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Gong T, Zhang F, Feng L, Zhu X, Deng D, Ran T, Li L, Kong L, Sun L, Ji X. Diagnosis and surgical outcomes of coarctation of the aorta in pediatric patients: a retrospective study. Front Cardiovasc Med 2023; 10:1078038. [PMID: 37554364 PMCID: PMC10405080 DOI: 10.3389/fcvm.2023.1078038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 07/10/2023] [Indexed: 08/10/2023] Open
Abstract
BACKGROUND Coarctation of the aorta (CoA) is a common congenital cardiovascular malformation, and improvements in the diagnostic process for surgical decision-making are important. We sought to compare the diagnostic accuracy of transthoracic echocardiography (TTE) with computed tomographic angiography (CTA) to diagnose CoA. METHODS We retrospectively reviewed 197 cases of CoA diagnosed by TTE and CTA and confirmed at surgery from July 2009 to August 2019. RESULTS The surgical findings confirmed that 19 patients (9.6%) had isolated CoA and 178 (90.4%) had CoA combined with other congenital cardiovascular malformations. The diagnostic accuracy of CoA by CTA was significantly higher than that of TTE (χ2 = 6.52, p = 0.01). In contrast, the diagnostic accuracy of TTE for associated cardiovascular malformations of CoA was significantly higher than that of CTA (χ2 = 15.36, p < 0.0001). Infants and young children had more preductal type of CoA, and PDA was the most frequent cardiovascular lesion associated with CoA. The pressure gradient was significantly decreased after the first operation, similar at 6 months, 1 year, and 3 years follow-ups by TTE. CONCLUSIONS CTA is more accurate as a clinical tool for diagnosing CoA; however, TTE with color Doppler can better identify associated congenital cardiovascular malformations. Therefore, combining TTE and CTA would benefit clinical evaluation and management in patients suspected of CoA. TTE was valuable for post-operation follow-up and clinical management.
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Affiliation(s)
- Ting Gong
- Department of Ultrasound, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Feiyan Zhang
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Department of Ultrasound, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, China
| | - Lingxin Feng
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xu Zhu
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Deng
- School of Medical Imaging, Changsha Medical University, Changsha, China
| | - Tingting Ran
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Liling Li
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Li Kong
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Xiaojuan Ji
- Department of Ultrasound, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Department of Ultrasound, Chongqing General Hospital, Chongqing, China
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Meidell Blylod V, Rinnström D, Pennlert J, Ostenfeld E, Dellborg M, Sörensson P, Christersson C, Thilén U, Johansson B. Interventions in Adults With Repaired Coarctation of the Aorta. J Am Heart Assoc 2022; 11:e023954. [PMID: 35861813 PMCID: PMC9707821 DOI: 10.1161/jaha.121.023954] [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] [Indexed: 11/16/2022]
Abstract
Background
Coarctation of the aorta coexists with other cardiac anomalies and has long‐term complications, including recoarctation, which may require intervention after the primary coarctation repair. This study aims to clarify the prevalence of and risk factors for interventions related to the coarctation complex as well as late mortality in a large contemporary patient population.
Methods and Results
The Swedish National Register of Congenital Heart Disease was used, which comprised 683 adults with repaired coarctation of the aorta. Analysis was performed on freedom from intervention thereafter at the coarctation site, aortic valve, left ventricular outflow tract, or ascending aorta. One hundred ninety‐six (29%) patients had at least 1 of these interventions. Estimated freedom from either of these interventions was 60% after 50 years. The risk of undergoing such an intervention was higher among men (hazard ratio, 1.6 [95% CI, 1.2–2.2]). Estimated freedom from another intervention at the coarctation site was 75% after 50 years. In women, there was an increase in interventions at the coarctation site after 45 years. Patients who underwent one of the previously mentioned interventions after the primary coarctation repair had poorer left ventricular function. Eighteen patients (3%) died during follow‐up in the register. The standardized mortality ratio was 2.9 (95% CI, 1.7–4.3).
Conclusions
Interventions are common after coarctation repair. The risk for and time of interventions are affected by sex. Our results have implications for planning follow‐up and giving appropriate medical advice to the growing population of adults with repaired coarctation of the aorta.
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Affiliation(s)
| | - Daniel Rinnström
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
- Department of Surgical and Perioperative Sciences Umeå University Umeå Sweden
| | - Johanna Pennlert
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Ellen Ostenfeld
- Department of Clinical Sciences Lund Clinical Physiology, Lund University Lund Sweden
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine University of Gothenburg Gothenburg Sweden
| | - Peder Sörensson
- Department of Medicine Solna Karolinska Institutet Stockholm Sweden
| | | | - Ulf Thilén
- Department of Clinical Sciences Lund Cardiology, Lund University Lund Sweden
| | - Bengt Johansson
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
- Department of Surgical and Perioperative Sciences Umeå University Umeå Sweden
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Homsi M, El Khoury M, Hmedeh C, Arabi M, El Rassi I, Bulbul Z, Sawaya F, Bitar F, Haddad F. Endovascular Stent Repair of Aortic Coarctation in a Developing Country: A Single-Center Experience. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 39:66-72. [PMID: 34916158 DOI: 10.1016/j.carrev.2021.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 10/10/2021] [Accepted: 10/21/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE CoA remains one of the most common congenital heart diseases and is associated with significant morbidity and mortality and if untreated. We aim to evaluate the safety, feasibility, and outcomes of endovascular stenting of Coarctation of the aorta (CoA) in a developing country with limited resources and compare it to available benchmarks. MATERIALS/METHODS A retrospectively review of all patients who underwent endovascular stent repair of aortic coarctation at our tertiary center since 2009 was done. RESULTS 18 patients were identified, sixteen had native CoA, while two had recurrent CoA. mean age at the time of procedure was 21.2 ± 9.8 years (range 10-45 years), and 12(66%) patients were males. The mean follow-up duration was 4 ± 2.8 years. Post stenting, the average ascending-to-descending aorta systolic gradient decreased by 42.9 ± 20.4 mmHg (p < 0.001). After the intervention, 13(72.2%) patients achieved normal BP while 5(27.8%) had residual hypertension. Fourteen patients received bare-metal stents, and four had covered stents. Attempted stent implantation was successful in all patients. Our procedural success rate was 94%. On follow-up, no dissections or aneurysmal changes were detected, four patients underwent re-expansion of the stent, one patient with suboptimal stenting result required surgery 6 months after stenting, and two patients had minor post-operative complications. CONCLUSIONS Endovascular stenting for de-novo or recurrent CoA in children and adults at a tertiary center in a developing country is feasible and safe with outcomes comparable to developed countries. A multidisciplinary team approach is paramount in achieving good results and low complication rates in limited-resource settings.
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Affiliation(s)
- Mouafak Homsi
- American University of Beirut Medical Center, Department of Vascular Surgery, Lebanon
| | - Maya El Khoury
- American University of Beirut Medical Center, Department of Pediatrics and Adolescent Medicine, Children Heart Center, Lebanon
| | - Caroline Hmedeh
- American University of Beirut Medical Center, Department of Vascular Surgery, Lebanon
| | - Mariam Arabi
- American University of Beirut Medical Center, Department of Pediatrics and Adolescent Medicine, Children Heart Center, Lebanon
| | - Issam El Rassi
- American University of Beirut Medical Center, Department of surgery, Children Heart Center, Lebanon
| | - Ziad Bulbul
- American University of Beirut Medical Center, Department of Pediatrics and Adolescent Medicine, Children Heart Center, Lebanon
| | - Fadi Sawaya
- American University of Beirut Medical Center, Department of Medicine, Lebanon
| | - Fadi Bitar
- American University of Beirut Medical Center, Department of Pediatrics and Adolescent Medicine, Children Heart Center, Lebanon
| | - Fady Haddad
- American University of Beirut Medical Center, Department of Vascular Surgery, Lebanon.
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Bhatt AB, Lantin-Hermoso MR, Daniels CJ, Jaquiss R, Landis BJ, Marino BS, Rathod RH, Vincent RN, Keller BB, Villafane J. Isolated Coarctation of the Aorta: Current Concepts and Perspectives. Front Cardiovasc Med 2022; 9:817866. [PMID: 35694677 PMCID: PMC9174545 DOI: 10.3389/fcvm.2022.817866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal diagnosis, high survival and improved understanding of long-term complication. Isolated CoA has heterogenous presentations, complex etiologic mechanisms, and progressive pathophysiologic changes that influence outcome. End-to-end or extended end-to-end anastomosis are the favored surgical approaches for isolated CoA in infants and transcatheter intervention is favored for children and adults. Primary stent placement is the procedure of choice in larger children and adults. Most adults with treated isolated CoA thrive, have normal daily activities, and undergo successful childbirth. Fetal echocardiography is the cornerstone of prenatal counseling and genetic testing is recommended. Advanced 3D imaging identifies aortic complications and myocardial dysfunction and guides individualized therapies including re-intervention. Adult CHD program enrollment is recommended. Longer follow-up data are needed to determine the frequency and severity of aneurysm formation, myocardial dysfunction, and whether childhood lifestyle modifications reduce late-onset complications.
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Affiliation(s)
- Ami B. Bhatt
- Departments of Internal Medicine and Pediatrics and Division of Cardiology, Harvard Medical School, Boston, MA, United States
| | - Maria R. Lantin-Hermoso
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Curt J. Daniels
- Departments of Pediatrics and Internal Medicine, The Ohio State University Medical Center, Columbus, OH, United States
| | - Robert Jaquiss
- Department of Cardiovascular and Thoracic Surgery and Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Benjamin John Landis
- Department of Pediatrics and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, United States
| | - Rahul H. Rathod
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Robert N. Vincent
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States
| | - Bradley B. Keller
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
- *Correspondence: Bradley B. Keller
| | - Juan Villafane
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
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Panzer J, Bové T, Vandekerckhove K, De Wolf D. Hypertension after coarctation repair-a systematic review. Transl Pediatr 2022; 11:270-279. [PMID: 35282025 PMCID: PMC8905104 DOI: 10.21037/tp-21-418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Coarctation of the Aorta (CoA) leads to increased morbidity and mortality later in life despite early surgical or percutaneous treatment. Many long-term complications are related to hypertension (HT) which is a common finding late after coarctation repair. METHODS A systematic Review was performed including articles published between February 2012 to December 2020. Systematic searches were conducted on PubMed and the Cochrane Controlled Trials Register to look for studies on HT after aortic CoA-repair. PRISMA guidelines were used. RESULTS In this systematic review on HT after CoA Repair the mean prevalence of HT was 47.3% (20-70%). A progressive character was of the HT was found, furthermore if only studies are included with 24 h blood pressure (BP) recording in addition to standard BP measurements, the incidence of HT rose to 57.8%. DISCUSSION Most clinical studies look at complications, mortality rate and residual pressure gradient rather than correlating hemodynamic indices with long-term outcome. Although HT is commonly based in measurement of peripheral BP, it has been shown that peripheral BP in CoA patients has a poor correlation with central aortic pressure. Central aortic hemodynamics are significantly altered in patients with repaired CoA, which can now adequately be investigated non-invasively. At the present time there are no studies linking long-term outcome with abnormal central hemodynamics.
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Affiliation(s)
- Joseph Panzer
- Departement Kindercardiologie, Universitair Ziekenhuis Gent (Pediatric Cardiology Department, University Hospital Ghent), Ghent, Belgium
| | - Thierry Bové
- Departement Hartchirurgie, Universitair Ziekenhuis Gent (Cardiac Surgery, University Hospital Ghent), Ghent, Belgium
| | - Kristof Vandekerckhove
- Departement Kindercardiologie, Universitair Ziekenhuis Gent (Pediatric Cardiology Department, University Hospital Ghent), Ghent, Belgium
| | - Daniël De Wolf
- Departement Kindercardiologie, Universitair Ziekenhuis Gent (Pediatric Cardiology Department, University Hospital Ghent), Ghent, Belgium
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Yevtushenko P, Goubergrits L, Gundelwein L, Setio A, Ramm H, Lamecker H, Heimann T, Meyer A, Kuehne T, Schafstedde M. Deep Learning Based Centerline-Aggregated Aortic Hemodynamics: An Efficient Alternative to Numerical Modelling of Hemodynamics. IEEE J Biomed Health Inform 2021; 26:1815-1825. [PMID: 34591773 DOI: 10.1109/jbhi.2021.3116764] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Image-based patient-specific modelling of hemodynamics are gaining increased popularity as a diagnosis and outcome prediction solution for a variety of cardiovascular diseases. While their potential to improve diagnostic capabilities and thereby clinical outcome is widely recognized, these methods require considerable computational resources since they are mostly based on conventional numerical methods such as computational fluid dynamics (CFD). As an alternative to the numerical methods, we propose a machine learning (ML) based approach to calculate patient-specific hemodynamic parameters. Compared to CFD based methods, our approach holds the benefit of being able to calculate a patient-specific hemodynamic outcome instantly with little need for computational power. In this proof-of-concept study, we present a deep artificial neural network (ANN) capable of computing hemodynamics for patients with aortic coarctation in a centerline aggregated (i.e. locally averaged) form. Considering the complex relation between vessels shape and hemodynamics on the one hand and the limited availability of suitable clinical data on the other, a sufficient accuracy of the ANN may however not be achieved with available data only. Another key aspect of this study is therefore the successful augmentation of available clinical data. Using a statistical shape model, additional training data was generated which substantially increased the ANNs accuracy, showcasing the ability of ML based methods to perform in-silico modelling tasks previously requiring resource intensive CFD simulations.
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7
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STRAZDINS U, BERGS GJ, BENETIS R, KALEJS M, PUTNINS I, STRIKE E, STRADINS P, ERGLIS A. David V procedure with concomitant ascending aorta, aortic arch and descending aorta replacement in adult patient with coarctation of aorta. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05063-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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8
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Yuan X, Mitsis A, Rigby M, Nienaber CA. Transcatheter management of adult aortic coarctation with "Railway" technique. Clin Case Rep 2021; 9:e04097. [PMID: 34026140 PMCID: PMC8122136 DOI: 10.1002/ccr3.4097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/08/2021] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
Endografting for atretic coarctation is technically feasible to avoid the risks of open surgery. It requires a strategic and structured endovascular approach such as the "Railway" technique for safe and successful restructuring of complete aortic atresia and avoiding rupture or bleeding.
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Affiliation(s)
- Xun Yuan
- Cardiology and Aortic CentreRoyal Brompton & Harefield Hospital NHS Trust FoundationLondonUK
- Cardiovascular DivisionFaculty of MedicineImperial Collage LondonNational Lung and Heart InstitutionLondonUK
| | - Andreas Mitsis
- Cardiology DepartmentNicosia General HospitalStrovolosCyprus
| | - Michael Rigby
- Cardiology and Aortic CentreRoyal Brompton & Harefield Hospital NHS Trust FoundationLondonUK
- Cardiovascular DivisionFaculty of MedicineImperial Collage LondonNational Lung and Heart InstitutionLondonUK
| | - Christoph A. Nienaber
- Cardiology and Aortic CentreRoyal Brompton & Harefield Hospital NHS Trust FoundationLondonUK
- Cardiovascular DivisionFaculty of MedicineImperial Collage LondonNational Lung and Heart InstitutionLondonUK
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9
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Aslan S, Mass P, Loke YH, Warburton L, Liu X, Hibino N, Olivieri L, Krieger A. Non-invasive Prediction of Peak Systolic Pressure Drop across Coarctation of Aorta using Computational Fluid Dynamics. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:2295-2298. [PMID: 33018466 DOI: 10.1109/embc44109.2020.9176461] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
This paper proposes a novel method to noninvasively measure the peak systolic pressure difference (PSPD) across coarctation of the aorta for diagnosing the severity of coarctation. Traditional non-invasive estimates of pressure drop from the ultrasound can underestimate the severity and invasive measurements by cardiac catheterization can carry risks for patients. To address the issues, we employ computational fluid dynamics (CFD) computation to accurately predict the PSPD across a coarctation based on cardiac magnetic resonance (CMR) imaging data and cuff pressure measurements from one arm. The boundary conditions of a patient-specific aorta model are specified at the inlet of the ascending aorta by using the time-dependent blood velocity, and the outlets of descending aorta and supra aortic branches by using a 3-element Windkessel model. To estimate the parameters of the Windkessel model, steady flow simulations were performed using the time-averaged flow rates in the ascending aorta, descending aorta, and two of the three supra aortic branches. The mean cuff pressure from one arm was specified at the outlet of one of the supra aortic branches. The CFD predicted PSPDs of 5 patients (n=5) were compared with the invasively measured pressure drops obtained by catheterization. The PSPDs were accurately predicted (mean µ=0.3mmHg, standard deviation σ =4.3mmHg) in coarctation of the aorta using completely non-invasive flow and cuff pressure data. The results of our study indicate that the proposed method could potentially replace invasive measurements for estimating the severity of coarctations.Clinical relevance-Peak systolic pressure drop is an indicator of the severity of coarctation of the aorta. It can be predicted without any additional risks to patients using non-invasive cuff pressure and flow data from CMR.
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10
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Novak AY, Alekyan BG. [Comparison of the results of surgical treatment and stenting for aortic coarctation and recoarctation]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:69-76. [PMID: 31503249 DOI: 10.33529/angid2019312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- A Ya Novak
- National Medical Research Centre for Cardiovascular Surgery named after A.N. Bakulev under the RF Ministry of Public Health, Moscow, Russia; National Medical Research Centre of Surgery named after A.V. Vishnevsky under the RF Ministry of Public Health, Moscow, Russia
| | - B G Alekyan
- National Medical Research Centre of Surgery named after A.V. Vishnevsky under the RF Ministry of Public Health, Moscow, Russia
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11
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12
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Beckmann E, Jassar AS. Coarctation repair-redo challenges in the adults: what to do? J Vis Surg 2018; 4:76. [PMID: 29780722 DOI: 10.21037/jovs.2018.04.07] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/02/2018] [Indexed: 01/06/2023]
Abstract
Aortic coarctation is one of the most common congenital cardiac pathologies. Repair of native aortic coarctation is nowadays a common and safe procedure. However, late complications, including re-coarctation and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both endovascular and conventional open repair play important roles in the treatment of late complications after previous coarctation repair. This article will review the incidence of late complications after coarctation repair and will discuss the treatment options for redo coarctation repair in adult patients.
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Affiliation(s)
- Erik Beckmann
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Arminder S Jassar
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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Nakamura E, Nakamura K, Furukawa K, Ishii H, Kawagoe K. Selection of a Surgical Treatment Approach for Aortic Coarctation in Adolescents and Adults. Ann Thorac Cardiovasc Surg 2018; 24:97-102. [PMID: 29459569 DOI: 10.5761/atcs.oa.17-00167] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Coarctation of the aorta (CoA) in adolescents and adults is relatively rare. Several operative techniques for CoA in adolescents and adults have been reported, but there is still no consensus. This study aims to highlight the use of individual patient characteristics to select optimal treatment strategies for CoA in adolescents and adults. METHODS Surgical repair of CoA was performed in five patients (mean age: 34 ± 14 years, range: 13-58 years). All patients had primary CoA, and one had aneurysm above the CoA. One patient had undergone previous aortic valve replacement (AVR) and graft replacement of the ascending aorta. One patient underwent resection of the coarctation without cardiopulmonary bypass (CPB) followed by direct end-to-end anastomosis. Three patients underwent CoA resection with an interposition graft through a lateral thoracotomy with partial CPB. One patient underwent AVR with extra-anatomical bypass (ascending-descending aorta). RESULTS No in-hospital deaths occurred, and there were no complications. During the follow-up period, there has been no recurrence of CoA. CONCLUSION CoA in adolescents and adults is associated with different issues from those encountered in infant patients, and comprehensive surgery should be performed in all cases.
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Affiliation(s)
- Eisaku Nakamura
- Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Kunihide Nakamura
- Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Koji Furukawa
- Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Hirohito Ishii
- Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
| | - Katsuya Kawagoe
- Division of Cardiovascular Surgery, Department of Surgery, University of Miyazaki, Miyazaki, Miyazaki, Japan
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14
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Salcher M, Naci H, Law TJ, Kuehne T, Schubert S, Kelm M, Kuehne T, Hennemuth A, Manset D, Mcguire A, Plank G, Ecabert O, Pongiglione G, Muthurangu V. Balloon Dilatation and Stenting for Aortic Coarctation: A Systematic Review and Meta-Analysis. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.115.003153. [PMID: 27296199 DOI: 10.1161/circinterventions.115.003153] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 04/29/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is no systematic assessment of available evidence on effectiveness and comparative effectiveness of balloon dilatation and stenting for aortic coarctation. METHODS AND RESULTS We systematically searched 4 online databases to identify and select relevant studies of balloon dilatation and stenting for aortic coarctation based on a priori criteria (PROSPERO 2014:CRD42014014418). We quantitatively synthesized results for each intervention from single-arm studies and obtained pooled estimates for relative effectiveness from pairwise and network meta-analysis of comparative studies. Our primary analysis included 15 stenting (423 participants) and 12 balloon dilatation studies (361 participants), including patients ≥10 years of age. Post-treatment blood pressure gradient reduction to ≤20 and ≤10 mm Hg was achieved in 89.5% (95% confidence interval, 83.7-95.3) and 66.5% (44.1-88.9%) of patients undergoing balloon dilatation, and in 99.5% (97.5-100.0%) and 93.8% (88.5-99.1%) of patients undergoing stenting, respectively. Odds of achieving ≤20 mm Hg were lower with balloon dilatation as compared with stenting (odds ratio, 0.105 [0.010-0.886]). Thirty-day survival rates were comparable. Numerically more patients undergoing balloon dilatation experienced severe complications during admission (6.4% [2.6-10.2%]) compared with stenting (2.6% [0.5-4.7%]). This was supported by meta-analysis of head-to-head studies (odds ratio, 9.617 [2.654-34.845]) and network meta-analysis (odds ratio, 16.23, 95% credible interval: 4.27-62.77) in a secondary analysis in patients ≥1 month of age, including 57 stenting (3397 participants) and 62 balloon dilatation studies (4331 participants). CONCLUSIONS Despite the limitations of the evidence base consisting predominantly of single-arm studies, our review indicates that stenting achieves superior immediate relief of a relevant pressure gradient compared with balloon dilatation.
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Affiliation(s)
- Maximilian Salcher
- From LSE Health, London School of Economics and Political Science, United Kingdom (M.S., H.N., T.J.L.); Department of Anesthesia, University of Toronto, Ontario, Canada (T.J.L.); and Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany (T.K., S.S., M.K.).Lynkeus, Rome, ItalyDeutsches Herzzentrum Berlin, Berlin, GermanyFraunhofer MEVIS, Bremen, Germanygnúbila, Argonay, FranceLondon School of Economics and Political Science, London, United KingdomMedizinische Universität Graz, Graz, AustriaSiemens AG, Munich, GermanyOspedale Pediatrico Bambino Gesù, Rome, ItalyUniversity College London, London, United Kingdom
| | - Huseyin Naci
- From LSE Health, London School of Economics and Political Science, United Kingdom (M.S., H.N., T.J.L.); Department of Anesthesia, University of Toronto, Ontario, Canada (T.J.L.); and Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany (T.K., S.S., M.K.).Lynkeus, Rome, ItalyDeutsches Herzzentrum Berlin, Berlin, GermanyFraunhofer MEVIS, Bremen, Germanygnúbila, Argonay, FranceLondon School of Economics and Political Science, London, United KingdomMedizinische Universität Graz, Graz, AustriaSiemens AG, Munich, GermanyOspedale Pediatrico Bambino Gesù, Rome, ItalyUniversity College London, London, United Kingdom
| | - Tyler J Law
- From LSE Health, London School of Economics and Political Science, United Kingdom (M.S., H.N., T.J.L.); Department of Anesthesia, University of Toronto, Ontario, Canada (T.J.L.); and Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany (T.K., S.S., M.K.).Lynkeus, Rome, ItalyDeutsches Herzzentrum Berlin, Berlin, GermanyFraunhofer MEVIS, Bremen, Germanygnúbila, Argonay, FranceLondon School of Economics and Political Science, London, United KingdomMedizinische Universität Graz, Graz, AustriaSiemens AG, Munich, GermanyOspedale Pediatrico Bambino Gesù, Rome, ItalyUniversity College London, London, United Kingdom
| | - Titus Kuehne
- From LSE Health, London School of Economics and Political Science, United Kingdom (M.S., H.N., T.J.L.); Department of Anesthesia, University of Toronto, Ontario, Canada (T.J.L.); and Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany (T.K., S.S., M.K.).Lynkeus, Rome, ItalyDeutsches Herzzentrum Berlin, Berlin, GermanyFraunhofer MEVIS, Bremen, Germanygnúbila, Argonay, FranceLondon School of Economics and Political Science, London, United KingdomMedizinische Universität Graz, Graz, AustriaSiemens AG, Munich, GermanyOspedale Pediatrico Bambino Gesù, Rome, ItalyUniversity College London, London, United Kingdom
| | - Stephan Schubert
- From LSE Health, London School of Economics and Political Science, United Kingdom (M.S., H.N., T.J.L.); Department of Anesthesia, University of Toronto, Ontario, Canada (T.J.L.); and Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany (T.K., S.S., M.K.).Lynkeus, Rome, ItalyDeutsches Herzzentrum Berlin, Berlin, GermanyFraunhofer MEVIS, Bremen, Germanygnúbila, Argonay, FranceLondon School of Economics and Political Science, London, United KingdomMedizinische Universität Graz, Graz, AustriaSiemens AG, Munich, GermanyOspedale Pediatrico Bambino Gesù, Rome, ItalyUniversity College London, London, United Kingdom
| | - Marcus Kelm
- From LSE Health, London School of Economics and Political Science, United Kingdom (M.S., H.N., T.J.L.); Department of Anesthesia, University of Toronto, Ontario, Canada (T.J.L.); and Department of Paediatric Cardiology and Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Germany (T.K., S.S., M.K.).Lynkeus, Rome, ItalyDeutsches Herzzentrum Berlin, Berlin, GermanyFraunhofer MEVIS, Bremen, Germanygnúbila, Argonay, FranceLondon School of Economics and Political Science, London, United KingdomMedizinische Universität Graz, Graz, AustriaSiemens AG, Munich, GermanyOspedale Pediatrico Bambino Gesù, Rome, ItalyUniversity College London, London, United Kingdom
| | | | | | | | | | - Alistair Mcguire
- London School of Economics and Political Science, London, United Kingdom
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15
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Pathirana D, Johnston B, Johnston P. The effects of tapering and artery wall stiffness on treatments for Coarctation of the Aorta. Comput Methods Biomech Biomed Engin 2017; 20:1512-1524. [PMID: 29119836 DOI: 10.1080/10255842.2017.1382483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Dilan Pathirana
- a School of Natural Sciences and Queensland Micro- and Nanotechnology Centre , Griffith University , Nathan , Australia
| | - Barbara Johnston
- a School of Natural Sciences and Queensland Micro- and Nanotechnology Centre , Griffith University , Nathan , Australia
| | - Peter Johnston
- a School of Natural Sciences and Queensland Micro- and Nanotechnology Centre , Griffith University , Nathan , Australia
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16
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Yokoyama U, Ichikawa Y, Minamisawa S, Ishikawa Y. Pathology and molecular mechanisms of coarctation of the aorta and its association with the ductus arteriosus. J Physiol Sci 2017; 67:259-270. [PMID: 28000176 PMCID: PMC10717425 DOI: 10.1007/s12576-016-0512-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 12/06/2016] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Utako Yokoyama
- Cardiovascular Research Institute, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Yasuhiro Ichikawa
- Cardiovascular Research Institute, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Susumu Minamisawa
- The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato, Tokyo, Japan
| | - Yoshihiro Ishikawa
- Cardiovascular Research Institute, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
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17
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Song J. Progress toward Approval of Stents in Coarctation of the Aorta. Korean Circ J 2017; 47:27-28. [PMID: 28154586 PMCID: PMC5287182 DOI: 10.4070/kcj.2016.0407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 12/12/2016] [Accepted: 12/15/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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18
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Bhatia A, Mehta TH, Manning P, Kuvin JT. Adults With Left-Sided Pressure Loading Lesions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:55. [DOI: 10.1007/s11936-015-0416-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Torok RD, Campbell MJ, Fleming GA, Hill KD. Coarctation of the aorta: Management from infancy to adulthood. World J Cardiol 2015; 7:765-775. [PMID: 26635924 PMCID: PMC4660471 DOI: 10.4330/wjc.v7.i11.765] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 08/19/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Coarctation of the aorta is a relatively common form of congenital heart disease, with an estimated incidence of approximately 3 cases per 10000 births. Coarctation is a heterogeneous lesion which may present across all age ranges, with varying clinical symptoms, in isolation, or in association with other cardiac defects. The first surgical repair of aortic coarctation was described in 1944, and since that time, several other surgical techniques have been developed and modified. Additionally, transcatheter balloon angioplasty and endovascular stent placement offer less invasive approaches for the treatment of coarctation of the aorta for some patients. While overall morbidity and mortality rates are low for patients undergoing intervention for coarctation, both surgical and transcatheter interventions are not free from adverse outcomes. Therefore, patients must be followed closely over their lifetime for complications such as recoarctation, aortic aneurysm, persistent hypertension, and changes in any associated cardiac defects. Considerable effort has been expended investigating the utility and outcomes of various treatment approaches for aortic coarctation, which are heavily influenced by a patient’s anatomy, size, age, and clinical course. Here we review indications for intervention, describe and compare surgical and transcatheter techniques for management of coarctation, and explore the associated outcomes in both children and adults.
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20
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Forbes TJ, Gowda ST. Intravascular stent therapy for coarctation of the aorta. Methodist Debakey Cardiovasc J 2015; 10:82-7. [PMID: 25114759 DOI: 10.14797/mdcj-10-2-82] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Intravascular stent therapy is considered a primary therapeutic option for most adults and adolescents with coarctation of the aorta. This review highlights the indications, technical considerations, procedural aspects, and limited long-term outcome data when using this intervention. Stent technology has continued to evolve with potential for further modifications since its inception in the early 1990s. The best therapeutic approach, e.g., stenting versus surgery, in the treatment of native coarctation continues to be debated due to the paucity of long-term clinical and imaging data in both groups.
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21
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Spranger K, Capelli C, Bosi G, Schievano S, Ventikos Y. Comparison and calibration of a real-time virtual stenting algorithm using Finite Element Analysis and Genetic Algorithms. COMPUTER METHODS IN APPLIED MECHANICS AND ENGINEERING 2015; 293:462-480. [PMID: 26664007 PMCID: PMC4643757 DOI: 10.1016/j.cma.2015.03.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 10/01/2014] [Accepted: 03/27/2015] [Indexed: 06/05/2023]
Abstract
In this paper, we perform a comparative analysis between two computational methods for virtual stent deployment: a novel fast virtual stenting method, which is based on a spring-mass model, is compared with detailed finite element analysis in a sequence of in silico experiments. Given the results of the initial comparison, we present a way to optimise the fast method by calibrating a set of parameters with the help of a genetic algorithm, which utilises the outcomes of the finite element analysis as a learning reference. As a result of the calibration phase, we were able to substantially reduce the force measure discrepancy between the two methods and validate the fast stenting method by assessing the differences in the final device configurations.
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Affiliation(s)
- K. Spranger
- Department of Engineering Science, University of Oxford, Parks Road, Oxford OX1 3PJ, UK
- Department of Mechanical Engineering, University College London, UK
| | - C. Capelli
- UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, London, UK
| | - G.M. Bosi
- UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, London, UK
| | - S. Schievano
- UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, London, UK
| | - Y. Ventikos
- Department of Mechanical Engineering, University College London, UK
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22
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Saha SP, Ziada KM, Whayne TF. Surgical, interventional, and device innovations in the management of hypertension. Int J Angiol 2015; 24:1-10. [PMID: 25780322 DOI: 10.1055/s-0034-1374808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The prevalence of hypertension around the world has increased significantly with projections for an increasing major global burden of hypertension. Medication-resistant hypertension can be perplexing and frustrating. The existence of these difficult patients results in the need for additional approaches to treatment including surgery, percutaneous interventions, and device management. The sophistication of these techniques has progressed markedly and initial procedures such as classical sympathectomy and renal artery bypass are almost never performed. Newer techniques of angioplasty with stenting, renal artery denervation, and baroreflex activation therapy via electrical stimulation of the carotid baroreceptors are now in use with increasing evidence for significant benefit.
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Affiliation(s)
- Sibu P Saha
- Division of Cardiothoracic Surgery, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | - Khaled M Ziada
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | - Thomas F Whayne
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
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23
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Dzsinich C, Vaszily M, Vallus G, Dzsinich M, Berek P, Barta L, Darabos G, Nyiri G, Nagy G, Pataki T, Szentpétery L. [Late complications and treatment options of aortic coarctation operated in childhood]. Orv Hetil 2014; 155:1189-95. [PMID: 25063701 DOI: 10.1556/oh.2014.29915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The prevalence of congenital aortic coarctation is 4 in 10 000 live birth. Aortic coarctation is typically located in the aortic isthmus, but it may occur at atypical sites. Treatment options include both surgical and endovascular interventions. In patients undergoing surgical or endovascular intervention late complications such as recoarctation or aortic aneurysm may develop. AIM The aim of the authors was to analyse their own experience in late complication and treatment options of aortic coarctation operated in childhood. METHOD Retrospective analysis of data of 32 patients treated between 1980 and 2014 for late complications 8-42 years after surgical treatment of aortic coarctation. RESULTS In 28 patients aneurysm formation after isthmic patch plasty was found. Two patients had aortobronchial fistula, 2 patients showed anastomosis disruption and 2 patients had graft stenosis. During operation hybrid solution was performed in 23 patients, isthmic aorto-aortic inlay graft interposition in 5 patients, aorto-aortic bypass in 2 patients, subclavio-aortic bypass in 2 patients, graft patch plasty in one patient and ilio-renal bypass in one patient. Complications included severe intraoperative bleeding in one patient and pneumothorax in one patient. No early or late mortality occurred. CONCLUSIONS The authors conclude that life long control is mandatory in order to detect late complications in patients who underwent operation of aortic coarctation in childhood.
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Affiliation(s)
- Csaba Dzsinich
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Miklós Vaszily
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gábor Vallus
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Máté Dzsinich
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Péter Berek
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - László Barta
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gábor Darabos
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gabriella Nyiri
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Gabriella Nagy
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - Tibor Pataki
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
| | - László Szentpétery
- Magyar Honvédség Egészségügyi Központ Szív-, Ér- és Mellkas-sebészeti Osztály Budapest Róbert Károly krt. 44. 1133
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Vanegas E, Marín MM, Santacruz D. Controversias en el manejo actual de la coartación de la aorta. REVISTA COLOMBIANA DE CARDIOLOGÍA 2013. [DOI: 10.1016/s0120-5633(13)70073-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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