CoA-repair. PRISMA guidelines were used.

RESULTS

In this systematic review on HT after CoA Repair the mean prevalence of HT was 47.3% (20-70%). A progressive character was of the HT was found, furthermore if only studies are included with 24 h blood pressure (BP) recording in addition to standard BP measurements, the incidence of HT rose to 57.8%.

DISCUSSION

Most clinical studies look at complications, mortality rate and residual pressure gradient rather than correlating hemodynamic indices with long-term outcome. Although HT is commonly based in measurement of peripheral BP, it has been shown that peripheral BP in CoA patients has a poor correlation with central aortic pressure. Central aortic hemodynamics are significantly altered in patients with repaired CoA, which can now adequately be investigated non-invasively. At the present time there are no studies linking long-term outcome with abnormal central hemodynamics.

Covered Stents in the Management of Aortic Coarctation and Right Ventricular Outflow Tract Obstruction

PURPOSE OF REVIEW

To review the use of covered stents in the treatment of coarctation of the aorta (CoA) and right ventricle to pulmonary artery (RV-PA) conduit obstruction.

RECENT FINDINGS

The only commercially available covered stent approved for treatment of CoA and dysfunctional RV-PA conduits is the covered Cheatham-Platinum stent (CCPS). Early outcomes have demonstrated its safety and have suggested its efficacy in treating or preventing aortic wall injury (AWI) or conduit disruption. A recent study of CCPS use for CoA reported a progressive risk of stent fracture over time and a risk of AWI despite the purported protection that the CCPS provides. The use of other covered stents has been reported, but large, systematic studies are lacking. CCPS use may reduce but does not eliminate the risk of conduit disruption or AWI. Structural limitations of the CCPS may predispose it to stent fracture. Access to a broad range of covered stents continues to be an unmet need in the field of congenital interventional cardiology.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The clinical presentation and outcome of aortic coarctation associated with left ventricular inflow and outflow tract lesion in adult patients: Shone syndrome and beyond

BACKGROUND

Aortic coarctation (AoCoa) is a congenital stenosis of aorta, which often co-exists with other congenital heart defects. Many studies have shown the importance of regular follow-up in these patients however there is scarcity of knowledge relating to the impact of left ventricle inflow lesions (LVIT) and left ventricle outflow track lesions (LVOT). The aim of this study is to evaluate the impact of isolated AoCoa with LVIT and/or LVOT on haemodynamic, morbidity and mortality.

METHODS

We have retrospectively analysed clinical data of all adult AoCoa patients who underwent echocardiography between 2010-2018 in our centre. Outcome measures included death, number of hospitalisations for cardiac causes, development of cardiac arrhythmia, new prescription of HF medication.

RESULTS

A total of 406 AoCoa patients were included and were followed for a median 4.2 years. At baseline, 38% patients had AoCoa alone, 54% patients had LVOT, 3% patients had LVIT, and 5% patients had mixed LVIT and LVOT, including patients with Shone syndrome. Patients with mixed LVIT and LVOT had the highest mortality of the four groups and the highest heart failure-related morbidity. Moreover, they were the most prone to have a higher indexed LA volume compared to patients with no LVOT (p=0.0001). During follow-up, 13 patients died, of which 21% patients were from the mixed LVIT and LVOT group.

CONCLUSIONS

AoCoa patients with a combination of LVIT and LVOT including Shone complex are associated with a significantly higher morbidity and mortality compared to AoCoa alone.

The effect of selective cerebral perfusion on cerebral versus somatic tissue oxygenation during aortic coarctation repair in neonates and infants

Background

Suboptimal tissue perfusion and oxygenation may be the root cause of certain perioperative complications in neonates and infants having complicated aortic coarctation repair. Practical, effective, and real-time monitoring of organ perfusion and/or tissue oxygenation may provide early warning of end-organ mal-perfusion.

Methods

Neonates/infants who were scheduled for aortic coarctation repair with cardiopulmonary bypass (CPB) and selective cerebral perfusion (SCP) from January 2015 to February 2017 in Children’s Hospital of Nanjing Medical University participated in this prospective observational study. Cerebral and somatic tissue oxygen saturation (SctO₂ and SstO₂) were monitored on the forehead and at the thoracolumbar paraspinal region, respectively. SctO₂ and SstO₂ were recorded at different time points (baseline, skin incision, CPB start, SCP start, SCP end, aortic opening, CPB end, and surgery end). SctO₂ and SstO₂ were correlated with mean arterial pressure (MAP) and partial pressure of arterial blood carbon dioxide (PaCO₂).

Results

Data of 21 patients were analyzed (age=75±67 days, body weight=4.4±1.0 kg). SstO₂ was significantly lower than SctO₂ before aortic opening and significantly higher than SctO₂ after aortic opening. SstO₂ correlated with leg MAP when the measurements during SCP were (r=0.67, p<0.0001) and were not included (r=0.46, p<0.0001); in contrast, SctO₂ correlated with arm MAP only when the measurements during SCP were excluded (r=0.14, p=0.08 vs. r=0.66, p<0.0001). SCP also confounded SctO₂/SstO₂’s correlation with PaCO₂; when the measurements during SCP were excluded, SctO₂ positively correlated with PaCO₂ (r=0.65, p<0.0001), while SstO₂ negatively correlated with PaCO₂ (r=-0.53, p<0.0001).

Conclusions

SctO₂ and SstO₂ have distinct patterns of changes before and after aortic opening during neonate/infant aortic coarctation repair. SctO₂/SstO₂’s correlations with MAP and PaCO₂ are confounded by SCP. The outcome impact of combined SctO₂/SstO₂ monitoring remains to be studied.

Implantation of Covered Stent for Coarctation of the Aorta and Secondary Hypertension in Adolescents—Case Report

Introduction: Coarctation of the aorta represents a narrowing of the thoracic aorta. Hypertensive patients with blood pressure differences ≥20 millimetres of mercury have an indication for surgical or interventional treatment. Implantation of a covered stent became the preferred therapy for the management of this pathology in adolescents/adults. Case report: We report the case of a 14-year-old male sportsman, who presented in the emergency room with headache, dizziness, and tinnitus. The clinical exam revealed blood pressure differences between the upper and lower limbs of up to 50 mmHg. Based on the clinical and paraclinical data, we established the diagnosis of coarctation of the aorta and severe secondary arterial hypertension. The case was discussed by a multidisciplinary team and accepted for covered stent implantation. The 24 h blood pressure Holter monitoring after the procedure indicated the persistence of stage I arterial hypertension. Conclusions: Coarctation of the aorta is a congenital cardiovascular anomaly with high morbidity and mortality rates. Arterial hypertension, heart failure, and aortic dissection are complications of this pathology, some of them being sometimes direct consequences of secondary hypertension. Periodic cardiology follow up after the procedure is mandatory to assess the hemodynamic response, to identify potential complications, and to stratify the cardiovascular risk.

Managing confounding and effect modification in pediatric/congenital interventional cardiology research

Measuring the effect of a treatment on outcomes is an important goal for research in pediatric/congenital interventional cardiology. The breadth of anatomic and physiologic variations, patient ages, and genetic syndromes and noncardiac comorbid conditions all represent sources of potential confounding and effect modification that are major obstacles to this goal. If not accounted for, these factors can obscure the "true" treatment effect and lead to spurious conclusions about the relative efficacy and/or safety of therapies. In this review, we discuss the importance of confounding and effect modification in pediatric/congenital interventional cardiology research. We define these terms and discuss strategies (both in study design and data analysis) to mitigate error introduced by confounding and effect modification. The importance of confounding by indication in pediatric/congenital cardiology is discussed along with specific methods to address it.

Coarctation of Aorta in Turner Mosaicism

The prevalence of hypertension in the pediatric age range is estimated at 1-5% worldwide, with higher rates in adolescence. Although primary hypertension is more common, due to the increasing prevalence of obesity and metabolic syndrome among adolescents, secondary hypertension should be always considered and excluded. We present the case of an adolescent with secondary hypertension and a challenging diagnosis associated with coarctation of aorta and Turner Mosaicism.

Transcatheter Intervention for Congenital Defects Involving the Great Vessels: JACC Review Topic of the Week

Since the development of balloon angioplasty and balloon-expandable endovascular stent technology in the 1970s and 1980s, percutaneous transcatheter intervention has emerged as a mainstay of therapy for congenital heart disease (CHD) lesions throughout the systemic and pulmonary vascular beds. Congenital lesions of the great vessels, including the aorta, pulmonary arteries, and patent ductus arteriosus, are each amenable to transcatheter intervention throughout the lifespan, from neonate to adult. In many cases, on-label devices now exist to facilitate these therapies. In this review, we seek to describe the contemporary approach to and outcomes from transcatheter management of major CHD lesions of the great vessels, with a focus on coarctation of the aorta, single- or multiple-branch pulmonary artery stenoses, and persistent patent ductus arteriosus. We further comment on the future of transcatheter therapies for these CHD lesions.

Case Report: Trans-axillary Artery Access for Rescue Stent Implantation in an Infant With Retrograde Non-passable Aortic Coarctation

Primary surgical repair remains the traditional treatment for patients with critical duct-dependent coarctation of the aorta (CoA). Initial surgical repair might not be possible or associated with higher risks if additional comorbidities arise in small infants and neonates. Balloon angioplasty (BA) has been described as a rescue strategy for these children. We describe the feasibility of a palliative BA and rescue stent implantation via an alternative antegrade right-axillary artery approach in an initially inoperable infant with pneumonia and respiratory failure and severe CoA, where the stenosis was not passable by traditional retrograde femoral access. This case adds new aspects to the therapy of critical CoA: Stent implantation provides a bridge to surgery in critically ill infants and does not preclude successful surgical repair. Further, if the classic retrograde approach is not possible, the right axillary artery access should be considered as an alternative to pass the stenosis.

Two decades of aortic coarctation treatment in children; evaluating techniques

Objective

This study focuses on the evolution of treatment techniques for aortic coarctation in children and assesses long-term morbidity.

Methods

This retrospective cohort study evaluates patients treated for native aortic coarctation, with at least 7 years of follow-up. To assess time-related changes, three time periods were distinguished according to year of primary intervention (era 1, 2 and 3). Operative and long-term follow-up data were collected by patient record reviews.

Results

The study population consisted of 206 patients (177 surgical and 29 catheter-based interventions), with a median follow-up of 151 months. Anterior approach with simultaneous repair of aortic arch and associated cardiac lesions was more common in the most recent era. Median age at intervention did not change over time. Reintervention was necessary in one third of the cohort with an event-free survival of 74% at 5‑year and 68% at 10-year follow-up. Reintervention rates were significantly higher after catheter-based interventions compared with surgical interventions (hazard ratio [HR] 1.8, 95% confidence interval [CI] 1.04–3.00, p = 0.04) and in patients treated before 3 months of age (HR 2.1, 95% CI 1.27–3.55, p = 0.003). Hypertension was present in one out of five patients.

Conclusion

Nowadays, complex patients with associated cardiac defects and arch hypoplasia are being treated surgically on bypass, whereas catheter-based intervention is introduced for non-complex patients. Reintervention is common and more frequent after catheter-based intervention and in surgery under 3 months of age. One fifth of the 206 patients remained hypertensive.

Aortic Coarctation

Aortic coarctation is a discrete narrowing of the thoracic aorta. In addition to anatomic obstruction, it can be considered an aortopathy with abnormal vascular properties characterized by stiffness and impaired relaxation. There are surgical and transcatheter techniques to address the obstruction but, despite relief, patients with aortic coarctation are at risk for hypertension, aortic complications, and abnormalities with left ventricular performance. This review covers the etiology, pathophysiology, diagnosis, and management of adults with aortic coarctation, with emphasis on multimodality imaging characteristics and lifelong surveillance to identify long-term complications.

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.

Self-Expandable Stents in Vascular Stenosis of Moderate to Large-Sized Vessels in Congenital Heart Disease: Early and Intermediate-Term Results

Background and Objectives

Vascular stenosis after surgical repair frequently occurs in congenital heart disease. Although conventional balloon dilation is a useful option for stenotic lesions, restenosis may occur. Consequently, balloon expandable stents have been used; however, there are a limited number of balloon expandable stents in our country. Here, we report the early and intermediate-term outcomes of self-expandable stents in vascular stenosis of moderate to large-sized vessels in congenital heart disease.

Methods

Twelve self-expandable stents were implanted in 9 patients between February 2012 and January 2019. The median age and weight were 12 years (range, 4–39 years) and 38 kg (range, 19–69 kg), respectively. The patients were followed-up for a median duration of 43 months (range, 1–83 months) after stent implantation.

Results

Nine self-expandable stents were implanted in the pulmonary artery, 2 stents in the right ventricle to the pulmonary artery conduit, and 1 stent in the coarctation. The narrowest diameter of the stented vessel increased from 5.7±3.2 mm to 12.6±3.4 mm (p<0.05). The mean pressure gradient across the stenotic lesion decreased from 23.0±28.2 mmHg to 3.2±3.6 mmHg (p<0.05). Distal migration of the stent occurred in 1 patient, and significant neointimal ingrowth was noted in 1 patient.

Conclusions

The self-expandable stent may be a useful option to relieve vascular stenosis in moderate to large-sized vessels with acceptable intermediate-term outcomes.

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.

Perioperative and Anesthetic Management of Coarctation of the Aorta

Isolated coarctation of the aorta is a relatively common form of congenital heart disease that is characterized by variable degrees of obstruction to aortic outflow. The clinical presentation varies from asymptomatic arterial hypertension to cardiogenic shock. The treatment options include surgical repair or interventional therapy with aortic balloon dilation and stent placement. This article will summarize the pathophysiology as well as describe the surgical and interventional procedures. The anesthetic management for those interventions will be reviewed.

Self-Expanding Versus Balloon-Expandable Stents in Patients With Isthmic Coarctation of the Aorta

Endovascular stent implantation has become the treatment of choice for the management of patients with native coarctation of the aorta (CoA). The aim of this study was to compare the outcomes of self-expandable stenting (SES) with balloon-expandable stenting (BES) in the treatment of native CoA. In this single-center retrospective study, all patients who underwent SES or BES for the management of native CoA were enrolled. Patients were followed up for a median period of 35 (inter-quartile range 15 to 71) months. The primary outcome of interest was a composite end point consisted of death, surgical repair, re-stenting, re-ballooning, and hospital admission for hypertension crisis. The CoA diameter has changed from 3.2 ± 2.1 to 14.2 ± 4.0 mm in the BES group and from 4.6 ± 2.6 to 12.2 ± 3.7 mm in the SES group (both p <0.001). The procedure was successful with residual pressure gradient <20 mm Hg in 99.0% and 98.6% of patients in the BES and SES groups, respectively. Major adverse events occurred in 6 (8.7%) in the SES groups and 14 (20.3%) in the BES group (p = 0.053). Kaplan-Meier curve showed no difference between the 2 groups in terms of survival from major adverse events (p = 0.10), but when groups were matched for the propensity of stenting methods, SES was associated with lower major adverse events (p = 0.01). In conclusion, the SES and BES methods were safe and durable in our cohort with low rates of adverse events. After adjustment for the propensity of treatment with each stenting method, SES was associated with better outcomes. Regardless of the outcome of each method, it should be noted that the taken approach should be tailored to the patient's anatomy.

Coarctation repair-redo challenges in the adults: what to do?

Aortic coarctation is one of the most common congenital cardiac pathologies. Repair of native aortic coarctation is nowadays a common and safe procedure. However, late complications, including re-coarctation and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both endovascular and conventional open repair play important roles in the treatment of late complications after previous coarctation repair. This article will review the incidence of late complications after coarctation repair and will discuss the treatment options for redo coarctation repair in adult patients.

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.

The effects of tapering and artery wall stiffness on treatments for Coarctation of the Aorta

Coarctation of the Aorta is a congenital narrowing of the aorta. Two commonly used treatments are resection and end-to-end anastomosis, and stent placements. We simulate blood flow through one-dimensional models of aortas. Different artery stiffnesses, due to treatments, are included in our model, and used to compare blood flow properties in the treated aortas. We expand our previously published model to include the natural tapering of aortas. We look at change in aorta wall radius, blood pressure and blood flow velocity, and find that, of the two treatments, the resection and end-to-end anastomosis treatment more closely matches healthy aortas.

Midterm to long-term safety and efficacy of self-expandable nitinol stent implantation for coarctation of aorta in adults

PURPOSE

Endovascular treatment of coarctation of aorta (CoA) by self-expandable Nitinol stents is one of the recognized treatment methods and may be an alternative to surgery or balloon-expandable stent implantation for CoA but there is little information about midterm to long term results of self-expandable stents.

METHODS

Sixty-two patients with CoA (40 men), with a mean age of 30.7 ± 11 years, (range 17-63 years) underwent stent implantation with Optimed self-expandable Nitinol stents between 2005 and 2014. Successful outcome was defined as peak systolic pressure gradient ≤20 mmHg after stent implantation. The patients were followed-up clinically and by echocardiography and in patients, in whom there was suspicion of recoarctation, CT angiography or recatheterization was performed.

RESULTS

65 stents were successfully implanted in all 62 patients. Peak systolic pressure gradient decreased from mean 62.4 ± 18 mmHg (range 35-100 mmHg) to mean 2.8 ± 5 mmHg (range 0-15 mmHg; P < 0.001). Stent displacement occurred in 3 patients during the procedure. These were managed successfully by an overlapping second stent. None of the patients had major complications such as aortic dissection, rupture, or vascular access problems. In follow up, only three patients had recoarctation, and two of these were managed successfully by balloon redilation or further stenting 16 and 18 months after the first procedure and one patient refused reintervention. There were two deaths, unrelated to the procedure, 12 and 78 months after the initial intervention. Follow-up of a mean of 45.5 ± 17 months (range 12-105 months) demonstrated no evidence of aneurysm formation or stent fracture.

CONCLUSIONS

Self-expandable nitinol stents for the treatment of native and recurrent CoA is safe and has good efficacy with acceptable midterm to long-term outcome.

Severe and resistant hypertension in an older woman with claudication

Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.

Antegrade transvenous balloon angioplasty for coarctation of the aorta in infants with ventricular septal defect

For a newborn, surgical correction has been the primary treatment of native coarctation at most centers; however, there has been an increased use of balloon angioplasty (BA). The anterograde transvenous (AT) technique is another alternative way for coarctation (AoC) angioplasty in low weight patients with large ventricular septal defect (VSD).

Four, 5-day-old to 7-month-old, infants weighing 2500, 2700, 2800, and 3400 g, respectively presented to emergency unit (EU) with cyanosis, tachypnea, and loss of weight. Echocardiography demonstrated AoC and VSD. All four children were admitted to the EU with hemodynamic compromise and critically ill status. We used femoral vein for sheath and used VSD to enter left ventricle from right antegrade route, and performed BA without any complication.

AT described in this report is another alternative way for coarctation angioplasty in patients with large VSD. We suggest that AT BA can be applied to small infants in situations where surgery might have been hazardous.

Effectiveness of Balloon Angioplasty in Children With Recurrent Aortic Coarctation Depends on the Type of Aortic Arch Pathology

OBJECTIVES

The aim of this study was to evaluate the effectiveness of balloon angioplasty (BAP) for recurrent aortic coarctation (ReCoA) in infants comparing simple and complex type of aortic arch pathology (Norwood I procedure).

BACKGROUND

ReCoA is a known complication after cardiovascular surgery for coarctation of the aortic arch.

METHODS AND RESULTS

In a single center case study, we analyzed 20 infants undergoing BAP for ReCoA comparing simple (n = 10) and complex type of aortic arch pathology (n = 10). At catherization diameter of ReCoA stenosis was 3.2 ± 0.7 mm (mean ± SD) with short localized (11/20) or long hypoplastic stenosis (9/20) before and 4.8 ± 1.2 mm after BAP (P < 0.001). Invasive systolic pressure gradient was reduced from 27.5 ± 16.2 mmHg before to 5.1 ± 6.6 mmHg after BAP (P < 0.001), comparable in simple and complex type of ReCoA. At day 1 after catherization noninvasive systolic arterial blood pressure gradient was reduced from 20.2 ± 23.1 to 6.7 ± 9.9 mmHg (P < 0.001), respectively, calculated continuous wave Doppler echo gradient from 36.3 ± 22 to 16.8 ± 9.6 mmHg (P < 0.01). Complications were aortic arch dissection (1/20), discrete aortic arch aneurysm formation (1/20), pericardial effusion (1/20), and peripheral arterial thrombosis (4/20). At a mid-term follow up of 9.5 months (1-40) after BAP, 3 infants needed early surgical reintervention due to secondary ReCoA, all with long hypoplastic aortic arch segments, but simple type of aortic arch pathology.

CONCLUSIONS

At mid-term follow up, BAP remains an effective catheter intervention for ReCoA for infants with localized ReCoA, but not with long hypoplastic aortic arch segments, even in simple type of aortic arch pathology.

Mycotic Pseudoaneurysm Complicating Stent Placement for Native Aortic Coarctation in a Child

Mycotic aneurysms of the aorta are uncommon life-threatening lesions. Sporadic cases have been reported in adults after surgical intervention for native and recurrent coarctation of the aorta. We report a case of a rapidly progressive, large mycotic pseudoaneurysm in a 13-year-old boy 3 months after a bare-metal stent was used to treat native coarctation. The boy presented with slurred speech, bacteremia, and systemic septic embolization. During an emergency operation, the pseudoaneurysm was resected, and the infected aorta was replaced with an interposition graft. This rare complication may occur early or late after stent placement for coarctation of the aorta.

Immediate Outcomes of Covered Stent Placement for Treatment or Prevention of Aortic Wall Injury Associated With Coarctation of the Aorta (COAST II)

OBJECTIVES

This study aimed to describe the safety and short-term efficacy of the Covered Cheatham-Platinum stent (CCPS) in treating or preventing aortic wall injury (AWI) in patients with coarctation of the aorta (CoA).

BACKGROUND

The COAST II trial (Covered Cheatham-Platinum Stents for Prevention or Treatment of Aortic Wall Injury Associated with Coarctation of the Aorta Trial) is a multicenter, single-arm trial using the CCPS for the treatment and/or prevention of AWI in patients with CoA and pre-existing AWI or increased risk of AWI.

METHODS

Patients were enrolled if they had a history of CoA with pre-existing AWI (Treatment group) or with increased risk of AWI (Prevention group). Pre/post-implant hemodynamics and angiography were reported. A core laboratory performed standardized review of all angiograms. One-month follow-up was reported.

RESULTS

A total of 158 patients (male = 65%; median age 19 years) underwent placement of CCPS. Eighty-three patients had pre-existing AWI. The average ascending-to-descending aorta systolic gradient improved from 27 ± 20 mm Hg to 4 ± 6 mm Hg. Complete coverage of pre-existing AWI was achieved in 66 of 71 patients (93%) with AWI who received a single CCPS. Ultimately, complete coverage of AWI was achieved in 76 of 83 patients (92%); 7 patients had minor endoleaks that did not require repeat intervention. Four patients experienced important access site vascular injury. There were no acute AWI, repeat interventions, or deaths.

CONCLUSIONS

The CCPS can effectively treat and potentially prevent AWI associated with CoA. Access site arterial injury is the most common important complication. Longer-term follow-up is necessary to define mid- and late-term outcomes.

Coarctation of the aorta: Management from infancy to adulthood

Coarctation of the aorta is a relatively common form of congenital heart disease, with an estimated incidence of approximately 3 cases per 10000 births. Coarctation is a heterogeneous lesion which may present across all age ranges, with varying clinical symptoms, in isolation, or in association with other cardiac defects. The first surgical repair of aortic coarctation was described in 1944, and since that time, several other surgical techniques have been developed and modified. Additionally, transcatheter balloon angioplasty and endovascular stent placement offer less invasive approaches for the treatment of coarctation of the aorta for some patients. While overall morbidity and mortality rates are low for patients undergoing intervention for coarctation, both surgical and transcatheter interventions are not free from adverse outcomes. Therefore, patients must be followed closely over their lifetime for complications such as recoarctation, aortic aneurysm, persistent hypertension, and changes in any associated cardiac defects. Considerable effort has been expended investigating the utility and outcomes of various treatment approaches for aortic coarctation, which are heavily influenced by a patient’s anatomy, size, age, and clinical course. Here we review indications for intervention, describe and compare surgical and transcatheter techniques for management of coarctation, and explore the associated outcomes in both children and adults.

Current management of coarctation of the aorta

Coarctation of the aorta (C) is the sixth most common lesion in congenital heart disease and represents a spectrum of aortic narrowing that varies from a discrete entity to tubular hypoplasia. This condition was once thought to be a relatively simple lesion that would be "cured" upon repair of the narrowing, however, despite relief of the anatomical obstruction the subsequent risk of early morbidity and death persists. This review outlines the optimal management strategy of this disease from neonatal to adult life and provides insights to approach this straightforward but challenging condition.

Contemporary Results of Aortic Coarctation Repair Through Left Thoracotomy

BACKGROUND

Although surgical results for repair of coarctation of the aorta (CoA) have steadily improved, management of this condition remains controversial. The purposes of this study were to analyze the long-term outcomes of patients undergoing CoA repair through left thoracotomy and to define risk factors for reintervention.

METHODS

All patients who were less than 18 years old and who underwent initial repair of CoA through left thoracotomy from 1995 to 2013 at Texas Children's Hospital (Houston, TX) were included. Patients were classified into 3 groups: 143 (42%) neonates (0 to 30 days old), 122 (36%) infants (31 days to 1 year old), and 78 (23%) older children (1 to 18 years old). Univariate and multivariate analyses were performed.

RESULTS

A total of 343 patients (129 [38%] girls) with median age of 53 days (interquartile range [IQR],12 days to 9 months) and weight of 4.1 kg (IQR, 3.1 to 8.0) underwent repair with extended end-to-end anastomosis (291 patients [85%]), end-to-end anastomosis (44 patients [13%]), interposition graft (2 patients [0.6%]), or subclavian flap (6 patients [2%]). Concomitant diagnoses included genetic abnormalities (48 patients [14%]), isolated ventricular septal defects (58 patients [17%]), small left-sided structures (53 patients,16%), or other complex congenital heart disease (18 patients [5%]). Perioperative mortality was 1% (n = 4, all neonates). At a median follow-up of 6 years (7 days to 19 years), only 14 (4%) patients required reintervention (10 catheter-based procedures, 6 surgical repairs). A postoperative peak velocity of 2.5 m/s or greater was an independent risk factor for reintervention (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.4 to 11.6). Within the cohort, 95 (33%) patients were hypertensive or remained on cardiac medications a median of 12 years (6 months to 19 years) after the surgical procedure. Development of perioperative hypertension was associated with higher risk of chronic hypertension or cardiac medication dependency (OR, 1.9; 95% CI, 1.1 to 3.3).

CONCLUSIONS

CoA repair through left thoracotomy is associated with low rates of morbidity, mortality, and reintervention. Aortic arch obstruction should be completely relieved at the time of surgical intervention to minimize the risk of long-term recoarctation.

The First Ten of Everything: A Review of Past and Current Practice in Pediatric Cardiac Percutaneous Interventions

OBJECTIVES

This study was designed to compare outcomes of the most common pediatric cardiac interventions from the time of implementation with the current era.

BACKGROUND

Since the introduction of semilunar valve balloon dilation and device closure of the arterial duct and septal defects, development of interventional techniques and devices has been rapid. However, few studies have compared outcomes between those initial interventions and those in the current era.

METHODS

Five validated common catheter-based therapies were chosen for analysis, including atrial and duct device closure, balloon dilation of the aortic and pulmonary valves, and native coarctation of the aorta. A retrospective review of the first and most recent 10 consecutive patients in each group was performed.

RESULTS

There was a high mortality (30%) among neonates who underwent aortic valve (AV) dilation in the early era, but no mortality noted in other groups. In the early era, transcatheter atrial defect closure and AV dilations were associated with a low success rate (60% for both lesions) and a high complication rate (40% for atrial septal defect, 30% for AV dilations). Among the last 10 children, the atrial defect occlusion was successful in 100% without complications and AV dilations where successful in all children with a 30% complication rate (one major, two minor).

CONCLUSIONS

A learning curve with device development plays a significant role in the evolution of transcatheter techniques. These data provide baseline estimates of success and may be used as a template in the future when new techniques are adapted into practice.