Adverse outcome of coarctation stenting in patients with Turner syndrome

Transition from pediatric to adult care in patients with Turner syndrome in Italy: a consensus statement by the TRAMITI project

PURPOSE

Transition from pediatric to adult care is associated with significant challenges in patients with Turner syndrome (TS). The objective of the TRansition Age Management In Turner syndrome in Italy (TRAMITI) project was to improve the care provided to patients with TS by harnessing the knowledge and expertise of various Italian centers through a Delphi-like consensus process.

METHODS

A panel of 15 physicians and 1 psychologist discussed 4 key domains: transition and referral, sexual and bone health and oncological risks, social and psychological aspects and systemic and metabolic disorders.

RESULTS

A total of 41 consensus statements were drafted. The transition from pediatric to adult care is a critical period for patients with TS, necessitating tailored approaches and early disclosure of the diagnosis to promote self-reliance and healthcare autonomy. Fertility preservation and bone health strategies are recommended to mitigate long-term complications, and psychiatric evaluations are recommended to address the increased prevalence of anxiety and depression. The consensus also addresses the heightened risk of metabolic, cardiovascular and autoimmune disorders in patients with TS; regular screenings and interventions are advised to manage these conditions effectively. In addition, cardiac abnormalities, including aortic dissections, require regular monitoring and early surgical intervention if certain criteria are met.

CONCLUSIONS

The TRAMITI consensus statement provides valuable insights and evidence-based recommendations to guide healthcare practitioners in delivering comprehensive and patient-centered care for patients with TS. By addressing the complex medical and psychosocial aspects of the condition, this consensus aims to enhance TS management and improve the overall well-being and long-term outcomes of these individuals.

Clinical practice guidelines for the care of girls and women with Turner syndrome

Turner syndrome (TS) affects 50 per 100 000 females. TS affects multiple organs through all stages of life, necessitating multidisciplinary care. This guideline extends previous ones and includes important new advances, within diagnostics and genetics, estrogen treatment, fertility, co-morbidities, and neurocognition and neuropsychology. Exploratory meetings were held in 2021 in Europe and United States culminating with a consensus meeting in Aarhus, Denmark in June 2023. Prior to this, eight groups addressed important areas in TS care: (1) diagnosis and genetics, (2) growth, (3) puberty and estrogen treatment, (4) cardiovascular health, (5) transition, (6) fertility assessment, monitoring, and counselling, (7) health surveillance for comorbidities throughout the lifespan, and (8) neurocognition and its implications for mental health and well-being. Each group produced proposals for the present guidelines, which were meticulously discussed by the entire group. Four pertinent questions were submitted for formal GRADE (Grading of Recommendations, Assessment, Development and Evaluation) evaluation with systematic review of the literature. The guidelines project was initiated by the European Society for Endocrinology and the Pediatric Endocrine Society, in collaboration with members from the European Society for Pediatric Endocrinology, the European Society of Human Reproduction and Embryology, the European Reference Network on Rare Endocrine Conditions, the Society for Endocrinology, and the European Society of Cardiology, Japanese Society for Pediatric Endocrinology, Australia and New Zealand Society for Pediatric Endocrinology and Diabetes, Latin American Society for Pediatric Endocrinology, Arab Society for Pediatric Endocrinology and Diabetes, and the Asia Pacific Pediatric Endocrine Society. Advocacy groups appointed representatives for pre-meeting discussions and the consensus meeting.

Prevalence and development of aortic dilation and dissection in women with Turner syndrome: a systematic review and meta-analysis

OBJECTIVES

Women with Turner syndrome (TS) have an increased risk of aortic disease, reducing life-expectancy. This study aimed to systematically review the prevalence of thoracic aortic dilatation, aortic dimensions and growth, and the incidence of aortic dissection.

METHODS

A systematic literature search was conducted up to July 2022. Observational studies with an adult TS population were included, and studies including children aged <15 years old or specific TS populations were excluded.

RESULTS

In total 21 studies were included. The pooled prevalence of ascending aortic dilatation was 23% (95% CI 19-26) at a mean pooled age of 29 years (95% CI 26-32), while the incidence of aortic dissection was 164 per 100.000 patient-years (95% CI 95-284). Three reporting studies showed aortic growth over time to be limited. Risk factors for aortic dilation or dissection were older age, bicuspid aortic valve, aortic coarctation, and hypertension.

CONCLUSION

In adult TS women, ascending aortic dilatation is common and the hazard of aortic dissection increased compared to the general population, whereas aortic growth is limited. Conventional risk markers do not explain all aortic dissection cases; therefore, new imaging parameters and blood biomarkers are needed to improve prediction, allowing for patient-tailored follow-up and surgical decision-making.

Procedural Characteristics and Outcomes of Transcatheter Interventions for Aortic Coarctation: A Report From the IMPACT Registry

Background

Although surgical repair was the traditional first-line treatment for native coarctation of the aorta (CoA), balloon angioplasty (BA) and stenting are now increasingly being performed. We aimed to determine the practice patterns and acute outcomes of transcatheter interventions for native coarctation in the largest multicenter registry for congenital catheterization.

Methods

CoA interventions from the IMPACT (IMproving Pediatric and Adult Congenital Treatment) National Cardiovascular Data Registry were analyzed. The procedure choice and acute outcomes were compared among patients with no prior interventions on the aortic isthmus (native CoA). Procedural success was defined as no major adverse events (MAEs) and a final peak gradient of <20 mm Hg and optimal outcome as no MAEs and a final gradient of <10 mm Hg.

Results

Over the 8-year study period, 5928 CoA procedures were performed, of which 1187 were performed in patients with native CoA. In this group, stenting was performed in more then half of children aged >1 year and >90% of those aged >8 years. Procedural success was achieved in >90% of stenting procedures but in only 69% of BAs. Stent implantation was associated with a higher likelihood of optimal gradient (<10 mm Hg) after adjustment for age and baseline characteristics. MAEs were most common in children aged <1 year (14%), occurred in 2% to 2.5% of those aged 1 to 18 years and in 6.6% of adults (P < .001), and were more likely after BA than after stenting (odds ratio, 0.5; 95% CI, 0.28-0.9; unadjusted P = .02).

Conclusions

Catheter interventions for native coarctation are performed safely in older children and adults, with a high degree of immediate procedural success, particularly with stenting.

Safety of Aortic Coarctation Treatment in Patients with Turner Syndrome: A Single-Country Case Series and Literature Review

OBJECTIVES

Coarctation of the aorta is a common cardiac disease in Turner syndrome. Evidence indicates that surgery and balloon angioplasty in infants and small children do not have any added risk of mortality or complication in these patients. Stenting in older patients may, however, pose higher risks of arterial wall injury and mortality.

METHODS

In this case series, we describe 15 patients with coarctation of the aorta in Turner syndrome: 9 received stenting, 4 underwent surgery, and 2 were treated via balloon angioplasty.

RESULTS

Dissection occurred in 2 patients after stenting: 1 in the aorta and the other in the external femoral artery. Both were managed promptly without any mortality or serious damage: 1 percutaneously and the other surgically.

CONCLUSIONS

Awareness of increased risks and preparedness for prompt interventions in case of an acute arterial wall injury are recommended when coarctation stenting is done for a patient with Turner syndrome.

Stent implantation in severe aortic coarctation in a pediatric patient with Turner syndrome: Case report and literature review

BACKGROUND

Turner syndrome is a rare systemic disease and a significant proportion of these patients experience aortic coarctation. Selection of optimal therapy for aortic coarctation in patients with Turner syndrome is difficult due to the pathologic change of the systemic vessel.

CASE PRESENTATION

We report one successful case of covered stent implantation for the treatment of severe native coarctation of the aorta in a 15-year-old patient with Turner syndrome weighing 36 kg. A covered stent was implanted in this patient. After the stent implantation, the peak systolic pressure gradient immediately decreased from 48 mmHg to 14 mmHg. The aortic diameter at the coarctation site increased from 3 mm to 10 mm after stenting. A femoral arterial complication occurred in this case, and we stabilized the situation finally.

RESULTS

During a follow-up of 3 years, no restenosis of aortic coarctation was observed and the patient no longer experienced hypertension. The dissection of the right femoral artery remained stable.

CONCLUSION

A covered stent implantation for severe aortic coarctation in patients with Turner syndrome could be safe and effective. However, caution should be taken when using the technique to prevent complications.

Outcomes in hospitalisations of women with Turner syndrome compared to women without Turner syndrome

OBJECTIVE

To evaluate outcomes in patients with Turner Syndrome, especially those with cardiac conditions, compared to those without Turner syndrome.

DESIGN

Retrospective cohort study utilising hospitalisation data from 2006 to 2012. Conditional logistic regression models are used to analyse outcomes of interest: all-cause mortality, increased length of stay, and discharge to home.

PARTICIPANTS

We identified 2978 women with Turner syndrome, matched to 11,912 controls by primary diagnosis.

RESULTS

Patients with Turner syndrome were more likely to experience inpatient mortality (odds ratio 1.44, 95% confidence interval 1.02-2.02, p = 0.04) and increased length of stay (OR 1.31, CI 1.18-1.46, p = 0.03) than primary diagnosis matched controls, after adjusting for age, race, insurance status, and Charlson comorbidity index. Patients with Turner syndrome were 32% less likely to be discharged to home (OR 0.68, CI 0.60-0.78, p < 0.001). When restricting the sample of patients to those admitted with a cardiac diagnosis, the likelihood of mortality (OR 3.10, CI 1.27-7.57, p = 0.01) and prolonged length of stay (OR 1.42, CI 1.03-1.95, p = 0.03) further increased, while the likelihood of discharge to home further decreased (OR 0.55, CI 0.38-0.80, p = 0.001) in Turner syndrome compared to primary diagnosis matched controls. Specifically, patients with congenital heart disease were more likely to have prolonged length of stay (OR: 1.53, CI 1.18-2.00, p = 0.002), but not increased mortality or decreased discharge to home.

CONCLUSIONS

Hospitalised women with Turner syndrome carry a higher risk of adverse outcomes even when presenting otherwise similarly as controls, an important consideration for those treating them in these settings.

Transcatheter Intervention for Congenital Defects Involving the Great Vessels: JACC Review Topic of the Week

Since the development of balloon angioplasty and balloon-expandable endovascular stent technology in the 1970s and 1980s, percutaneous transcatheter intervention has emerged as a mainstay of therapy for congenital heart disease (CHD) lesions throughout the systemic and pulmonary vascular beds. Congenital lesions of the great vessels, including the aorta, pulmonary arteries, and patent ductus arteriosus, are each amenable to transcatheter intervention throughout the lifespan, from neonate to adult. In many cases, on-label devices now exist to facilitate these therapies. In this review, we seek to describe the contemporary approach to and outcomes from transcatheter management of major CHD lesions of the great vessels, with a focus on coarctation of the aorta, single- or multiple-branch pulmonary artery stenoses, and persistent patent ductus arteriosus. We further comment on the future of transcatheter therapies for these CHD lesions.

Successful hybrid TEVAR for distal anastomotic pseudoaneurysm and coarctation following previous palliative left subclavian artery to descending aorta bypass: A case report

INTRODUCTION

Anastomotic pseudoaneurysm is one of the most common but catastrophic complications in coarctation of the aorta (CoA); this is equally true even if the initial surgery is not directly related to the coarctation. Redo open heart surgery is usually required for the pseudoaneurysm; however, redo surgery remains challenging with high morbidity and mortality rates.

PRESENTATION OF CASE

A 38-year-old woman with CoA, who had undergone left subclavian artery (LSCA) to descending aorta bypass 21 years prior, was referred to us for the treatment of distal anastomotic pseudoaneurysm. Zone 2 thoracic endovascular aortic repair (TEVAR) with LSCA debranching was performed to exclude the distal anastomotic pseudoaneurysm and expand the CoA using a stent graft. The patient completely recovered and resumed work without delay.

DISCUSSION

In patients who require surgical treatment for both pseudoaneurysm and CoA, hybrid TEVAR can be an alternative surgical option instead of conventional open repair.

CONCLUSION

TEVAR for concomitant pseudoaneurysm and native CoA is feasible and less invasive, especially for young patients who have to resume work early after surgery.

A sudden turner of events

The authors report the case of an 18-year-old woman with Turner Syndrome and aortic coarctation, who developed aortic dissection after percutaneous stenting. Surgical treatment was necessary as the lesion progressed. This case highlights both the importance of awareness as well as multidisciplinary management of this potential complication.

Bicuspid aortic valve and aortic coarctation in congenital heart disease-important aspects for treatment with focus on aortic vasculopathy

Prevalence of congenital heart disease (CHD) is constantly increasing during the last decades in line with the treatment options for patients ranging from the surgical as well to the interventional spectrum. This mini-review addresses two of the most common defects with bicuspid aortic valve (BAV) and coarctation of the aorta (CoA). Both diseases are connected to aortic vasculopathy which is one of the most common reasons for morbidity and mortality in young patients with CHD. The review will focus as well on other aspects like medication and treatment of pregnant patients with BAV and CoA. New treatment aspects will be as well reviewed as currently there are additional treatment options to treat aortic regurgitation or aortic aneurysm especially in patients with valvular involvement and a congenital BAV thus avoiding replacement of the aortic valve and potentially improving the future therapy course of the patients.

Aortic dilatation and outcome in women with Turner syndrome

BACKGROUND

Women with Turner syndrome (TS) are at increased risk of aortic dissection, which is related to ascending aortic diameter. However, the relation between aortic diameter and outcome is not well determined. This study evaluates the prevalence of aortic dilatation, the growth rate of the aorta and the risk of aortic complications in adults with TS.

METHODS

Single centre, retrospective study of all women with TS followed with a strict protocol in an outpatient TS clinic. Aortic diameters were analysed using advanced imaging. The primary outcome was a combined endpoint of aortic-related mortality, aortic dissection and preventive aortic surgery. The secondary endpoint was aortic growth and prevalence of aortic dilatation, defined as an aortic size index >20 mm/m² at baseline.

RESULTS

At least one cardiac MR/CT was available in 268 women with TS, having median age of 28.7 (IQR: 21.3-39.7) years. Aortic dilatation was present in 22%. Linear regression identified independent factors associated with larger aortic diameters: age (coefficient=0.23; p<0.001), hypertension (coefficient=2.7; p<0.001), bicuspid aortic valve (coefficient=3.3; p<0.001), 45XO karyotype (coefficient=1.7; p=0.002), weight (coefficient=0.075; p<0.001) and growth hormone treatment (coefficient=1.4; p=0.044). During follow-up (6.8±3.2 years), five women (2%) reached the primary endpoint (two dissections, three aortic surgery). Women withmore than one scan (n=171; 1015 patient-years follow-up), the median aortic growth was 0.20 (IQR: 0.00-0.44) mm/year. In multivariate analysis, aortic growth was not associated with baseline aortic diameter or other variables.

CONCLUSIONS

Aortic dilatation is common and known associations were confirmed in large adult TS cohort However, aortic dissection, related mortality and preventive aortic surgery are rare. Growth hormone treatment in childhood was associated with aortic dimensions.

Cardiovascular imaging in Turner syndrome: state-of-the-art practice across the lifespan

Cardiovascular imaging is essential to providing excellent clinical care for girls and women with Turner syndrome (TS). Congenital and acquired cardiovascular diseases are leading causes of the lifelong increased risk of premature death in TS. Non-invasive cardiovascular imaging is crucial for timely diagnosis and treatment planning, and a systematic and targeted imaging approach should combine echocardiography, cardiovascular magnetic resonance and, in select cases, cardiac CT. In recent decades, evidence has mounted for the need to perform cardiovascular imaging in all females with TS irrespective of karyotype and phenotype. This is due to the high incidence of outcome-determining lesions that often remain subclinical and occur in patterns specific to TS. This review provides an overview of state-of-the-art cardiovascular imaging practice in TS, by means of a review of the most recent literature, in the context of a recent consensus statement that has highlighted the role of cardiovascular diseases in these females.