51
|
Abstract
Untreated thoracic aortic coarctation leads to early death predominantly because of hypertension and its cardiovascular sequelae. Surgical treatment has been available for > 50 years and has improved hypertension and survival. More recently, endovascular techniques have offered a minimally invasive alternative to traditional open repair. Early and intermediate results suggest angioplasty and stenting have an important role in the management of aortic coarctation, particularly in adults and older children.
Collapse
Affiliation(s)
- D R Turner
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
| | | |
Collapse
|
52
|
Prediction of recurrent coarctation by early postoperative blood pressure gradient. J Thorac Cardiovasc Surg 2011; 142:1130-6, 1136.e1. [PMID: 21741056 DOI: 10.1016/j.jtcvs.2011.02.048] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2010] [Revised: 12/15/2010] [Accepted: 02/23/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Blood pressure gradients that are noted early after repair of coarctation in neonates and infants are often attributed to proximal arch hypoplasia. Rapid growth of the hypoplastic proximal arch is usually observed, although in some individuals an early gradient predicts the subsequent need for reintervention. To define the predictive reliability of blood pressure gradients between arms and legs and to identify predictors of arch growth, we undertook a retrospective study. METHODS Between January 2000 and June 2008, 77 infants underwent surgical repair of coarctation. Data collected included preoperative dimensions of aortic segments. Blood pressure gradients between arms and legs determined by cuff were compared intraoperatively and postoperatively, as well as 2-dimensional echocardiographic dimensions of the aorta between those who did not require reintervention for recoarctation (group A) and those who did (group B). Receiver operating characteristic curve analysis was applied to evaluate discrimination of the systolic gradient in differentiating the 2 groups of patients. RESULTS At surgery, patients' median age was 10 days and weight was 3.3 kg. There was 1 early death. Median follow-up was 40 months (interquartile range, 24-63 months). Recoarctation developed in 11 patients (14.3%), defined as a resting blood pressure gradient of greater than 20 mm Hg with a corresponding decrease in the diameter of the aorta by 50%. Freedom from recoarctation was 87% at 1 year and 85% at 5 years. Multivariable logistic regression analysis identified the size of the ascending aorta as a risk factor for recoarctation. Blood pressure gradient at the end of surgery was not predictive of recoarctation. The ascending aorta and transverse arch showed rapid growth in group A, and this was associated with a decrease in blood pressure gradient over time. In comparison, the growth of the ascending aorta and arch in group B was significantly less than in group A and associated with worsening of gradients. Receiver operating characteristic curve analysis revealed that gradients at the time of hospital discharge (>13 mm Hg) had excellent discriminative accuracy in identifying patients in whom subsequent recoarctation developed. CONCLUSIONS Small size of the ascending aorta is a risk factor for recoarctation. Limb gradient in the operating room at completion of surgery is not a reliable tool to assess repair of coarctation, although the gradient at the time of hospital discharge can be used to accurately predict recoarctation. Rapid growth of both the ascending and the transverse aorta is frequently observed and associated with improvement in gradients over time.
Collapse
|
53
|
Angtuaco MJ, Vyas HV, Morrow WR, Imamura M, Jaquiss RDB, Sachdeva R. Aortopulmonary index as a novel morphologic correlate of early recurrence of coarctation of aorta after surgical repair in infancy. J Am Soc Echocardiogr 2011; 24:841-6. [PMID: 21570255 DOI: 10.1016/j.echo.2011.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to determine morphologic correlates of early reintervention for recurrent coarctation in infants undergoing surgical repair in the current era. METHODS Medical records of infants who underwent repair of coarctation were retrospectively reviewed. Z scores for aortic segments, relative aortic arch segmental dimensions (indexed to ascending or descending aortic dimension), and aortopulmonary index (the ratio of aortic to pulmonary annular diameter) were derived from preoperative echocardiograms. RESULTS Eighty-seven patients underwent repair (median age, 13 days). Early arch reintervention (<1 year after surgery) was performed in 11. Lower aortopulmonary index and Z scores of the aortic annulus and sinotubular junction were associated with early reintervention. Aortopulmonary index < 0.6 was the best correlate (sensitivity, 72.7%; specificity, 73.7%; area under the curve, 0.732). Aortic arch dimensions were not correlated with early reintervention. CONCLUSION In the current era, aortopulmonary index rather than aortic arch hypoplasia is correlated with the need for reintervention for recurrent coarctation within 1 year of surgery.
Collapse
Affiliation(s)
- Michael J Angtuaco
- Department of Pediatrics, Division of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
| | | | | | | | | | | |
Collapse
|
54
|
Kaushal S, Backer CL, Patel JN, Patel SK, Walker BL, Weigel TJ, Randolph G, Wax D, Mavroudis C. Coarctation of the Aorta: Midterm Outcomes of Resection With Extended End-to-End Anastomosis. Ann Thorac Surg 2009; 88:1932-8. [DOI: 10.1016/j.athoracsur.2009.08.035] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 08/10/2009] [Accepted: 08/13/2009] [Indexed: 12/15/2022]
|
55
|
Burch PT, Cowley CG, Holubkov R, Null D, Lambert LM, Kouretas PC, Hawkins JA. Coarctation repair in neonates and young infants: is small size or low weight still a risk factor? J Thorac Cardiovasc Surg 2009; 138:547-52. [PMID: 19698833 DOI: 10.1016/j.jtcvs.2009.04.046] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2008] [Revised: 03/25/2009] [Accepted: 04/27/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Previous reports of neonatal coarctation repair demonstrate a high rate of recurrent arch obstruction in small neonates. This study assesses the effect of patient size on reintervention and survival in neonates and infants undergoing repair of simple aortic coarctation. METHODS From 1996 to 2006, 167 neonates and infants younger than 90 days with simple coarctation underwent repair. Median patient age was 16 days (range, 1-85 days). Median patient weight was 3.4 kg (range, 0.8-6.0 kg), with 29 patients weighing less than 2.5 kg. All 167 patients included in the study underwent repair through a left thoracotomy. RESULTS There was 1 early death (1/167, 0.6%). Median follow-up of 4.8 years (range, 0-11.8 years) demonstrated 2 late deaths unrelated to recurrent coarctation. Eighteen patients underwent intervention for recurrent arch obstruction a median of 0.48 years postoperatively (range, 0.14-9.8 years). All were treated with balloon angioplasty and have required no additional intervention. Actuarial freedom from reintervention was 90% at 1 year and 89% at 5 years for infants weighing more than 2.5 kg and 89% at 1 year and 86% at 5 years (P = .31) for infants weighing less than 2.5 kg. There was no difference between survival or reintervention for neonates 30 days of age or younger compared with infants 31 to 90 days of age. Use of polypropylene sutures and female sex did correlate with increased reintervention. CONCLUSIONS Low weight does not affect survival or reintervention rates after coarctation repair in neonates and infants less than 3 months of age. Balloon angioplasty is an effective treatment for recurrent obstruction after coarctation repair in infancy. In the current era, timing of the operation should be based on clinical status.
Collapse
Affiliation(s)
- Phillip T Burch
- Division of Cardiothoracic Surgery, Primary Children's Medical Center and the University of Utah, Salt Lake City, Utah, USA.
| | | | | | | | | | | | | |
Collapse
|
56
|
Cantinotti M, Maizza AF, Murzi M, Assanta N, Margaryan R, Recla S, Murzi B. Aortic arch laceration during aortic coarctation repair in a low-weight neonate and use of an extra-anatomical conduit. J Cardiovasc Med (Hagerstown) 2009; 10:497-8. [PMID: 19359996 DOI: 10.2459/jcm.0b013e32832a49b7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a 3-day-old male baby, weighing 1.6 kg with severe aortic coarctation and associated cardiac anomalies and extracardiac defects. We adopted an extra-anatomical conduit running from the left carotid artery to the descending aorta after laceration of the distal aortic arch due to extreme tissue fragility and baby immaturity.
Collapse
|
57
|
Maddali MM, Valliattu J, al Delamie T, Zacharias S. Selection of Monitoring Site and Outcome after Neonatal Coarctation Repair. Asian Cardiovasc Thorac Ann 2008; 16:236-9. [DOI: 10.1177/021849230801600312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To assess whether simultaneous invasive arterial pressure monitoring of right upper and lower limbs in neonatal aortic coarctation with or without arch hypoplasia has an impact on surgical decision-making and outcome, data of 140 newborns who underwent emergency surgical repair over 15 years were analyzed retrospectively. The 36 who had simultaneous right arm and lower limb arterial pressure monitored intraoperatively were assigned to group 1. The other 104 who had blood pressure monitored invasively at a single site (either upper or lower limb) were allocated to group 2. In group 1, a residual gradient across the repaired segment was detected intraoperatively in 13% of patients, and corrected at the same sitting. In group 2, 6% needed subsequent balloon angioplasty. In all babies with arch hypoplasia in group 1, the proximal aortic cross clamp was readjusted at least once to avoid compromise of carotid blood flow. Simultaneous right upper and lower limb invasive pressure monitoring has an impact on the overall outcome in these sick neonates.
Collapse
Affiliation(s)
| | - John Valliattu
- Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
| | - Taha al Delamie
- Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
| | - Sunny Zacharias
- Department of Cardiothoracic Surgery, Royal Hospital, Muscat, Oman
| |
Collapse
|
58
|
Abstract
In severe aortic coarctation in the neonatal period, surgical repair is required soon after clinical stabilization. Elective repair of isolated aortic coarctation is nowadays indicated at 3-6 months of life or at the time of diagnosis. At present, no single operation appears to have a clear superiority. However, during the first months of life, an extended end-to-end anastomosis is considered the best option by most authors, even though weight at operation and anatomy of the aortic arch are also significant determinants of late recoarctation. In cases of aortic arch hypoplasia, which occurs in up to 70% of neonatal and infant coarctations, especially when associated anomalies are present, surgery seems the treatment of choice. After 3 months of age and in the adult population, balloon angioplasty and stent placement are considered a suitable option. Recently, we adopted a median sternotomy approach without the use of extracorporeal circulation for the treatment of aortic coarctation with a hypoplastic aortic arch. We treated 11 patients with satisfactory results at an average follow-up of 40 months.
Collapse
|
59
|
Abstract
Disease of the aortic arch is a common component of congenital heart disease requiring surgical treatment in the neonate. While sometimes found in isolation, aortic arch disease must be placed into the larger context of frequently associated pathology. This review describes the anatomic variations of neonatal aortic arch pathology, surgical approaches and techniques, and expected outcomes.
Collapse
Affiliation(s)
- Frank A Pigula
- Department of Cardiac Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA.
| |
Collapse
|
60
|
Abstract
Today, the availability of competing techniques for coarctation repair, including numerous surgical approaches as well as interventional ones, raises important questions about indications, risks and criteria for procedural success. Surgical treatment of coarctation is an extremely well tolerated procedure with excellent long-term efficacy due to an 88 to 96% 5 years freedom from re-intervention in patients operated on within the first months of life. If compared with surgery, balloon angioplasty features a higher risk for aneurysm formation, aortic rupture and a lower degree of success, with potentially important residual pressure gradient in up to 20.7% of patients. Stents are believed to overcome the problems of simple dilation, but concerns remain about the materials and the potential of re-expandibility in view of the growth of the treated aorta. Moreover, serious complications, including death, have been reported by stent implantation as well, similar to aneurysms or dissections (4.3%), balloon rupture with stent migration or cerebral vascular injury (9%). There is no evidence to date for the superiority of any interventional approach to surgical treatment of primary coarctation. The favorable long-term surgical results outweigh the proposed short-term benefits of angioplasty and stenting, which should be restricted to well selected cases.
Collapse
Affiliation(s)
- Tom R Karl
- Pediatric Heart Center, University of California, San Francisco, California 94143, USA.
| |
Collapse
|
61
|
Lai WW, Geva T, Shirali GS, Frommelt PC, Humes RA, Brook MM, Pignatelli RH, Rychik J. Guidelines and standards for performance of a pediatric echocardiogram: a report from the Task Force of the Pediatric Council of the American Society of Echocardiography. J Am Soc Echocardiogr 2006; 19:1413-30. [PMID: 17138024 DOI: 10.1016/j.echo.2006.09.001] [Citation(s) in RCA: 574] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Wyman W Lai
- Mount Sinai Medical Center, New York, NY 10029, USA
| | | | | | | | | | | | | | | |
Collapse
|
62
|
Agnoletti G, Raisky O, Boudjemline Y, Ou P, Bonnet D, Sidi D, Vouhé P. Neonatal Surgical Aortic Commissurotomy: Predictors of Outcome and Long-Term Results. Ann Thorac Surg 2006; 82:1585-92. [PMID: 17062209 DOI: 10.1016/j.athoracsur.2006.05.049] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 05/10/2006] [Accepted: 05/11/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective of this study was to review our institutional experience concerning neonatal aortic commissurotomy and to identify predictors of outcome. METHODS From January 1, 1990, to January 1, 2005, 65 neonates were referred for critical aortic stenosis. Among these 36 consecutive patients underwent surgical valvotomy by the same surgeon and 16 patients had balloon valvotomy. We examined clinical records to establish determinants of outcome and illustrate long-term results. RESULTS In the surgical group 6 patients had nonstenotic parachute mitral valve, 6 had aortic coarctation, 13 had endocardial fibroelastosis; and 15 had depressed fractional shortening. In the balloon valvotomy group most infants had associated mitral stenosis (n = 7), small aortic annulus (n = 5), multiple anomalies (n = 2), endocardial fibroelastosis (n = 9), and depressed fractional shortening (n = 13). In the surgical group global mortality was 19%; 47% in infants with depressed fractional shortening and 0% in infants with normal fractional shortening. Mortality in the balloon valvotomy group was 56%. Low fractional shortening, low mean aortic gradient, endocardial fibroelastosis, and small aortic annulus were associated with fatal outcome. In the surgical group 6 patients needed Ross operation at a median interval of 4 years from commissurotomy. In the balloon valvotomy group 3 patients needed early mitral replacement and 5 aortic valve surgery. At a median follow-up of 6 years, all children are in New York Heart Association class I, all have a normal ventricular function, 2 have aortic restenosis, and 5 have at least moderate aortic incompetence. CONCLUSIONS In a selected population of neonates with isolated aortic stenosis, surgical valvotomy offers an excellent long-term outcome to patients with a normokinetic left ventricle, while patients with a hypokinetic left ventricle have a poor outcome. Balloon valvotomy offers poor results when performed in patients with complex anomalies.
Collapse
|
63
|
Sudarshan CD, Cochrane AD, Jun ZH, Soto R, Brizard CP. Repair of coarctation of the aorta in infants weighing less than 2 kilograms. Ann Thorac Surg 2006; 82:158-63. [PMID: 16798207 DOI: 10.1016/j.athoracsur.2006.03.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2005] [Revised: 02/28/2006] [Accepted: 03/03/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND We retrospectively reviewed our experience in aortic coarctation repair on infants weighing less than 2 kg to evaluate the results and assess the rate of recoarctation in this group of patients. METHODS Twenty-four consecutive babies weighing 2 kg or less were operated on over a period of 15 years. Median gestational age was 33 weeks (range, 30 to 36), and median weight was 1.6 kg (range, 1.0 to 2.0). Seventeen of them had associated cardiac anomalies. The methods of repair undertaken were resection with extended end-to-end anastomosis (n = 13), subclavian flap angioplasty (n = 9), carotid flap angioplasty (n = 1), and patch repair using pulmonary homograft tissue (n = 1). RESULTS Mean follow-up was 52.5 months (range, 0.5 to 151). There were 3 in-hospital deaths and 2 late deaths. Recoarctation developed in 7 babies. Four underwent balloon dilatation; 1 of them required further surgery; 3 others have mild recoarctation, but have not required further intervention. Risk factor analyses revealed that the presence of preoperative congestive cardiac failure, and coexisting noncardiac lesions as well as the duration of descending aortic cross-clamp and postoperative ventilation had a significant influence on mortality after repair. CONCLUSIONS Coarctation repair in infants less than 2 kg can be performed safely. The incidence of recoarctation is acceptable and comparable with that of other pediatric cohorts that have been reported. Preoperative cardiac function and associated noncardiac lesions may influence the incidence of mortality after repair. Delaying the timing of surgical repair to achieve growth is not necessary.
Collapse
|
64
|
Thomson JDR, Mulpur A, Guerrero R, Nagy Z, Gibbs JL, Watterson KG. Outcome after extended arch repair for aortic coarctation. Heart 2006; 92:90-4. [PMID: 15845612 PMCID: PMC1860999 DOI: 10.1136/hrt.2004.058685] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2005] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To assess survival and long term arch patency rates in a consecutive group of children after extended arch repair for coarctation of the aorta. METHODS Review of 191 consecutive children (154 (81%) under 1 year of age) operated on between 1990 and 2002 by a single surgeon using extended arch reconstructive techniques. For assessment of survival patients were divided into three groups: 1, coarctation alone, n = 104; 2, coarctation and ventricular septal defect, n = 38; and 3, coarctation in association with complex intracardiac anomalies, n = 49. A prospective and systematic clinical and echocardiographic evaluation of the aortic arch was undertaken. RESULTS Median time to follow up was 4.2 years (range 1-10.6 years). Overall actuarial survival was 92%, 88%, and 88% at two, five, and 10 years. Mortality was significantly higher in those patients with complex intracardiac anatomy. Arch obstruction recurred in seven of 165 (4.2%) patients: four of 139 (2.9%) term and three of 10 (30%) premature infants (p < 0.001). CONCLUSIONS Survival after extended arch reconstruction for coarctation is excellent. At long follow up recurrent arch obstruction is rare, with prematurity the only risk factor.
Collapse
Affiliation(s)
- J D R Thomson
- Department of Congenital Cardiology, Yorkshire Heart Centre, Leeds General Infirmary, Leeds, UK.
| | | | | | | | | | | |
Collapse
|
65
|
Fesseha AK, Eidem BW, Dibardino DJ, Cron SG, McKenzie ED, Fraser CD, Price JF, Chang AC, Mott AR. Neonates With Aortic Coarctation and Cardiogenic Shock: Presentation and Outcomes. Ann Thorac Surg 2005; 79:1650-5. [PMID: 15854946 DOI: 10.1016/j.athoracsur.2004.11.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2004] [Indexed: 12/01/2022]
Abstract
BACKGROUND Some neonates with coarctation of the aorta (COA) present with cardiogenic shock and secondary end-organ injury. The management of this subgroup imposes unique challenges. We review our perioperative strategy and outcomes for neonates with COA who presented with cardiogenic shock. METHODS Neonates (younger than 30 days) with isolated COA or COA with aortic arch hypoplasia were identified. Retrospective review was performed to identify and characterize patients who presented with cardiogenic shock, defined as impaired left ventricular (LV) or right ventricular (RV) systolic function, or both, respiratory failure requiring tracheal intubation, and metabolic acidosis. RESULTS Thirteen neonates presented in cardiogenic shock and underwent surgical repair. No patients required catheter or surgical reintervention for recoarctation. There were no deaths at a mean follow-up of 54 months. Group I neonates (isolated COA, n = 7) underwent end-to-end anastomosis through left thoracotomy. The mean age and pH at presentation were 9 (+/-1.1) days and 7.07 (+/-0.21), respectively. The mean preoperative and postoperative LV myocardial performance indices (MPI) were 0.81 (+/-0.22) and 0.37 (+/-0.16), respectively (p = 0.002). Group II neonates (COA with arch hypoplasia +/- ventricular septal defect, n = 6) underwent aortic arch advancement and ventricular septal defect closure through median sternotomy. The mean time from diagnosis to surgery in group II was 5.5 (+/-1.9) days versus 2.4 (+/-1.5) days in group 1 (p = 0.01). The mean age and pH at presentation were 11.8 (+/-9.3) days and 7.02 (+/-0.21), respectively. The mean preoperative and postoperative LV MPI were 0.46 (+/-0.13) and 0.35 (+/-0.11), respectively (p = 0.02). The total hospital length of stay in group II patients was 18 (+/-6.23) days versus 11.3 (+/-5. 7) days in group I (p = 0.04). CONCLUSIONS Timely intervention with a strategy individualized to the patient anatomy can be performed with excellent outcomes in neonates with COA and cardiogenic shock. Neonates with isolated COA had worse preoperative LV MPI, which reflects more significant global left ventricular systolic dysfunction in this subgroup. The elapsed time from diagnosis to surgery was decreased in neonates with isolated COA.
Collapse
Affiliation(s)
- Assaf K Fesseha
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
66
|
Rome JJ, Kreutzer J. Pediatric interventional catheterization: reasonable expectations and outcomes. Pediatr Clin North Am 2004; 51:1589-610, viii. [PMID: 15561175 DOI: 10.1016/j.pcl.2004.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article considers the role transcatheter therapy plays in the treatment of each major type of congenital heart lesion. The focus is on the clinical ramifications of the interventions rather than their technical aspects.
Collapse
Affiliation(s)
- Jonathan J Rome
- Department of Pediatrics, University of Pennsylvania School of Medicine, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | | |
Collapse
|
67
|
Puchalski MD, Williams RV, Hawkins JA, Minich LL, Tani LY. Follow-up of aortic coarctation repair in neonates. J Am Coll Cardiol 2004; 44:188-91. [PMID: 15234432 DOI: 10.1016/j.jacc.2004.01.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2003] [Revised: 12/17/2003] [Accepted: 01/19/2004] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purposes of this study were to assess the growth of left heart (LH) structures, to evaluate midterm outcomes, and to define echocardiographic parameters predictive of increased risk of re-intervention in patients born with aortic coarctation and hypoplasia of LH structures that underwent neonatal coarctation repair. BACKGROUND Neonatal coarctation is often associated with hypoplasia of LH structures. Although previous studies have shown that coarctation repair can be performed with good results in these neonates, there are little data regarding growth of the LH structures or outcomes in these patients. METHODS Patients with isolated coarctation and at least one hypoplastic LH valve (mitral or aortic Z-score <-2) who underwent a neonatal coarctation repair were identified. Clinic charts and the latest echocardiograms were reviewed. RESULTS All 55 patients were alive and well, and no patient had clinical evidence of mitral stenosis. Three patients (5%) required re-intervention. Thirty-eight patients had echocardiograms that demonstrated normal left ventricular (LV) size and function with a follow-up duration of 73 +/- 19 months (range 3 to 9 years). Both mitral and aortic annulus Z-scores increased significantly: -3.1 +/- 1.5 to -0.5 +/- 1.6 (p < 0.001) and -3.5 +/- 1.9 to 0.7 +/- 1.6 (p < 0.001), respectively. Nine patients (24%) developed LV outflow tract obstruction by echocardiographic criteria. CONCLUSIONS After neonatal coarctation repair with associated LH hypoplasia, LH structures increase substantially in size, and clinical outcomes are excellent at midterm follow-up. Despite initial annular hypoplasia, the need for intervention for mitral or aortic/subaortic stenosis is uncommon.
Collapse
Affiliation(s)
- Michael D Puchalski
- Primary Children's Medical Center, University of Utah, Salt Lake City, Utah 84113, USA.
| | | | | | | | | |
Collapse
|
68
|
DiBardino DJ, Heinle JS, Kung GC, Leonard GT, McKenzie ED, Su JT, Fraser CD. Anatomic reconstruction for recurrent aortic obstruction in infants and children. Ann Thorac Surg 2004; 78:926-32; discussion 926-32. [PMID: 15337022 DOI: 10.1016/j.athoracsur.2004.02.126] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients undergoing operative repair of aortic obstruction are at a lifelong risk of recurrent obstruction, and there is controversy regarding the optimal surgical technique. We have used an alternative strategy for recurrent aortic obstruction, typically involving anatomic reconstruction by means of a median sternotomy, and describe our techniques and results. METHODS Twenty-one patients presented with recurrent aortic arch obstruction. Mean age and weight were 7.8 +/- 5.4 years (range, 0.21 to 15.2 years) and 30.6 +/- 21.8 kg (range, 3.6 to 90 kg), respectively. Recurrence involved the aortic arch to some degree in each case, as the mean preoperative transverse aortic arch z score was -2.9 +/- 1.6 (range, -7.0 to 0.1). Thoracotomy was possible in 2 patients, using re-resection with end-to-end anastomosis (n = 1) and patch aortoplasty (n = 1). The remaining 19 patients required median sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest for complete relief of obstruction by aortic arch advancement (n = 10), patch aortoplasty (n = 8), or interposition grafting (n = 1). RESULTS There was 1 hospital death. Invasive blood pressure monitoring revealed no residual arm-to-leg gradient in 19 patients and a 20-mm Hg gradient in 2 patients. There have been no late deaths. No patients have undergone subsequent aortic intervention, and all are asymptomatic up to 85 months postoperatively. Two patients are currently followed with a 10-mm Hg arm-to-leg blood pressure gradient. CONCLUSIONS Anatomic reconstruction for recurrent aortic obstruction can be safely accomplished in the majority of patients. We favor median sternotomy because of the ability of establishing cardiopulmonary bypass, the facility of anatomic reconstruction techniques, and the ability to repair concomitant cardiovascular lesions.
Collapse
Affiliation(s)
- Daniel J DiBardino
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA.
| | | | | | | | | | | | | |
Collapse
|
69
|
Wood AE, Javadpour H, Duff D, Oslizlok P, Walsh K. Is extended arch aortoplasty the operation of choice for infant aortic coarctation? Results of 15 years' experience in 181 patients. Ann Thorac Surg 2004; 77:1353-7; discussion 1357-8. [PMID: 15063265 DOI: 10.1016/j.athoracsur.2003.07.045] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recurrent coarctation is an ever-present complication of surgical treatment of coarctation of aorta (CoA) among infants. No single operation appears to have a clear superiority. METHODS From January 1, 1986, to June 30, 2002, a consecutive series of 181 patients less than 1 year of age (range 1 to 300 days, median 13.5 days) were referred for CoA repair. Neonates accounted for 135 patients, and hypoplastic arch (less than 1 mm/kg plus 1) was present in 107 infants. Coarctation of aorta was simple (group 1) in 71 patients; complicated by ventricular septal defect (group 2) in 62; and complicated by complex congenital heart disease (group 3) in 48. All patients were assessed by right arm/left leg Dynamap pressures and routine follow-up was performed by the cardiologists. Follow-up was complete in all patients (range 6 months to 16 years, median 7.5 years). RESULTS The overall hospital/30-day mortality was 0.5% (group 1 = 0, group 2 = 0, group 3 = 1 [2.0%]). Complications other than recoarctation occurred in 5 patients (2.7%). Late mortality occurred in 15 (11 at intracardiac repair). Recoarctation, ie, a gradient of more than 20 mm Hg, occurred in 4 patients (2.2%). All 4 patients were noted to have a gradient of more than 10 mm Hg (right arm/left leg) postoperatively and as such had residual coarctation. All 4 were successfully treated by balloon aortoplasty. CONCLUSIONS Extended arch aortoplasty in association with ductal and coarctation excision provides excellent coarctation repair with a low incidence of recoarctation. Recoarctation occurred only in proximal aortic arch hypoplasia or low birth weight. Balloon aortoplasty easily and effectively relieved the recoarctation in all cases.
Collapse
Affiliation(s)
- Alfred E Wood
- Department of Cardiothoracic Surgery, Our Lady's Hospital for Sick Children, Crumlin, Dublin, Ireland.
| | | | | | | | | |
Collapse
|
70
|
Pearl JM, Manning PB, Franklin C, Beekman R, Cripe L. Risk of recoarctation should not be a deciding factor in the timing of coarctation repair. Am J Cardiol 2004; 93:803-5. [PMID: 15019901 DOI: 10.1016/j.amjcard.2003.11.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2003] [Revised: 11/26/2003] [Accepted: 11/26/2003] [Indexed: 10/26/2022]
Abstract
To determine whether early coarctation repair is a significant risk for recoarctation in the modern era, 120 patients, including 87 infants, who underwent isolated coarctation repair at a single institution, were reviewed. At a mean follow-up of 44.4 months, there have were no late reoperations, and 2 patients required balloon aortoplasty. The overall incidence of late reintervention was 1.7%, with only 2.4% (2 of 83) in those <1 year old.
Collapse
Affiliation(s)
- Jeffrey M Pearl
- Division of Pediatric Cardiothoracic Surgery, Children's Hospital Medical Center, and the Department of Surgery, University of Cincinnati, Cincinnati, Ohio 45229, USA.
| | | | | | | | | |
Collapse
|
71
|
Tomita H, Yazaki S, Kimura K, Hayashi G, Fujita H, Okada Y, Watanabe K, Kurosaki KI, Ono Y, Yagihara T, Echigo S. Balloon angioplasty of postoperative coarctation in the transverse arch in infants: protecting the common carotid artery. Catheter Cardiovasc Interv 2003; 60:529-33. [PMID: 14624435 DOI: 10.1002/ccd.10667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We performed balloon angioplasty in three patients with postoperative coarctation in the transverse arch adjacent to the left common carotid artery. The age at arch reconstruction was 5, 6, and 2 days, while the interval between operation and balloon dilatation was 59 days, 87 days, and 12 months, respectively. Two balloons, one in the stenosis and the other in the left common carotid artery, were introduced over a wire sequentially and inflated simultaneously until the waist of the balloon in the arch disappeared. After balloon dilatation, a significant reduction in the peak-to-peak pressure gradient and an increase in vessel diameters were observed in all patients. Further growth of the transverse arch was documented at follow-up in two patients. No aneurysm has been detected in any patients. We believe that placing a protective balloon in the neck vessel increases safety during balloon dilatation of coarctation in the transverse arch.
Collapse
Affiliation(s)
- Hideshi Tomita
- Department of Pediatrics, National Cardiovascular Center, Osaka, Japan.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
72
|
Seipelt RG, Backer CL, Mavroudis C, Stellmach V, Seipelt IM, Cornwell M, Hernandez J, Crawford SE. Topical VEGF enhances healing of thoracic aortic anastomosis for coarctation in a rabbit model. Circulation 2003; 108 Suppl 1:II150-4. [PMID: 12970224 DOI: 10.1161/01.cir.0000087388.15066.1f] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recurrent stenosis after extended end-to-end anastomosis for aortic coarctation is the primary indication for further interventions in children. Tension because of the extended resection and local arterial wall hypoxia are possible pathogenetic mechanisms. We hypothesized that (1) tension interferes with healing and (2) that vascular endothelial growth factor (VEGF), a hypoxia sensitive angiogenic inducer, may enhance healing of the vascular anastomosis. METHODS AND RESULTS In a model of coarctation repair, rabbits underwent thoracic aortic end-to-end anastomosis after transection (no-tension; n=15), resection of an aortic ring (tension; n=14) or resection and topical VEGF treatment (0.75 microg VEGF165; tension+VEGF; n=14). Gross and histologic characteristics of the aortic wall were assessed at 1 week, 1 and 2 months. In the tension only group at 1 month, the severity of vascular remodeling was increased with fibrosis and calcification compared with controls. At 2 months, this group also revealed more luminal stenosis (29% versus 19%; P<0.001). Exogenous VEGF resulted in significantly less fibrosis, calcification and chondroid metaplasia at 1 month (P<0.05) and luminal area was only reduced 3% at 2 months (P<0.001 versus tension group). CONCLUSIONS In a rabbit model of coarctation repair, the addition of tension on the vascular anastomosis resulted in poor healing and luminal stenosis. Topical VEGF maintained luminal integrity by decreasing fibrosis and calcification. These findings suggest that topical VEGF may be a promising new strategy to enhance healing and improve the outcome of vascular anastomoses for coarctation of the aorta.
Collapse
Affiliation(s)
- Ralf G Seipelt
- Division of Pediatric Cardiovascular Thoracic Surgery, Children's Memorial Hospital, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60614, USA
| | | | | | | | | | | | | | | |
Collapse
|
73
|
Stayer SA, Andropoulos DB, Russell IA. Anesthetic management of the adult patient with congenital heart disease. ACTA ACUST UNITED AC 2003; 21:653-73. [PMID: 14562571 DOI: 10.1016/s0889-8537(03)00040-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
As the number of CHD repairs in adults continues to increase, these operations will be performed in a wider variety of institutions and systems. Unfortunately, not all of these centers will have an optimal environment for correcting CHD in adults. This type of surgery is best accomplished in a facility specifically designed for treating adults with CHD. Optimal care of these patients is provided by cardiologists who are trained and experienced in pediatric and adult cardiology, by surgeons who are trained and experienced in treating CHD, and by anesthesiologists who are experienced in caring for adults with CHD. Whatever the setting, cardiac anesthesiologists involved in these cases must be thoroughly aware of the anesthetic implications for the unique pathophysiology of each patient, and they must not rely on their "usual" expectations of either true pediatric CHD or acquired adult heart disease.
Collapse
Affiliation(s)
- Stephen A Stayer
- Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin, Houston, TX 77030, USA.
| | | | | |
Collapse
|
74
|
Woods WA, Schutte DA, McCulloch MA. Care of children who have had surgery for congenital heart disease. Am J Emerg Med 2003; 21:318-27. [PMID: 12898491 DOI: 10.1016/s0735-6757(03)00042-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Children who have had surgical correction for congenital heart disease can present to the ED with an acute illness that could be associated with their cardiac lesion. There is no data available to summarize complications that could be associated with surgically corrected congenital heart disease. This work was undertaken to describe the common procedures used, list known complications of these procedures, and review general management principles in caring for the acutely ill child who has had heart surgery.
Collapse
Affiliation(s)
- William A Woods
- Department of Emergency Medicine, PO Box 800699, University of Virginia Health System, Charlottesville, VA 22908, USA.
| | | | | |
Collapse
|