[Primary stent implantation in aortic coarctation: mid-term follow-up]

BACKGROUND

The use of balloon-expandable stents provides an effective alternative therapy in patients with stenotic lesions in congenital heart disease. Stents implantation has served to improve the results and to reduce complications of balloon angioplasty for coarctation and recoarctation of the aorta.

OBJECTIVE

We report our results after primary stents implantation for coarctation and recoarctation of the aorta.

PATIENTS AND METHODS

Balloon-expandable stents were implanted in 14 patients (mean age 20 +/- 12 years) with coarctation of the aorta (11 native and 3 postoperative); 2 patients had associated malformations. The morphology varied: 10 resembled a located-diaphragm (one of them with moderate arch hypoplasia); 2 had distorted coarctation and 2 had a complete aortal obstruction. Five patients were hypertensive and 1 had cardiogenic shock and severe arrhythmias which did not respond to intensive medical therapy. In all cases 14 Palmaz stents (7 P308 and 7 P4014) were implanted with the primary technique through a Mullin's sheath. The balloon-to-descending aorta diameter ratio, measured at the level of the diaphragm, was 1. A special technique was carried out in the 2 cases with complete aortal obstruction.

RESULTS

The procedure was effective in all 14 cases. The coarctation diameter increased from 4 +/- 2 to 15 +/- 2 mm (p < 0.0001) and transcoarctation systolic pressure gradient decreased from 43 +/- 19 to 2 +/- 2 mmHg (p < 0.0001). The ratio of the coarctation to descending aorta diameter measured at the level of the diaphragma increased from 0.3 +/- 0.1 to 0.95 +/- 0.05 (p < 0.001). At 19 +/- 8 months follow up, all patients showed sustained clinical improvement. The patient with complete aortal obstruction experienced a dramatic improvement, but she died from a sudden cardiac event 22 months after the procedure. At angiographic follow up in 7 patients, 1 year after implantation, no recoarctation was observed with secondary vessels patent, and absence of restenosis.

CONCLUSIONS

a) Percutaneous endovascular stents implantation in coarctation and recoarctation of the aorta may become an effective treatment modality in the older child, adolescent and adults; b) stents are particularly attractive in those patients with a more complex anatomy and higher surgical risk; c) primary stenting is expected to have a lower rate of complications, and d) we describe a special technique with a right femoral-left humeral arterial circuit that is successfully applied to patients with complete aortal obstruction.

[The angioplasty of a postsurgical obstruction of the superior vena cava]

A case of superior vena cava obstruction secondary to surgical repair of partial anomalous pulmonary venous drainage was successfully treated with balloon angioplasty in a double procedure. Dilatation was effective with a significant clinical benefit and patient remains symptoms free at mid-term.

[The transcatheter closure of the persistent ductus arteriosus in an adult]

Transcatheter closure of a patent ductus arteriosus was successfully performed in a symptomatic 48-year-old man. Pulmonary to systemic flow ratio was of 2.8:1 and ductus arteriosus closure was carried out percutaneously, using a 17 mm. Rashkind umbrella. One month later, the patient presented a significant clinical improvement and there also was a reduction of the left ventricle dilatation, objectively assessed by two-dimensional echocardiography.

Balloon dilation of tricuspid and pulmonary valves in carcinoid heart disease

Heart involvement is usually the cause of death in patients with carcinoid syndrome, who may survive a long time even after the disease has entered an advanced stage. For this reason, carcinoid heart disease patients have undergone surgical replacement of affected valves. Two of our patients were not good candidates for surgery, due to the extent of hepatic metastasis. Alternatively, we performed percutaneous balloon valvuloplasty on both the tricuspid and pulmonary valves in both patients. To our knowledge, there has been only 1 previous report of successful tricuspid valvuloplasty in a case of carcinoid heart disease, and this did not involve concomitant pulmonary valvuloplasty. Before the procedure, both of our patients had low cardiac output with restriction in the right ventricle, pulmonary and tricuspid stenosis, and moderate tricuspid regurgitation. In the 1st patient, valvuloplasty reduced tricuspid and pulmonary gradients without change in cardiac output. This patient experienced initial clinical improvement but died 8 months after the procedure, of portal hypertension and extensive hepatic metastasis. The 2nd patient showed notably diminished gradients and a very significant increase in cardiac output. She advanced from New York Heart Association functional class IV to class I, and is now maintained with diuretic therapy. In our judgment, balloon valvuloplasty is a sound alternative to surgery for patients with carcinoid heart disease, especially when stenosis is the dominant symptom. Valvuloplasty is contraindicated in cases of severe tricuspid regurgitation.

[Anomalous origin of the coronary artery in the pulmonary artery. Report of a case in adulthood]

We report a 50 year old patient who was admitted because of congestive heart failure. Under hemodynamic and angiographic study she was diagnosed of anomalous origin of the left coronary artery from the pulmonary trunk. We examine the main aspects of the disease, physiopathology and treatment.

Direct communication between the right pulmonary artery and the left atrium

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