Coarctation of the aorta: Management from infancy to adulthood

Analysis of factors associated with prolonged post-operative course after surgical repair of aortic coarctation

OBJECTIVE

We sought to describe patient characteristics associated with prolonged post-operative length of stay in a contemporary cohort of infants who underwent isolated repair of aortic coarctation.

METHODS

We reviewed patients less than 1 year of age who underwent isolated repair of aortic coarctation at our institution from 2009 to 2016. Prolonged post-operative length of stay was defined as length of stay within the upper tertile for the cohort. Bivariate and multi-variable analyses were performed to determine independent risk factors for prolonged length of stay.

RESULTS

We reviewed 95 consecutive patients who underwent isolated repair of aortic coarctation, of whom 71 were neonates at the time of diagnosis. The median post-operative length of stay was 6.5 days. The upper tertile for post-operative length of stay was greater than 10 days; 32 patients within this tertile and 1 patient who died at 8.5 days after surgery were analysed as having prolonged post-operative length of stay. In a multi-variable analysis, pre-maturity (odds ratio: 3.5, 95% confidence interval: 1.2, 10.7), genetic anomalies (odds ratio: 4.7, 95% confidence interval: 1.2, 18), absence of pre-operative oral feeding (odds ratio: 7.4, 95% confidence interval: 2.4, 22.3), and 12-hour vasoactive-ventilation-renal score greater than 25 (odds ratio: 7.4, 95% confidence interval: 1.9, 29) were independently associated with prolonged length of stay.

CONCLUSIONS

In neonates and infants who underwent isolated repair of aortic coarctation, pre-maturity, genetic anomalies, lack of pre-operative oral feedings, and 12-hour vasoactive-ventilation-renal score more than 25 were independent risk factors for prolonged post-operative length of stay. Further study on the relationship between pre-operative oral feedings and post-operative length of stay should be pursued.

Improved detection of coarctation of the aorta using speckle-tracking analysis of fetal heart on last examination prior to delivery

OBJECTIVE

The false-positive rate for prenatal diagnosis of coarctation of the aorta (FP-CoA) commonly exceeds 50%, with an accurate detection rate of < 50%. This study was conducted to determine if the sensitivity for prenatal detection of true CoA and the FP-CoA rate could be improved by evaluating the fetal epicardial size and shape in the four-chamber view (4CV) and the endocardial right (RV) and left (LV) ventricular size, shape and contractility.

METHODS

We analyzed retrospectively Digital Imaging and Communications in Medicine (DICOM) clips of the 4CV from the last examination prior to delivery in a series of 108 fetuses with CoA suspected prenatally by pediatric cardiologists using traditional diagnostic criteria. Postnatal evaluation distinguished those fetuses which subsequently required CoA surgery (true positives; true CoA) from those that were FP-CoA. Postnatal cardiac abnormalities were identified for each group. For the prenatal evaluation, we measured the 4CV end-diastolic epicardial area, circumference, length, width and global sphericity index. Speckle-tracking analysis was used to compute the endocardial RV and LV end-diastolic area, length, 24-segment sphericity index, 24-segment transverse width and the following functional parameters: fractional area change; global longitudinal, free-wall and septal-wall strain; basal-apical-length, basal free-wall and basal septal-wall fractional shortening; septal-wall annular plane systolic excursion; 24-segment transverse-width fractional shortening; and LV end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction. In addition, the RV/LV end-diastolic area ratio was computed. Using a control group of 200 normal fetuses, the mean and SD for each of the above cardiac measurements was used to compute the Z-scores for each measurement in each of the 108 study fetuses. Logistic regression analysis was then performed on the Z-score values to identify variables that separated the true CoA group from the FP-CoA group.

RESULTS

Of the 108 study fetuses, 54 were confirmed postnatally to have true CoA and 54 were FP-CoA. Right/left area disproportion > 90^th  centile was present in 80% (n = 43) of the true-CoA fetuses and 76% (n = 41) of the FP-CoA fetuses. Fetuses with true CoA had a significantly greater number of associated cardiac abnormalities (93%, n = 50) compared with the FP-CoA fetuses (61%, n = 33) (P < 0.001). The most common associated malformations were bicuspid aortic valve (true CoA, 46% (n = 25) vs FP-CoA, 22% (n = 12); P < 0.01), aortic arch hypoplasia (true CoA, 31% (n = 17) vs FP-CoA, 11% (n = 6); P < 0.01), ventricular septal defect (true CoA, 33% (n = 18) vs FP-CoA, 11% (n = 6); P < 0.05) and mitral valve abnormality (true CoA, 30% (n = 16) vs FP-CoA, 4% (n = 2); P < 0.01). Logistic regression analysis identified 28 variables that correctly identified 96% (52/54) of the fetuses with true CoA, with a false-positive rate of 4% (2/54) and a false-negative rate of 4% (2/54). These variables included the epicardial size in the 4CV, size and shape of RV and LV, and abnormal contractility of RV and LV. The area under the receiver-operating-characteristics curve was 0.98 (SE, 0.023; 95% CI, 0.84-1). There was no significant difference in the percent of fetuses with RV/LV area disproportion between those with CoA and those that were FP-CoA.

CONCLUSIONS

Speckle-tracking analysis of multiple ventricular measurements may be helpful to refine the diagnosis in fetuses that are suspected to have CoA prenatally. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Successful Two-Stage Treatment for Coarctation of the Aorta-postductal Type and Aortic Regurgitation with Thoracic Endovascular Aortic Repair and Aortic Valve Replacement

We herein report a case of a 20-year-old man with aortic regurgitation (AR), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). The preoperative ankle–brachial pressure index was 0.56 in bilateral extremities. Enhanced computed tomography revealed CoA-postductal type. We decided to perform a two-stage surgery: thoracic endovascular aortic repair (TEVAR) for CoA and PDA and then open surgery for AR. TEVAR was successfully performed with deployment of the stent graft at a 31-mm diameter subsequent to balloon dilation. At 8 days after TEVAR, the patient underwent aortic valve replacement via median sternotomy and was discharged without a complication.

How often is coarctation of aorta correctly diagnosed antemortem in children with fatal illnesses? A retrospective review of medical and autopsy records

This retrospective study analyzed the level of concordance between clinical and autopsy diagnosis of coarctation of aorta over 10 years. Utilizing the Goldmann classification, the concordance rate was found to be 16%. Major discrepancies (Class I and II) were found in 56% cases and minor discrepancies (Class III and IV) in 28% cases.

Late diagnosis of coarctation of the aorta in a 44-year-old male: a case report

BACKGROUND

Coarctation of the aorta is a rare congenital disease. In adults, the main manifestations include hypertension, weak or absent femoral pulses, heart failure, and left ventricular hypertrophy.

CASE PRESENTATION

We present a case involving a late diagnosis of coarctation of the aorta detected during aortography in a 44-year-old man. The patient underwent stent implantation and aortoplasty. After 2 years of follow-up, the patient was in good condition.

CONCLUSIONS

This case shows that coarctation of the aorta can be cured and that hypertension caused by the condition can be controlled to some extent with medication. Based on our findings, we recommend a detailed physical examination for all patients suspected of having coarctation of the aorta; the examination should include blood pressure measurements of both the upper and lower extremities. The case of coarctation of the aorta is not common or easy to be found in medium-aged population. Better BP control, earlier repair, and transcatheter intervention may result in a good outcome in that case.

The efficacy and safety of percutaneous balloon angioplasty for aortic coarctation in children. Acute and mid-term results in a single center experience

OBJECTIVES

To assess the efficacy and safety of balloon angioplasty (BAP) procedure for treatment of coarctation of the aorta (CoA) in children. Methods: A retrospective study included 27 consecutive children, underwent BAP for either native-CoA (Na-CoA) or recoarctation (Re-CoA). Medical records, echocardiographic findings, angiographic and hemodynamic data were collected from the hospital database. Follow‑up was scheduled at 1, 3, 6, 12 months after the procedure. The study took place over a period of 4.5 years, from April 2014 to January 2019, in Madinah Cardiac Center, Madinah, Northwest region, Saudi Arabia.

RESULTS

The mean age of patients was 11.86±8.96 months. Seven children had Na-CoA and 20 children had Re-CoA. The success rate of the procedure was achieved in 23 children (85%), as BAP reduced the mean systolic pressure gradient across the CoA (Na-CoA: from 45.28± 18.3 to 9.8± 6.57 mm Hg, p=0.0009), and in Re-CoA groups (from 42.48±16.7 to 10.9±8.5 mm Hg, p less than 0.0001). In mid-term follow-up, the need for re-intervention occurred in 8 children of the cohort (3 children [42.8%] from the Na-CoA group, and 5 children [25%] from the Re-CoA group).  Conclusions: Balloon angioplasty is considered a safe procedure for the management of CoA, but its efficacy remains questionable especially for young infants with Na-CoA type. However, it is a reliable option for managing Re-CoA children, with a lower rate of future re-intervention.

Prevalence of arterial hypertension, hemodynamic phenotypes, and left ventricular hypertrophy in children after coarctation repair: a multicenter cross-sectional study

BACKGROUND

This study aimed to evaluate hemodynamic phenotypes and prevalence of left ventricular hypertrophy in children after coarctation repair with right arm and leg blood pressure difference < 20 mmHg. Secondary objectives were analysis of effects of age at intervention, residual gradient across the descending aorta, and type of correction.

METHODS

Blood pressure status and left ventricular hypertrophy were diagnosed according to European Society of Hypertension 2016 guidelines.

RESULTS

Of 90 patients with a median age 12.5 (8.9-15.8) years, 8.5 (6.0-11.8) years after coarctation repair who were included, 42 (46.7%) were hypertensive. Isolated systolic hypertension dominated among 29 hypertensive patients with uncontrolled or masked hypertension (25 of 29; 86.2%). Of the 48 patients with office normotension, 14.6% (7) had masked hypertension, 8.3% (4) had ambulatory prehypertension, and 54.2% (26) were truly normotensive. Left ventricular hypertrophy was diagnosed in 29 patients (32.2%), including 14 of 42 (33.3%) hypertensive and 15 of 48 (31.3%) normotensive patients. The peak systolic gradient across the descending aorta was greater in hypertensive subjects (33.3 ± 12.7 mmHg) compared with normotensive subjects (25 ± 8.2 mmHg, p = 0.0008). Surgical correction was performed earlier than percutaneous intervention (p < 0.0001) and dominated in 40 of 48 (83.3%) normotensive versus 24 of 42 (57.1%) hypertensive patients (p = 0.006).

CONCLUSIONS

Arterial hypertension with isolated systolic hypertension as the dominant phenotype and left ventricular hypertrophy are prevalent even after successful coarctation repair. Coarctation correction from the age of 9 years and older was associated with a higher prevalence of hypertension.

Sudden death in a dog with aortic coarctation

A previously healthy, one-year-old, intact female Vizsla dog collapsed and experienced cardiopulmonary arrest after a stressful event. Postmortem examination identified juxtaductal aortic coarctation (AoCo) with complex morphology. Located in the isthmus aorta adjacent to the ligamentum arteriosum, the AoCo comprised a shelf-like structure caused by invagination of the aortic wall into the lumen. Just distally, a second region of aortic occlusion resulted from an obstructing aortic membrane that restricted blood flow into the descending aorta through a small, eccentric ostium. Plausibly, the AoCo contributed to high afterload which led to reduction of coronary blood flow, myocardial hypoxia, and sudden death during physical stress. Although AoCo is a well-recognized congenital defect in humans, it has been reported only rarely in animals. The present case details the gross and histologic features of a complex, juxtaductal AoCo in a dog who died suddenly after stress. These morphologic findings may be informative when contemplating diagnosis of this anomaly.

Immediate results of percutaneous management of coarctation of the aorta: A 7-year single-centre experience

BACKGROUND

Coarctation of the aorta (CoA) is often treated percutaneously. The aim of this study was to describe the immediate results of percutaneous management of native aortic coarctation (NaCoA) and recoarctation of the aorta (ReCoA) at our institution.

METHODS

We identified all patients with NaCoA or ReCoA who underwent percutaneous dilatation by either balloon angioplasty (BAP) or endovascular stent implantation (ESI) between 2011 and 2017. Success was defined as a residual peak-to-peak gradient (PPG) <20 mmHg or a ≥50% reduction in the gradient if the pre-intervention PPG was <20 mmHg.

RESULTS

63 patients (median age 6.8 years, interquartile range [IQR] 0.4-14.2) were identified. Among 11 patients with NaCoA, 7 underwent BAP and 4 had ESI, and among 52 patients with ReCoA, 42 underwent BAP and 10 had ESI. In patients with NaCoA, BAP was successful in 71%, with median PPG decreasing from 32 mmHg (IQR 25-46) to 17 mmHg (IQR 4-23) (p = .02), and ESI was successful in 100%, with median PPG decreasing from 20 mmHg (IQR 14.5-40) to 2 mmHg (IQR 0-6) (p < .01). In patients with ReCoA, BAP was successful in 69%, with median PPG decreasing from 20 mmHg (IQR 16-31.3) to 9 mmHg (IQR 0-14.3) (p < .001), and ESI was successful in 100%, with median PPG decreasing from 18 mmHg (IQR 11.5-22.8) to 0 mmHg (IQR 0-3.5) (p < .01). ESI was more successful than BAP (p = .01). There was only one complication.

CONCLUSIONS

Percutaneous management of CoA is safe and effective in both NaCoA and ReCoA. Stent implantation is more effective than BAP.

Towards non-invasive computational-mechanics and imaging-based diagnostic framework for personalized cardiology for coarctation

Coarctation of the aorta (COA) is a congenital narrowing of the proximal descending aorta. Although accurate and early diagnosis of COA hinges on blood flow quantification, proper diagnostic methods for COA are still lacking because fluid-dynamics methods that can be used for accurate flow quantification are not well developed yet. Most importantly, COA and the heart interact with each other and because the heart resides in a complex vascular network that imposes boundary conditions on its function, accurate diagnosis relies on quantifications of the global hemodynamics (heart-function metrics) as well as the local hemodynamics (detailed information of the blood flow dynamics in COA). In this study, to enable the development of new non-invasive methods that can quantify local and global hemodynamics for COA diagnosis, we developed an innovative fast computational-mechanics and imaging-based framework that uses Lattice Boltzmann method and lumped-parameter modeling that only need routine non-invasive clinical patient data. We used clinical data of patients with COA to validate the proposed framework and to demonstrate its abilities to provide new diagnostic analyses not possible with conventional diagnostic methods. We validated this framework against clinical cardiac catheterization data, calculations using the conventional finite-volume method and clinical Doppler echocardiographic measurements. The diagnostic information, that the framework can provide, is vitally needed to improve clinical outcomes, to assess patient risk and to plan treatment.

A Patient-Specific CFD Pipeline Using Doppler Echocardiography for Application in Coarctation of the Aorta in a Limited Resource Clinical Context

Congenital heart disease (CHD) is the most common birth defect globally and coarctation of the aorta (CoA) is one of the commoner CHD conditions, affecting around 1/1800 live births. CoA is considered a CHD of critical severity. Unfortunately, the prognosis for a child born in a low and lower-middle income country (LLMICs) with CoA is far worse than in a high-income country. Reduced diagnostic and interventional capacities of specialists in these regions lead to delayed diagnosis and treatment, which in turn lead to more cases presenting at an advanced stage. Computational fluid dynamics (CFD) is an important tool in this context since it can provide additional diagnostic data in the form of hemodynamic parameters. It also provides an in silico framework, both to test potential procedures and to assess the risk of further complications arising post-repair. Although this concept is already in practice in high income countries, the clinical infrastructure in LLMICs can be sparse, and access to advanced imaging modalities such as phase contrast magnetic resonance imaging (PC-MRI) is limited, if not impossible. In this study, a pipeline was developed in conjunction with clinicians at the Red Cross War Memorial Children’s Hospital, Cape Town and was applied to perform a patient-specific CFD study of CoA. The pipeline uses data acquired from CT angiography and Doppler transthoracic echocardiography (both much more clinically available than MRI in LLMICs), while segmentation is conducted via SimVascular and simulation is realized using OpenFOAM. The reduction in cost through use of open-source software and the use of broadly available imaging modalities makes the methodology clinically feasible and repeatable within resource-constrained environments. The project identifies the key role of Doppler echocardiography, despite its disadvantages, as an intrinsic component of the pipeline if it is to be used routinely in LLMICs.

Management of adults with coarctation of aorta

Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.

Long-term observation of adults after successful repair of aortic coarctation

Introduction

Despite successful repair of aortic coarctation, cardiovascular complications occur.

Aim

To analyse type and frequency of late complications and their impact on exercise capacity in adults after aortic coarctation repair.

Material and methods

Fifty-eight adults after aortic coarctation repair, 36 male, median age 27.46 ±10.57, were compared to 30 healthy volunteers. Physical examination, transthoracic echocardiography, carotid intima-media thickness measurement, cardiopulmonary exercise test and 24-hour ambulatory blood pressure monitoring were performed.

Results

The main complications were: arterial hypertension 48.3%, myocardial hypertrophy in echocardiography 29.34%, recoarctation 25.86%, aortic dilation 13.79% and coronary artery disease 6.89%. Exercise tolerance was reduced in the cardiopulmonary exercise test. The VO₂/kg peak was lower, 29.01 ±8.79 vs. 49.16 ±7.38 ml/kg/min, p < 0.001, VE/VCO₂ peak higher 28.18 ±4.69 vs. 26.78 ±3.13, p = 0.017. The peak heart rate was reduced, 157.28 ±22.22 vs. 177.93 ±23.08 bpm, p < 0.001, peak systolic blood pressure was higher, 174.79 ±17.62 vs. 153.33 ±4.79 mm Hg, p < 0.001. Systolic blood pressure in 24-hour ambulatory monitoring correlated with left ventricle mass index, r = 0.29, p = 0.025, wall thickness, r = 0.31, p = 0.039. Age at operation was related to left ventricle wall thickness, r = 0.27, p = 0.041, and carotid intima-media thickness, r = 0.26, p = 0.046. There was no association of any cardio-pulmonary parameters with time from surgery, type of operation or echocardiography results.

Conclusions

Adults after aortic coarctation repair suffer from arterial hypertension, recurrent aortic stenosis, aortic aneurysms, and coronary artery disease. Reduced exercise capacity in cardio-pulmonary exercise test is related to hypertensive reaction and chronotropic incompetence.

320-slice Computed Tomography Angiography Imaging Findings and Follow-up in A Patient with Aortic Coarctation Misdiagnosed as Hypertension: A Case Report and Literature Review

In this case, we report a simple coarctation of the aortic isthmus (CoA) in a patient without intracardiac abnormalities or patent ductus arteriosus, who was misdiagnosed as essential hypertension for over 20 years. The patient underwent X-rays, echocardiography, and 320-slice CT angiography (CTA). Among them, CTA comprehensively showed the diameter of the aortic coarctation, the anatomy and morphology of the heart and aortic arch, and the collateral circulation before surgery. It also accurately evaluated the postoperative status of the bypass vessel. This article highlights the excellent performance of 320-slice CTA in the diagnosis, surgical planning, and follow-up in CoA. Moreover, when adolescents suffer from refractory hypertension, the possibility of organic cardiovascular disease should be considered.

Cardiovascular Risks and Organ Damage in Secondary Hypertension

Secondary hypertension is associated with increased cardiovascular risk and exaggerated target organ damage, not only due to the higher and more sustained blood pressure values often observed in these patients but also because certain forms of hypertension can increase cardiovascular risk and organ damage by the neurohormonal and/or molecular pathways activation they exert. Early identification of secondary forms of hypertension can help mitigate organ damage and prevent cardiovascular complications. Signs and symptoms distinction among types of secondary hypertension is essential in order to prevent complications.

Assessing a new coarctation repair simulator based on real patient's anatomy

OBJECTIVES

To perform the preliminary tests of coarctation of aorta repair trainer, evaluate the surgical properties of the simulation and to assess and enhance residents' skills.

METHODS

Single patient's angio-CT anatomy data were converted into magnified 3D-printed model of aortic coarctation with hypoplastic aortic arch, serving for creation of a mould used during wax copies casting. Wax cores were painted with six layers of elastic silicone and melted, yielding phantoms that were consecutively fixed in a mounting with and without a thoracic wall. Simulation included: proximal and distal aortic arch clamping, incision of its lesser curvature, extended end-to-end anastomosis with 7-0 suture. A head-mounted camera video recording enabled anastomosis time and mean one suture bite time evaluation. Leakage assessment was done by a water test.

RESULTS

Two residents performed nine simulations each. Last four runs were performed with thoracic wall attached. All phantoms performed well, enabling tissue-like handling and cutting, excellent suture retention, and satisfactory elasticity. Median anastomosis times were 22'33″ and 24'47″ for phantoms without and with thoracic wall (p = not significant (NS)). Median times needed to pass suture through one side of anastomosis and regrasp needle were, respectively, 9″ and 13″ (p < 0.001). Median total number of leakages per phantom equalled 2 for both difficulty levels. There were no significant inter-resident differences in all assessed parameters.

CONCLUSIONS

This medium-fidelity aortic coarctation repair trainer showed its feasibility in replication of major critical steps of the real operation. Objective surgical efficiency parameters could be obtained from each simulation and compared between trainees and at different adjustable difficulty levels.

[Comparison of the results of surgical treatment and stenting for aortic coarctation and recoarctation]

Aortic coarctation is one the most commonly encountered congenital defects of the cardiovascular system. The natural course of the defect is unfavourable: 50 % of patients with aortic coarctation die before reaching the age of 32 years. Surgical operations aimed at correcting aortic coarctation were first introduced into clinical practice as early as in 1944, with the first use of stenting dating back to 1993. Great experience in surgical and endovascular interventions for aortic coarctation and recoarctation has since been accumulated. The article is a review of both foreign and Russian literature concerning current problems of surgical treatment and stenting for aortic coarctation and recoarctation, also containing a detailed analysis of the works aimed at comparing the immediate and remote results of surgical treatment and stenting for aortic coarctation in senior children, adolescents, and adults. It was shown that in some patients stenting for aortic coarctation and recoarctation may be considered as an alternative to conventional surgical methods of treatment.

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.

Medium-term systemic blood pressure after stenting of aortic coarctation: a systematic review and meta-analysis

OBJECTIVE

Long-term prognosis of patients with coarctation of the aorta (CoA) is impaired due to the high prevalence of hypertension and consequent cardiovascular complications. Although stent implantation results in acute anatomical and haemodynamic benefit, limited evidence exists regarding the late clinical outcome. In this meta-analysis, we aimed to evaluate the medium-term effect of stent placement for CoA on systemic blood pressure (BP).

METHODS

PubMed, EMBASE and Cochrane databases were searched for non-randomised cohort studies addressing systemic BP ≥12 months following CoA stenting. Meta-analysis was performed on the change in BP from baseline to last follow-up using a random-effects model. Subgroup analyses and meta-regression were conducted to identify sources of heterogeneity between studies.

RESULTS

Twenty-six studies with a total of 1157 patients and a median follow-up of 26 months were included for final analysis. Meta-analysis showed a 20.3 mm Hg (95% CI 16.4 to 24.1 mm Hg; p<0.00001) reduction in systolic BP and an 8.2 mm Hg (12 studies; 95% CI 5.2 to 11.3 mm Hg; p<0.00001) reduction in diastolic BP. A concomitant decrease in the use of antihypertensive medication was observed. High systolic BP and peak systolic gradient at baseline and stenting of native CoA were associated with a greater reduction in systolic BP at follow-up.

CONCLUSIONS

Stent implantation for CoA is associated with a significant decline in systolic and diastolic BP during medium-term follow-up. The degree of BP reduction appears to be dependent on baseline systolic BP, baseline peak systolic gradient, and whether stenting is performed for native or recurrent CoA.

The importance of the early diagnosis of aorta coarctation

INTRODUCTION

Coarctation of the aorta is a congenital heart disease characterized by a narrowing that occurs in the aortic artery. This constriction can occur anywhere along its entire length; however, it is more common between the origin of the left subclavian artery and the ductus arteriosus. Its incidence corresponds to 3 cases per 10,000 births. Thus, it is a common cardiopathy, but with high mortality and morbidity rates, which are related to a failure in the early diagnosis.

METHOD

In the research, articles of the national and international literature in Pubmed, Scielo and Lilacs databases were selected using the following descriptors: coarctation, aorta, diagnosis, heart diseases, congenital abnormalities.

RESULTS

The pathophysiology of CoA and its systemic implications in the life of newborn and adults are well elucidated. However, due to the lack of habit to palpate pulses and to check the blood pressure in both upper and lower limbs during the physical examination, it is still a pathology little diagnosed in childhood. There are several techniques used in the repair of coarctation, each with their specifics, although, when not treated, aneurysms, heart failure, coronary diseases, and stroke are the main complications arising from the evolution of this pathology, which explains the low survival rate of these patients.

CONCLUSION

Coarctation of the aorta is, therefore, a cardiac malformation of significant importance due to its incidence and its significant mortality risk. In this sense, the early diagnosis stands out as an essential piece for better prognosis of the patient.

A review of the clinical anatomy of hypertension

Hypertension is defined as the persistent elevation of blood pressure above normal limits. It can be classified according to whether the contributing factors are genetics and environmental (primary hypertension) or underlying medical conditions and medications (secondary hypertension). The goal of this review is to increase recognition of the various anatomical etiologies of hypertension. Clin. Anat. 32:678-681, 2019. © 2019 Wiley Periodicals, Inc.

Hemodynamics and Wall Mechanics after Surgical Repair of Aortic Arch: Implication for Better Clinical Decisions

Graft repair of aortic coarctation is commonly used to mimic the physiological aortic arch shape and function. Various graft materials and shapes have been adopted for the surgery. The goal of this work is to quantitatively assess the impact of graft materials and shapes in the hemodynamics and wall mechanics of the restored aortic arch and its correlation with clinical outcomes. A three-dimensional aortic arch model was reconstructed from magnetic resonance images. The fluid–structure interaction (FSI) analysis was performed to characterize the hemodynamics and solid wall mechanics of the repaired aortic arch. Two graft shapes (i.e., a half-moon shape and a crescent one) were considered. Material choices of the aortic arch repair included three commonly used graft materials (i.e., polytetrafluoroethylene (PTFE) synthetic graft, CorMatrix extracellular matrix, and pulmonary homograft) as well as one native tissue serving as a control. The pathological hemodynamic parameters, in terms of the percentage area of low wall shear stress (WSS), high oscillatory shear index (OSI), and high relative residence time (RRT), were quantified to be associated with potential clinical outcomes. Results have shown that the peak von Mises stress for the aortic arch repaired by the crescent graft was 76% less than that of the half-moon graft. Flow disturbance and recirculation were also minimized with the crescent graft. Moreover, pathological hemodynamic parameters were significantly reduced with the crescent graft. The graft material mismatch with the surrounding tissue aggregated the stress concentration on the aortic wall, but had minimal impact on flow dynamics. The present work demonstrated the role and importance of the graft geometry and materials on hemodynamics and wall mechanics, which could guide optimal graft decisions towards better clinical outcomes.

Non-Invasive Assessment of Intravascular Pressure Gradients: A Review of Current and Proposed Novel Methods

Invasive catheterization is associated with a low risk of serious complications. However, although it is the gold standard for measuring pressure gradients, it induces changes to blood flow and requires significant resources. Therefore, non-invasive alternatives are urgently needed. Pressure gradients are routinely estimated non-invasively in clinical settings using ultrasound and calculated with the simplified Bernoulli equation, a method with several limitations. A PubMed literature search on validation of non-invasive techniques was conducted, and studies were included if non-invasively estimated pressure gradients were compared with invasively measured pressure gradients in vivo. Pressure gradients were mainly estimated from velocities obtained with Doppler ultrasound or magnetic resonance imaging. Most studies used the simplified Bernoulli equation, but more recent studies have employed the expanded Bernoulli and Navier⁻Stokes equations. Overall, the studies reported good correlation between non-invasive estimation of pressure gradients and catheterization. Despite having strong correlations, several studies reported the non-invasive techniques to either overestimate or underestimate the invasive measurements, thus questioning the accuracy of the non-invasive methods. In conclusion, more advanced imaging techniques may be needed to overcome the shortcomings of current methods.

Recent advances and challenges on application of tissue engineering for treatment of congenital heart disease

Congenital heart disease (CHD) affects a considerable number of children and adults worldwide. This implicates not only developmental disorders, high mortality, and reduced quality of life but also, high costs for the healthcare systems. CHD refers to a variety of heart and vascular malformations which could be very challenging to reconstruct the malformed region surgically, especially when the patient is an infant or a child. Advanced technology and research have offered a better mechanistic insight on the impact of CHD in the heart and vascular system of infants, children, and adults and identified potential therapeutic solutions. Many artificial materials and devices have been used for cardiovascular surgery. Surgeons and the medical industry created and evolved the ball valves to the carbon-based leaflet valves and introduced bioprosthesis as an alternative. However, with research further progressing, contracting tissue has been developed in laboratories and tissue engineering (TE) could represent a revolutionary answer for CHD surgery. Development of engineered tissue for cardiac and aortic reconstruction for developing bodies of infants and children can be very challenging. Nevertheless, using acellular scaffolds, allograft, xenografts, and autografts is already very common. Seeding of cells on surface and within scaffold is a key challenging factor for use of the above. The use of different types of stem cells has been investigated and proven to be suitable for tissue engineering. They are the most promising source of cells for heart reconstruction in a developing body, even for adults. Some stem cell types are more effective than others, with some disadvantages which may be eliminated in the future.

One-Stage Repair of Adult Aortic Coarctation and Concomitant Cardiac Diseases: Ascending to Abdominal Aorta Extra-Anatomical Bypass Combined with Cardiac Surgery

BACKGROUND

To evaluate one-stage repair with ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery for adult aortic coarctation (COA) concomitant with cardiac diseases.

METHODS

Between February 2009 and September 2016, 24 consecutive patients (79.17% male, mean age 36.04±13.67years) with COA and concomitant cardiac diseases underwent one-stage repair (ascending to abdominal aorta extra-anatomical bypass combined with cardiac surgery). Two (2) patients who underwent off-pump coronary artery surgery combined with ascending to abdominal aorta bypass did not require cardiopulmonary bypass. Twenty-two (22) patients underwent one-stage repair under cardiopulmonary bypass.

RESULTS

No in-hospital mortality was observed. There was a significant reduction in baseline systolic blood pressure from 159.80±23.58 to 127.0±6.86mmHg. Mean upper-lower limb blood gradient pressure decreased significantly from 37.80±8.73 to 11.47±2.12mmHg after surgery. Two (2) patients required prolonged mechanical ventilation for respiratory dysfunction. One patient needed temporary continuous renal replacement therapy. No re-exploration for bleeding and gastrointestinal complications was needed. There was no postoperative paraplegia or permanent neurological abnormalities. Grafts were patent for all patients and no graft-related complications were observed in the hospital. Median follow-up was 41.50 months (interquartile range [IQR] 16.75-64.50 months) and 6-year survival was 76.39%. Median number of antihypertensive drugs was 0 (IQR 0-1), which was a significant reduction compared with preoperative drugs (2, IQR 1-3).

CONCLUSIONS

Ascending to abdominal extra-anatomical aorta bypass combined with cardiac surgery is a safe and effective one-stage repair technique for patients with COA concomitant with cardiac diseases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Histopathological evaluation of aortic coarctation after conventional balloon angioplasty in neonates

BACKGROUND

Optimal management strategy for native aortic coarctation in neonates and young infants is still a matter of debate. The surgical procedure, histopathologic research, and clinical outcome in 15 neonates who underwent surgery after successful balloon angioplasty is the basis of this study.

METHOD

Between 01 October, 2014 and 01 August, 2017, we enrolled 15 patients with native aortic coarctation for this study. These patients had complications regarding recoarctation, following balloon angioplasty intervention at our institute and other centres. Surgically extracted parts were examined histopathologically and patient's data were collected retrospectively.ResultThe reasons for recurrence of recoarctation after balloon angioplasty are as follows: patients with higher preoperative echocardiographic gradients had recoarctation earlier, neointimal proliferation, aortic intimal fibrosis at the region of ductal insertion, and ductal residual tissue debris after balloon angioplasty. No repeat intervention was required in the 15 patients who underwent surgery followed by balloon angioplasty. Early mortality was seen in one patient after surgery. Postoperative complication in the surgical group occurred in the form of chylothorax in one patient.

CONCLUSION

In centres in which the neonatal ICU is inexperienced, balloon angioplasty is particularly recommended. In developing neonatal clinics, balloon angioplasty, when performed on patients at their earliest possible age, delays actual corrective operation to a later date, which in turn provides less risky surgical outcomes in infants who are gaining weight, growing, and do not have any haemodynamic complaints.

Single-stage endovascular management of complicated thoracic aorta coarctation concurrent with aortic arch aneurysm using a novel fenestration device

To present a case with aorta coarctation complicated by aortic arch aneurysm which is clinical rare and entails a high risk of rupture. Here we reported a 46-year-old female patient diagnosed with aortic arch aneurysm combined with coarctation. The computed tomography angiography shows that an irregular aneurysm was located at the aortic arch site with its maximal diameter 86.55 mm and the right end of aneurysm was located 10 mm away from the ostium of left common carotid artery (LCCA). The aneurysm body invaded the left subclavian artery, and at the distal end of aneurysm a coarctation had been observed with a minimum diameter reaching 2.7 mm. We performed percutaneous balloon angioplasty, thoracic endovascular aortic repair to exclude the aneurysm, and simultaneously used a novel in situ fenestration device (Quick-Fenestrater) to revascularize the covered LCCA. This is first case of using a novel fenestration device single-stage endovascular treatment of complicated thoracic aorta coarctation concurrent with aortic arch aneurysm. Combined endovascular techniques can elevate the success rate of reconstruct complicated aorta aneurysm concurrent with coarctation and reduce complications. Under the guidance of Quick-Fenestrater, in situ fenestration could be performed with safety and a high success frequency.

The spectrum and management of noniatrogenic vascular trauma in the pediatric population

BACKGROUND

To describe the spectrum of noniatrogenic pediatric vascular injuries and their outcomes at a large tertiary pediatric hospital.

METHODS

Retrospective review of a prospectively-maintained trauma database, identifying children with noniatrogenic vascular injuries managed between 1994 and 2014.

RESULTS

A total of 198 patients were identified. Those patients with a digital or intracerebral vascular injury (92/198) were excluded from further analysis. The remaining 106 patients represented 1.2% of all traumas managed at our institution during the 21-year study period. The majority were male (75%), and between 1 and 12years of age (71% of all patients). Median time from trauma scene to any hospital was 48min (range 0-132), and most patients were transferred from another hospital (64%). Three patients were declared dead upon arrival (3%). Penetrating injuries accounted for most injuries (72%), while blunt injuries accounted for the remainder. Ulnar, radial, or brachial artery trauma accounted for 47% of injuries. Most vessels were treated operatively, by primary repair (49%), vessel ligation (15%), or interposition graft (12%). Fourteen patients (13%) were managed nonoperatively and most patients (74%) experienced no complications in hospital or during follow-up.

CONCLUSION

Noniatrogenic pediatric vascular injuries are rare and represent a highly heterogeneous population. Most children recover well, with minimal perioperative complications.

LEVEL OF EVIDENCE

IV (case series with no comparison group).

A single-stage hybrid approach for the management of severely stenotic bicuspid aortic valve, ascending aortic aneurysm, and coarctation of the aorta with a literature review

The combination of aortic stenosis in the context of bicuspid aortic valve, aneurysmal dilatation of the ascending aorta, and coarctation is not uncommon. This condition has conventionally been addressed either by a complex open surgical approach or by staged hybrid approach combining open surgery of the ascending aorta with subsequent endovascular stenting of the coarctation. So far, the risk of a complex open approach for the aortic valve and ascending aorta and the cumulative risk of a staged second procedure for management of the coarctation are unknown; and similarly, the risk of a complex single-staged surgical procedure as an option instead of a single-staged hybrid approach is unknown. For the first time, we present a case of a patient with bicuspid aortopathy and concomitant coarctation who was simultaneously managed with both stenting of the coarctation and subsequent surgical replacement of the aortic valve and ascending aorta in one session. This new strategy has potential to become a future standard of care with various advantages. <Learning objective: Endovascular techniques are more frequently being used in the management of coarctation of the aorta, especially when associated with other cardiac pathologies. The definitive role of these techniques is still to be defined. A review of the risks and benefits of different management strategies may be beneficial with regard to making the right choice for each patient and a hybrid technique may be superior to purely surgical management, especially in a high-risk patient.>.

Emergent Presentation of an Adult with Undiagnosed Coarctation of the Aorta

Coarctation of the aorta is typically thought to be a childhood disease. However, emergency physicians must keep a broad differential diagnosis when faced with a young patient with signs and symptoms of acute congestive heart failure. The authors present a case of newly diagnosed coarctation of the aorta in a 26-year-old male who was first misdiagnosed with pneumonia.

Surgical Management of Aortic Coarctation from Infant to Adult

Objective

In the present study, we aimed to retrospectively investigate the early and late results of different surgical treatment techniques applied in different age groups with coarctation of the aorta (CoA).

Materials and Methods

Between January 2007 and February 2017, 26 patients (12 males, 14 females; mean age: 12.2±12.4 years; range: 29 days-34 years) who underwent surgery with the diagnosis of CoA were evaluated. Overall, 11 of these patients (42.3%) were in the infantile period, whereas 15 patients (57.7%) aged between 6 and 34 years. Resection and end-to-end anastomosis were performed in 13 patients (50%). Bypass grafting was performed in six patients (23.1%), and patch plasty was performed in seven patients (26.9%).

Results

A patient (3.8%) who was operated on during the infantile period died early, whereas another patient (3.8%) died 2 years after the surgery. Recoarctation was detected in two patients. A patient underwent balloon dilatation, whereas another patient underwent balloon dilatation and stenting. In patients who underwent re-section and end-to-end anastomosis based on postoperative echocardiography results during follow-up, a lower statistically significant gradient was observed compared with the preoperative period. Despite the decrease in the left ventricular systolic diameter (LVSD) and the increase in the ejection fraction (EF) the decrease in LVSD and increase in EF were not statistically significant. In patients who underwent patch plasty or graft interposition, the low values of the gradient and left ventricular diastolic diameter in the postoperative follow-up were statistically significant. However, the decrease in LVSD and increase in EF were not statistically significant.

Conclusions

Our clinical experience suggests that repairing with resection and end-to-end anastomosis is a more appropriate treatment option during the infancy, whereas patch plasty or bypass grafting may be preferred in advanced ages.

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.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Pathology and molecular mechanisms of coarctation of the aorta and its association with the ductus arteriosus

Coarctation of the aorta (CoA) is defined as a congenital stenosis of the thoracic aorta and is one of the most common congenital cardiovascular diseases. Despite successful surgical treatment for CoA, arterial abnormalities, including refractory hypertension, aortic aneurysm, and proatherogenic phenotypic changes, frequently affect patients' quality of life. Emerging evidence from morphological and molecular biological investigations suggest that the area of CoA is characterized by phenotypic modulation of smooth muscle cells, intimal thickening, and impaired elastic fiber formation. These changes extend to the pre-and post-stenotic aorta and impair arterial elasticity. The aim of this review is to present current findings on the pathology and molecular mechanisms of vascular remodeling due to CoA. In particular, we will discuss the association between CoA and the ductus arteriosus since the most common site for the stenosis is in the proximity of the ductus arteriosus.

Infantile Aortic Coarctation in an Adult with Heart Failure

OBJECTIVE

The aim of this case report is to highlight the importance of excluding aortic coarctation in a patient with a bicuspid aortic valve.

CLINICAL PRESENTATION AND INTERVENTION

A 56-year-old woman with hypertension was admitted complaining of progressive dyspnea. Transthoracic echocardiography showed a calcified, bicuspid aortic valve with severe stenosis. Aortography revealed the presence of severe narrowing of the aorta between the carotid and subclavian arteries. The patient was referred for cardiovascular surgery in which successful aortic valve replacement and aortic correction were performed.

CONCLUSION

This case report shows an uncommon finding of infantile aortic coarctation in an adult patient admitted with heart failure.

De Novo Migraine With Aura After Surgical Repair of Aortic Coarctation

Coarctation of the aorta (CoA) is reported to be associated with an increased risk for migraine. We describe here the case of a 13-year-old female patient who presented migraine with aura after surgical repair of CoA with a stent. As possible reasons for her condition, we postulate host responses to stent placement and/or disturbed cerebral autoregulation related to intracranial hypertension before the surgical repair and hypotension afterward, leading to hypoperfusion. This case demonstrates that de novo migraine with aura can occur after surgical repair of CoA and should be recognized as a potential complication.

Three-dimensional rotational angiography in children with an aortic coarctation

Background

Children with aortic coarctations (CoA) are increasingly percutaneously treated. Good visualisation of the CoA is mandatory and can be obtained with three-dimensional rotational angiography (3DRA). This study aims to compare the diagnostic and therapeutic additional value of 3DRA with conventional biplane angiography (CA) in children with a CoA.

Methods

Patients undergoing percutaneous treatment of CoA with balloon angioplasty (BA) or stent between 2003 and 2015, were retrospectively reviewed on success rate, complications, radiation and technical settings. Diagnostic quality of CA and 3DRA and additional value of 3DRA were scored.

Results

In total, 134 patients underwent 183 catheterisations, 121 CA and 62 3DRA-guided. Median age was 0.52 years in the BA group and 11.19 years in the stent group. 3DRA was superior to CA in displaying the left ventricle (p = 0.008), ascending aorta (p < 0.001), aortic arch (p = 0.005) and coronary arteries (p < 0.001). In the BA group, 3DRA had a significantly higher success rate than CA (100.0 % versus 68.9 %, p = 0.016). All stent interventions were successful. Complication rates did not differ significantly. The median total dose area product did not significantly differ between CA and 3DRA in the BA (27.88 μGym²/kg versus 15.81 μGym²/kg, p = 0.275) or stent group (37.34 μGym²/kg versus 45.24 μGym²/kg, p = 0.090). 3DRA was of additional value in 96.8 % of the interventions.

Conclusions

3DRA is superior to CA in diagnostic quality and not associated with increased radiation exposure. It provides high additional value in guiding CoA related interventions.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-016-0899-2) contains supplementary material, which is available to authorized users.