Sequential balloon dilatation for combined aortic valvular stenosis and coarctation of the aorta in a single catheterization procedure: a prognostic evaluation based on long-term follow up

BACKGROUND

Combined aortic valvular stenosis (AVS) and coarctation of the aorta (CoA) is uncommon. There are only a few case reports that discuss the treatment choices and prognosis. We present the immediate and long-term results for a group of children with combined AVS and CoA who underwent sequential percutaneous balloon dilatation in a single catheterization procedure.

PATIENTS AND METHODS

The cases of 13 children with combined AVS and CoA who underwent balloon dilatation in a single catheterization session between August 1995 and May 2002 were retrospectively evaluated. The group was comprised of 9 boys and 4 girls of mean age 14.9 +/- 24.2 months (range = 19 days to 7 years).

RESULTS

The pressure gradients at the valvular level before and after the intervention were 51.5 +/- 22.3 mmHg (range = 8 to 85 mmHg) and 22.4 +/- 18.3 mmHg (range = 2 to 57 mmHg), respectively (p < 0.001). The corresponding findings for the coarctation segment were 22.3 +/- 13.5 mmHg (range = 0 to 45 mmHg), and 5.2 +/- 7.0 mmHg (range = 0 to 24 mmHg; p < 0.001). After the intervention, mild aortic regurgitation occurred in 5 children (38.5%). Mild aortic regurgitation became moderate in 1 patient (7.7%). Three patients developed peripheral arterial occlusion treated with heparin and streptokinase after intervention. There were no deaths during or early after the procedures. Four patients (30.8%) died, all in the first 6 months after the intervention, and the mean follow-up time for the 9 survivors was 57.6 +/- 38.9 months (range = 6 to 107 months). Recurrence of stenosis and coarctation occurred in 2 (15.4%) and 4 (30.8%) cases, respectively. Four patients (30.8%) underwent cardiac surgery. The event-free survival rates were 76.9% at 6 months, 61.5% at 12 months through 24 months, and 30.8% at 60 months. The overall survival rates were 76.9% at 3 months, 69.2% at 6 months, and it remained 69.2% for the rest of the follow-up period. NOTE: Outcomes for 13 patients with combined AVS and CoA who underwent single-session sequential balloon dilatation are described. The results were favorable; there were no severe complications related to the procedures, and no deaths occurred during or in the early period after the intervention.

[Sugical treatment of aortic coarctation. Long-term results at National Institute of Cardiology of Mexico]

OBJECTIVES

Evaluate long-term evolution of patients submitted to surgery for coarctation of the aorta. Compare event free survival in younger vs older patients at the time of surgical correction.

METHODS

We reviewed the clinical records of patients operated for coarctation of the aorta from January 1 1980 to December 31 1994. The mean follow-up ranged from 9 to 23 years (mean 10.9 y). Final events registered were recoarctation, death, systemic hypertension, endocarditis, stroke, aneurisms.

RESULTS

Two hundred and sixteen patients were found with mean age 13 +/- 12 y male gender was most frequent (61%). Recoarctation was found in 13 patients (6.02%), persistent hypertension in 14.1%. Event free survival at 10 years was 86.2%. In patients less than 10 y was 89% vs 80.2% in older patients. Hypertension free survival in patients less than 10 y was 98.3% vs 80.1% in older patients (p < 0.001).

CONCLUSIONS

Our data confirms that surgical treatment for coarctation of the aorta is associated with low morbidity and mortality at long-term with reduced rate of recoarctation (7%). Early correction (< 10 y) is associated with a better long term survival. Hypertension and use of pharmacologic treatment are reduced after surgery and persist in the long-term evolution.

Epidemiology of noncomplex left ventricular outflow tract obstruction malformations (aortic valve stenosis, coarctation of the aorta, hypoplastic left heart syndrome) in Texas, 1999-2001

BACKGROUND

The left ventricular outflow tract (LVOT) malformations aortic valve stenosis (AVS), coarctation of the aorta (CoA), and hypoplastic left heart syndrome (HLHS) contribute significantly to infant mortality due to birth defects. Previous epidemiology data showed rate differences between male and female and white and black ethnic groups. The Texas Birth Defects Registry, an active surveillance program, enables study in a large, diverse population including Hispanics.

METHODS

Records of children up to 1 year old with AVS, CoA, and HLHS born in Texas from 1999 to 2001, were collected from the registry. Those including additional heart defects or a chromosomal anomaly were excluded. Multivariate analysis included: infant sex; United States-Mexico border county residence; and maternal age, race/ethnicity, birthplace, and education.

RESULTS

There were 910 cases among 1.08 million live births, of which 499 met inclusion criteria. Multivariate modeling of all LVOT malformations combined demonstrated lower prevalence rate ratios (PRRs) for black males (0.26) and Hispanic males (0.70). Similar results were found for CoA but not AVS or HLHS. Higher PRRs were noted for increased maternal age for LVOT (1.3 for 24-34 years; 1.7 for >34 years), AVS, and HLHS, but not CoA, and higher PRRs across all diagnoses for males (LVOT PRR, 2.4) were noted. CoA PRRs were higher in border county vs. non-border county residents (PRR, 2.1). Maternal education and birthplace were not significant factors.

CONCLUSIONS

There are rate differences for males among all 3 ethnic groups. Sex and ethnic differences suggest genetic etiologies, where the ethnic differences could be used to find susceptibility loci with mapping by admixture linkage disequilibrium. Increased CoA rates along the U.S.-Mexico border suggest environmental causes that will require further monitoring.

[Coarctation of the aorta in infants under one year of age. An analysis of 20 years of experience]

OBJECTIVE

A review of experience with techniques of correction used, in the last 20 years, in children younger than one year old.

METHODS

In the period from 1978 to 1998, 148 patients (pt) with coarctation of the aorta (CoAo), under one year of age, with or without associated intracardiac defects, were submitted to surgery. Median age 50 days, 92 female pt (62.1%). The average weight was 4,367 +/- 1,897 gr. The average follow-up was 1,152 +/- 1,462 days. The population was divided in 3 groups: Group I, isolated CoAo: 74 pt (50%); Group II, CoAo and interventricular communication (IVC): 41 pt (27.7%) and Group III, CoAo with complex intracardiac malformations: 33 pt (22.3%).

RESULTS

The total mortality was of 43 patients (29%). In patients younger than 30 days, the mortality was 53%, p=0.009, DR=4.5, between 31 and 90 days, 14.7%, p=0.69, and over 91 days, 15%, p=0.004. The probability of actuarial survival of the whole population was 67% at 5 and 10 years. Thirty-six patients (24.3%) had recoarctation, from which 18 patients (50%) were younger than 30 days, DR=6.35. The incidence of recoarctation was with Waldhausen technique in 4 patients (10%) and with the classic termino-terminal technique in 19 patients (26%) p=0.03, and isthmusplastic operation in 6 patients (37.5%). The patients younger than 30 days showed a relative risk for recoarctation de DR=6.35. The probability of actuarial survival, free of coarctation repair, at 5 and 10 years was of 69% with Waldhausen's technique and 63% with the classic termino-terminal technique.

CONCLUSION

Patients younger than 30 days showed increased mortality and recoarctation risk. Waldhausen's technique in patients older than 30 days showed effective. The classic termino-terminal technique did not show to be a good option in all age ranges, being imperative to carry out more radical technical variations, such as the extended termino-terminal.

Impact of re-coarctation following the Norwood operation on survival in the balloon angioplasty era

OBJECTIVES

The objective of this study was to determine the efficacy of balloon angioplasty (BA) by comparing the immediate and long-term outcomes of patients with and without re-coarctation after a Norwood procedure.

BACKGROUND

Although BA has become the standard means for treating recurrent coarctation following a Norwood operation, it has been suggested that re-coarctation remains a significant cause of morbidity and mortality.

METHODS

Patients who survived a Norwood operation from December 1986 through June 2001 were studied. Differences between groups were evaluated by t test and logistic regression. Survival differences were tested by log-rank tests using Kaplan-Meier survival curves.

RESULTS

Fifty-eight of 633 patients underwent treatment for re-coarctation (9.2%). Thirty-five patients underwent BA (before 1988, 23 had surgery). Median age at catheterization was 6.6 months (1.9 to 35.6 months). Balloon angioplasty was successful (gradient <10 mm Hg) in 32 of 35 patients (92%). There were no BA-related deaths or neurologic complications. Recurrent obstruction after BA occurred in seven patients (20%); five underwent re-dilation. Kaplan-Meier estimates of freedom from recurrent obstruction after initial BA were 97% at one month, 79% at one year, and 79% at five years. There were no differences in survival between patients with re-coarctation treated by BA and patients who did not undergo treatment for re-coarctation.

CONCLUSIONS

We found that 9.2% of patients underwent treatment for re-coarctation following a Norwood operation. Balloon angioplasty is effective, with low morbidity, no early mortality, and no difference in long-term survival when compared with patients who did not have re-coarctation. Recurrent coarctation following BA occurred in 17% of patients, usually within the first year after BA.

Total Circulatory Arrest for the Replacement of the Descending and Thoracoabdominal Aorta

HYPOTHESIS

Hypothermic total circulatory arrest (TCA) in the resection and replacement of the thoracoabdominal and descending thoracic aorta is safe, will significantly decrease the incidence of postoperative renal failure, and should be preferentially performed over left heart bypass (LHB).

DESIGN

Retrospective review case series.

SETTING

Large, private, urban teaching hospital.

PATIENTS

All adult patients with aortic disease that involved the distal aortic arch, the descending thoracic aorta, or the thoracoabdominal aorta who underwent resection and graft replacement of the diseased segment via LHB or TCA at our institution from 1989 to 2001 are included in this study. A total of 59 patients were evaluated: 10 had descending thoracic aneurysms, 20 had thoracoabdominal aneurysms, 22 had chronic type B dissections, 4 had acute type B dissections, and 3 had adult coarctations.

INTERVENTIONS

In 1989 to 1994, LHB was primarily used; in 1994 to 2001, TCA was primarily used.

MAIN OUTCOME MEASURES

Renal failure, 30-day operative mortality, paraplegia, and any other morbidities.

RESULTS

A significant decrease occurred in the incidence of postoperative renal failure from 15% (3/20) in patients who underwent LHB to 0% (0/39) in patients who underwent TCA (P = .04). Furthermore, a significant decrease occurred in the 30-day operative mortality, which decreased from 20% (4/20) in patients who underwent LHB to 5% (2/39) in patients who underwent TCA (P = .04). Postoperative paraplegia decreased from 5% (1/20) in patients who underwent LHB to 2.6% (1/39) in patients who underwent TCA (P > .99).

CONCLUSIONS

Our use of TCA in the resection and replacement of the diseased thoracoabdominal and descending thoracic aorta has produced excellent results. Our patients have experienced no postoperative renal failure and a low 30-day operative mortality. The use of TCA in this patient population is a viable option for surgeons comfortable with the technique.

Nonductal dependent coarctation: a 20-year study of morbidity and mortality comparing early-to-late surgical repair

OBJECTIVE

The objective of this study was to evaluate the effect of the timing of surgical repair of nonductal dependent coarctation on the short-term outcome.

METHODS

The medical records of 76 patients, diagnosed and treated for a nonductal dependent mild-to-moderate coarctation at a tertiary care institute over a 20-year period, were retrospectively reviewed with the age at repair compared against outcome measures. Multiple logistic regression was performed to assess the timing of repair, the presence of congestive heart failure or associated cardiac defects on the outcome measures.

RESULTS

The mean age of surgery for the mild-to-moderate coarctation repair was 3.1 years (range: three days to 12 years). The most common cause for referral to a pediatric cardiologist was the clinical finding of a cardiac murmur. The timing of surgical repair was not found to be a predictor of morbidity or mortality. There was no significant difference in outcome measures defined as residual hypertension, residual coarctation gradient, persistent cardiomegaly, postoperative neurological sequelae, the requirement for a second surgery or the need for balloon dilatation for residual postoperative coarctation and the need for antihypertensive medications within five years postsurgery.

CONCLUSION

The timing of surgical repair in the setting of nonductal dependent, mild-to-moderate coarctation of the aorta, does not adversely affect the short term (less than 20 years) outcome in children.

Surgical management of transposition in the setting of obstruction within the aortic arch

The presence of an obstructed aortic arch in patients with transposition, or the Taussig-Bing variant of double outlet right ventricle, presents a formidable surgical challenge. Over the years, there have been several controversies with respect to primary versus staged repair, the best technique for reconstruction of the aortic arch, and whether to use circulatory arrest or antegrade regional cerebral perfusion. In this review, I will address all these issues and describe my favoured surgical approach at The Montreal Children's Hospital, namely the single-stage arterial switch operation with concomitant repair of the aortic arch with a patch fashioned from a pulmonary homograft, all conducted using antegrade regional cerebral perfusion.

[Surgery for coarctation of the aorta in infants younger than three months]

INTRODUCTION

Recurrent coarctation is a complication which is seen at a consistent rate following repair for coarctation of the aorta in young infants.

OBJECTIVE

This retrospective analysis was carried out to compare the results between resection with end-to-end anastomosis (ETE), and resection with extended end-to-end anastomosis (E-ETE), in this age group during late follow-up period. The role of ductus arteriosus is not clearly defined and the second objective of this study was to analyze intimal thickening in aortic coarctation.

MATERIAL AND METHODS

From 1999 to 2003, 45 patients less than 3 months of age underwent repair of aortic coarctation. Mean age was 24 days (2-89 days), average weight was 3.5 +/- 0.6 kg (2.4-5.2 kg). The method of repair was ETE in 14 (31.1%) patients, E-ETE in 29 (64.4%) patients and other techniques were applied in 2 cases. Demographic, morphometric, clinical and operative variables were analyzed for correlation with recurrent arch obstruction. In order to characterize the components of intimal thickening in coarctation, narrowed segments of aorta resected from 16 neonates during surgery were examined immunocytochemically and by electron microscopy. For light microscopy, the specimens were dehydrated in graded ethanol (70-100%), cleared in xylol and embedded in paraffin. Immunocytochemical staining was performed in 5 microm sections from formaldehyde-fixed paraffin-embedded blocks, using a labeled streptavidin-biotin method with an LSAB kit (Dako).

RESULTS

Early mortality was 6.7% (CI 95%, 2.9%-10.4%). All early deaths (3 patients) occurred in infants with associated ventricular septal defects (p<0.05). The mean follow-up for all patients was 30 +/- 21 months (range 1.5-63 months). During mean follow-up of 2 months, recurrent arch obstruction was diagnosed in 9 patients (21.4%). Two patients with associated complex heart defects died before re-intervention, one had mild gradient on catheterization (20 mm Hg) and one is waiting for catheterization. Five patients were reoperated and the mean time to re-intervention was 4 months (range 2.6-6 months). Kaplan-Meier freedom from recoarctation was 78.1 +/- 6.4% at 5 years in the whole group. Freedom from recoarctation was 60.6 +/- 15.4% at 25 months in ETE group and 86.2 +/- 6.4% at 60 months in E-ETE group (p=0.062). Factors associated with recoarctation, obtained by univariable Cox regression, included abnormal right subclavian artery (p=0.003), hypoplastic proximal transverse aortic arch (Z < or = -2, p=0.025) and weight at operation < or = 3 kg (p=0.02). Abnormal origin of the right subclavian artery was the only independent predictor of recoarctation obtained by multivariable Cox regression analysis.

DISCUSSION

All examined specimens had intimal thickening of the posterior aortic wall, with accumulation of smooth muscle cells (SMC) with alpha smooth muscle actin (alpha-SMA) and vimentin-immunoreactivity (but not desmin and MHC) and also expressed PCNA and S-100. In the inner media of the anteromedial wall of the aorta, all specimens had large number of SMC expressing desmin and MHC. SMC in the inner media exhibit contractile phenotype and their origin could be ductal.

CONCLUSION

Both procedures are effective for coarctation repair in young infants. Risk of recoarctation is a function of the complex anatomy of the arch, while residual ductal tissue may play a significant role.

Left-sided lesions after anatomic repair of transposition of the great arteries, ventricular septal defect, and coarctation: Surgical factors

OBJECTIVE

This study was undertaken to identify potential anatomic and surgical factors creating left-sided lesions, namely recoarctation of the aorta and neoaortic regurgitation, after anatomic repair of transposition of the great arteries with ventricular septal defect and aortic coarctation.

METHODS

From 1983 to September 2002, 109 survivors out of 120 patients were studied. Two-stage repair was performed in 42 patients (group A), and single-stage repair was performed in 67 (groups B and C). Before repair, the diameters of the ascending aorta and main pulmonary artery were measured. In the patients with single-stage repair, coarctation was repaired by extended end-to-end anastomosis in 35 patients (group B) and by pulmonary homograft patch augmentation in 32 patients (group C). The ventricular septal defect was closed through the pulmonary artery in 70 patients and through the right ventricle or atrium in 39 patients. The neoaorto-aortic discrepancy was treated by V-shaped resection of the posterior sinus of Valsalva in 7 cases, pulmonary homograft patch in 32 cases, and anterior splitting of the ascending aorta in all cases. Before discharge from the hospital, neoaortic root and ascending aorta diameters and aortic regurgitation grade were recorded. Neoaortic regurgitation progression and reintervention were the end points of follow-up (97.2 +/- 61.2 months).

RESULTS

Early and late survivals were significantly better in group C (P <.001). Risk factors for neoaortic regurgitation at discharge by univariate analysis were single-stage repair (P <.05) and ventricular septal defect closure through the pulmonary artery (P =.0076). On multivariate analysis, the latter was the only risk factor for neoaortic regurgitation at discharge and at last follow-up. Multivariate analysis showed that higher neoaortic root/ascending aorta ratio and ventricular septal defect closure through the pulmonary artery were risk factors for neoaortic regurgitation evolution at last follow-up. There were 29 reinterventions, 19 for recoarctation of the aorta and 10 for neoaortic regurgitation with or without aortic root dilatation. Group B (P <.05), high neoaortic root/ascending aorta ratio (P <.01), and progressive neoaortic regurgitation (P <.05) were risk factors for recoarctation of the aorta. Group A was a risk factor for aortic valve replacement at 10 years (P <.05).

CONCLUSION

Neonatal single-stage repair with pulmonary homograft aortic augmentation remains the optimal approach to transposition of the great arteries with ventricular septal defect and aortic coarctation. It provides better early and late survivals and freedoms from left-sided lesions. Avoidance of late recoarctation of the aorta and progressive neoaortic regurgitation requires meticulous closure of the ventricular septal defect and evenly sized reconstruction of the aorta from root to distal arch.

Is surgical intervention still indicated in recurrent aortic arch obstruction?

BACKGROUND

Introduction of balloon dilatation has become the standard treatment for recurrent aortic arch obstruction and has changed the therapeutic approach to patients with this disorder.

OBJECTIVES

Whether all patients with recurrent aortic arch obstruction are candidates for balloon dilatation remains unanswered. In addition, only few reports have tried to compare the results between patients undergoing balloon dilatation or redo operations.

METHODS

Since 1983, 97 patients underwent reintervention for recurrent aortic arch obstruction (42 dilations and 55 reoperations). Eight had immediate unsuccessful dilatation and were shifted to the surgical group (n = 63). The median age at reintervention was 21.7 months (10 days-45 years), and the median delay was 13.6 months (7 days-17 years). Anatomy of the aortic arch oriented the surgical approach to treat arch hypoplasia. It could be performed through a left thoracotomy in 52 patients, with extended end-to-end anastomosis in 34 patients, subclavian flap repair in 9 patients, conduit insertion in 6 patients, and patch enlargement in 3 patients. More recently, an anterior approach with cardiopulmonary bypass without circulatory arrest was applied to enlarge the patch in all the aortic arches.

RESULTS

There was one early death in the surgical intervention group and 2 late deaths in the dilation group. Major complications and recurrence were higher in the dilated group (4 vs 0, P <.01, and 14 vs 5, P <.0004, respectively). At a mean follow-up of 11.8 +/- 4.1 years in the surgical intervention group and 7.5 +/- 2.5 years in the dilated group, systemic hypertension was normalized in all but 5 patients in the surgical intervention group and 6 patients in the dilated group.

CONCLUSION

Reoperation for recurrent aortic arch obstruction can be performed safely, with low rates of mortality and morbidity. This approach should be considered versus balloon angioplasty, especially in patients older than 4 years and in the presence of aortic arch hypoplasia.

Coarctation of aorta repair at the National Heart Institute (1983-1994)

This retrospective study illustrates our approach to this problem over the years, from performing subclavian flap aortoplasty initially to the more accepted procedure now, which is resection and end-to-end anastomosis. Coarctation of aorta in our population is seen in a varying age groups and are also associated with other cardiac anomalies including both acyanotic and cyanotic congenital cardiac defects. Therefore a wide variety of surgical procedures were performed including resection of the coarcted segment and end-to-end anastomosis, subclavian flap aortoplasty, patch aortoplasty and synthetic tube graft interposition. Subclavian flap aortoplasty is not widely practised anymore in favour of resection with end-to-end anastomosis. Fifty four point four percent of patients had isolated coarctation, 10.5% had associated valvular defects, 28.1% had other simple congenital defects and 7.0% had associated complex cyanotic congenital defects. Perioperative mortality was 5.26% and is correlated with the younger age of patients at time of surgery and severity of cardiac failure at time of presentation. We did not see any difference in mortality for patients with complex congenital disease or between the different surgical procedures. However, we did find that in the early period when resection with end-to-end anastomosis was performed, there was a significantly higher incidence of morbidities.

Complications of coarctation repair

Surgery's role in the treatment of coarctation has been established, and the benefit to life expectancy and quality of life is undeniable. Three postaortic coarctation repair complications are discussed, with review of existing literature: recurrent or residual aortic coarctation, postrepair aneurysm formation, and spinal cord ischemia. Incidence, potential causative factors, and outcome of surgical or transcatheter treatment for recurrent and residual aortic coarctation are reviewed. A literature review of postrepair aneurysm formation focuses on etiologic factors such as use of patch aortoplasty repair techniques, aortic arch hypoplasia, congenital abnormality of the aortic wall, and persistent hypertension after repair. The spectrum, onset, incidence, and potential risk factors for postcoarctation repair spinal cord ischemia are reviewed. Use of adenosine receptor agonists to achieve a state of ischemic resistance is under investigation to address this potential hazard of coarctation repair. Complications after surgery do occur in certain subsets of patients, but the risk of subsequent intervention is still lower than the hazards associated with the natural course of the defect.

Improved patient survival following surgery for coarctation of the aorta

BACKGROUND

We conducted a retrospective review of children undergoing surgery for coarctation of the aorta in our institution over the last ten years with the aim of evaluating overall patient survival as well as detecting factors affecting it. We tried to identify the risk factors for mortality.

METHODS AND DATA

Between January 1992 and December 2001, 201 patients with aortic coarctation were operated on at the Department of Cardiac Surgery of the Children's University Hospital, Bratislava. The three classes of aortic coarctation were represented: isolated coarctation, coarctation with ventricular septal defect (VSD) and coarctation with complex cardiac anomalies. Patients' preoperative, operative and immediate postoperative medical records were carefully studied with special attention paid to the type of lesion, patients' preoperative state, type of surgical technique employed, as well as the period of operation. For comparison, two equal time periods of follow-up were reviewed--1992 to 1996 and 1997 to 2001. The overall postoperative conditions of patients were also regularly monitored. Patient data were statistically analyzed using the JMP program version 4.04.

RESULTS

An overall survival of 90% was recorded over the period of follow-up, ranging between one and ten years. A further break down showed a statistically significant difference between the various types of aortic coarctation, p=0.0001. Patients with simple or isolated coarctation had a survival rate of 100%, those with ventricular septal defect (VSD) in addition to coarctation had a survival rate of 80% while patients with associated complex cardiac anomalies had a survival rate of 65%. An improvement on overall patient survival was recorded in the period between 1997 and 2001--96% as against 86% for the period between 1992 and 1996. On univariate statistical analysis, the following variables were identified as significant risk factors for death: 1) Complex cardiac anomalies (p<0.0001), 2) Age at operation less than one month (p<0.0001) and 3) Treatment prior to the year 1997 (p=0.02).

CONCLUSION

A considerable improvement on patient survival following surgery for coarctation of the aorta was recorded over the last five years. This could be attributed to new measures in preoperative, operative and postoperative care for patients with aortic coarctation. (Tab. 4, Fig. 5, Ref. 8.).

Coarctation repair with prosthetic material: surgical experience with aneurysm formation

BACKGROUND

Late aneurysm formation is a common complication after repair of an aortic coarctation with prosthetic material; its incidence varies between 5 and 46%. We reviewed our experience with the management of this complication and propose a radical surgical treatment, which has proved to be free from severe complications; furthermore, we suggest the possibility of a new percutaneous management of this complication.

METHODS

From September 1974 to November 2002, 195 patients underwent primary repair of an aortic coarctation with prosthetic material (Dacron, polytetrafluorethylene or heterologous pericardium), with patch aortoplasty as the most common technique. During the follow-up period, reoperation for aneurysm formation was required in 13 asymptomatic patients. The diagnosis was made at angiography in 3 patients and at magnetic resonance imaging in 10. The indication for reoperation was an isthmic-diaphragmatic aortic diameter ratio > 1.5. Aneurysmectomy and tube graft interposition was performed in 12 patients; femoro-femoral cardiopulmonary bypass with a period of deep hypothermic circulatory arrest was carried out in 7 cases while 5 patients were submitted to normothermic atrio-femoral bypass; 1 patient underwent endovascular prosthesis implantation.

RESULTS

There were no in-hospital deaths. Three patients experienced postoperative complications: bleeding (n = 1), left phrenic nerve paresis (n = 1), and chylothorax (n = 1). The mean follow-up period was 51.8 +/- 46.2 months; all patients were asymptomatic without clinical or instrumental evidence of recurrence.

CONCLUSIONS

Aneurysm formation after primary repair of an aortic coarctation using prosthetic material is a potentially worrisome late complication and lifelong surveillance of these patients by means of magnetic resonance is mandatory. Surgical management, when indicated, has proved to be a definitive treatment and free from major complications. In highly selected patients, interventional management by percutaneous techniques may provide promising results.

[New strategies in surgical management of coarctation of the aorta 1975-2001]

AIM

This article presents the early and late surgical results of 401 newborns and infants among the 569 children with coarctation of aorta who were operated on between 1975-2001.

RESULTS

The early results were dependent on the anatomy of the aortic arch, the age and weight of babies and the types of the associated heart defects. The mortality rate was reduced from 15% (isolated coarctation 7.3%, complex coarctation 34%) to 3.0% (isolated 1.9%, complex 4.9%). 77.3% of 320 infants (follow-up 1 month-26 years, mean: 17 years) were free from re-operation or intervention. The (extended) end-to-end anastomosis and the subclavian flap method produced the best surgical results.

CONCLUSIONS

They suggest the extended end to end anastomosis technique for repair of the aortic arch together with the reconstruction of the associated heart defects in the youngest age if it is possible. The balloon angioplasty of the recoarctation of the aorta produces a good result.

[Surgical treatment of aortic coarctation in adults: mid-term results and effects on the systolic blood pressure]

OBJECTIVE

To evaluate the outcome and the systolic blood pressure changes after surgical treatment of aortic coarctation in adults.

METHODS

Between February 1995 and January 2001, 12 adult patients with a mean age of 29+/-10 years, underwent repair of aortic coarctation in our clinic. The diagnostic and operative data of these patients were retrospectively analyzed. Follow-up was complete in all hospital survivors.

RESULTS

The mean systolic blood pressure of 8 hypertensive patients decreased from 155+/-7 mmHg to 115+/-9 mmHg after surgical intervention. One patient with a dilated cardiomyopathy died one day after the operation due to an intractable ventricular fibrillation (mortality 8.3%). Four patients had been operated for coexisting cardiovascular pathologies during a mean follow-up period of 32+/-26 months.

CONCLUSION

Surgical treatment of aortic coarctation in adults can be safely performed with an acceptable mortality and morbidity, both resulting from coexisting cardiovascular disorders in our patient group. The systolic blood pressure may decrease significantly after the operation.

Poor outcome of very low birthweight babies with serious congenital heart disease

OBJECTIVE

To evaluate incidence and mortality of congenital heart disease in very low birthweight babies.

METHOD

Retrospective analysis of a 12 year period.

RESULTS

Forty seven babies were diagnosed with severe congenital heart disease. The most common lesions were ventricular septal defect and coarctation of the aorta. Mortality attributed to congenital heart disease was 32%. Coarctation of the aorta, the second most common lesion, was fatal in 62% of cases. Closure of a patent ductus arteriosus with indomethacin proved to be detrimental in babies with undiagnosed coarctation, causing rapid deterioration in some.

CONCLUSION

Very low birthweight neonates with severe congenital heart disease have a higher mortality than babies with higher birth weight. A contributing factor is closure of a patent ductus arteriosus if an underlying lesion has not been recognised. This could be of significance if the use of prophylactic treatment with indomethacin becomes more common.

Long-term follow-up of patients after coarctation of the aorta repair

Late cardiovascular complications after operative repair of coarctation of the aorta include systemic hypertension, premature coronary artery disease, aortic valve abnormalities, aortic aneurysm, and recoarctation. We report the outcome in 274 subjects greater-than-or-equal50 years after coarctation repair. Operative repair of simple coarctation was performed on 274 patients at the University of Minnesota Hospital between 1948 and 1976. Twenty patients (7%) died in the immediate postoperative period. Of the 254 survivors, 2 were lost to follow-up, 45 (18%) died at a mean age of 34 years, and 207 (81%) were alive greater-than-or-equal50 years after the original operation. Coronary artery disease and perioperative deaths at the time of a second cardiac operation accounted for 17 of the 45 late deaths. Predictors of survival were age at operation and blood pressure at the first postoperative visit. Of the 207 long-term survivors, 92 (48%) participated in a clinical cardiovascular evaluation. Thirty-two of the 92 subjects had systemic hypertension that was predicted by age at operation, blood pressure at the first postoperative visit, and paradoxic hypertension at operative repair. New cardiovascular abnormalities detected at follow-up evaluation included evidence of a previous myocardial infarction, cardiomyopathy, atrial fibrillation, moderate to severe left ventricular outflow tract obstruction, moderate aortic valve regurgitation, recoarctation, and ascending aortic dilation. Thus, long-term survival is significantly affected by age at operation, with the lowest mortality rates observed in patients who underwent surgery between 1 and 5 years of age. More than 1/3 of the survivors developed significant late cardiovascular abnormalities.

Repair of critical aortic coarctation in neonatal age

BACKGROUND

The data of 111 (male: 64; female: 47) in the period of 1967 until 12/93 consecutive operated neonatals (<1 month) were studied retrospectively (mean weight 3270 g, mean age at operation 14 days).

METHODS

Preductal anatomy was present in 96 patients. The coarctation was isolated in 30 patients (group I), 34 patients had additional large ventricular septal defects (group II) and 47 had complex heart disease (group III). The preoperative heart catheterization revealed a gradient of <20 mmHg in 35%, >20 mmHg in 51.4% and >50 mmHg in 12.9%. The indication for repair was conservatively untreatable heart insufficiency. In the vast majority (n=97) of patients resection and end-to-end anastomosis were performed, in 31 cases using an absorbable suture, in 18 of these using a continuous suture line. In 4 patients a subclavian flap angioplasty (SFA) was done, in 4 a patch enlargement, 4 times a repair was described as not possible and in 2 patients there was no gradient after division of the ductus.

RESULTS

Early lethality was 3.3% (n=1) in group I, 24.2% (n=8) died in group II and 39.1% (n=18) in group III; after introducing Prostaglandin E1 0% in group I, 15% in II and 25% in III. Relevant recoarctation (Gradient >20 mmHg) developed in 9 (among them 4 with hypoplastic arch, 2 after SFA) of the 77 long-term survivors; 6 of these were reoperated on, 5 without residual gradient, 1 with a gradient of 25 mmHg without clinical symptoms (after 4 years). In the last 3 patients a balloon dilation was carried out without residual gradient. Mean follow-up time was 6 (0-24) years. No patient needs antihypertensive treatment. The cumulative survival rate is 96.7% (+6.6%) for group I, 77.4% (+15.0%) for II and 51.9% (+16.6%) for III.

CONCLUSIONS

Resection and end-to-end anastomosis using a continuous absorbable suture is the method of choice at theoretical considerations and in our experiences. The number of recoarctations in neonatal age is relatively high; reinterventions (operation respectively dilation) can be done safely and successfully.