Follow-up results of balloon angioplasty of native coarctation in neonates and infants

Balloon Dilatation in the Management of Congenital Obstructive Lesions of the Heart: Review of Author's Experiences and Observations-Part I

Balloon dilatation techniques became available to treat congenital obstructive lesions of the heart in the early/mid-1980s. The purpose of this review is to present the author's experiences and observations on the techniques and outcomes of balloon dilatation of pulmonary stenosis (PS), aortic stenosis (AS) and aortic coarctation (AC), both native and postsurgical re-coarctations. Balloon dilatation resulted in a reduction of peak pressure gradient across the obstructive lesion at the time of the procedure as well as at short-term and long-term follow-ups. Complications such as recurrence of stenosis, valvar insufficiency (for PS and AS cases) and aneurysm formation (for AC cases) have been reported, but infrequently. It was recommended that strategies be developed to prevent the reported complications.

Surgical Treatment Following Stent Angioplasty for High-Risk Neonates With Critical Coarctation of the Aorta

BACKGROUND

Neonatal coarctation of the aorta (CoA) is primarily treated by surgical repair. However, under certain high-risk constellations, initial stent angioplasty may be considered followed by surgical repair. We report our experience with this staged approach. Methods: All patients undergoing surgical CoA repair following prior stenting at our institution between January 2011 and December 2019 were included in this retrospective analysis. The patients were classified to be at high risk because of cardiogenic shock, associated complex cardiac malformations, neonatal infection, necrotizing enterocolitis, and extracardiac conditions, respectively. Outcomes were analyzed and compared with neonates who underwent surgical CoA repair without prior stenting in the same observation period.

RESULTS

Twenty-six neonates received stent implantation at a median age of 20 days (IQR 9-33 days). Subsequent surgical repair was conducted at an age of 4.2 months (IQR 3.2-6.1 months) with a median body weight of 5.6 kg (IQR 4.5-6.5 kg). Cardiopulmonary bypass was applied in 96% of cases. Extended end-to-end anastomosis was possible in 11 patients. Extended reconstruction with patch material was necessary in the remaining patients. One fatality (3.8%) occurred 33 days postoperatively. At a median follow-up of 5.2 years after initial stenting, all remaining patients were alive; 15/25 patients (60%) were free from re-intervention. Of note, re-intervention rates were comparable in neonates (n = 76) who were operated on with native CoA (28/74 patients; 38%; P = .67).

CONCLUSIONS

Neonatal stent angioplasty for CoA results in increased complexity of the subsequent surgical repair. Nevertheless, this staged approach allows to bridge high-risk neonates to later surgical repair with reduced perioperative risk and acceptable midterm outcomes.

Single Ventricle-A Comprehensive Review

In this paper, the author enumerates cardiac defects with a functionally single ventricle, summarizes single ventricle physiology, presents a summary of management strategies to address the single ventricle defects, goes over the steps of staged total cavo-pulmonary connection, cites the prevalence of inter-stage mortality, names the causes of inter-stage mortality, discusses strategies to address the inter-stage mortality, reviews post-Fontan issues, and introduces alternative approaches to Fontan circulation.

Aortic Coarctation/Arch Hypoplasia Repair: How Small Is Too Small

Aortic coarctation/arch hypoplasia is a relatively common congenital heart disease that leads to severe cardiovascular complications if left untreated. During the modern era, the mortality of the primary surgical repair is very low but the long-term issues, such as recurrent coarctation/arch reobstruction and hypertension, are still significant challenges. The former is related to the surgical repair performed particularly in the management of the smallish distal aortic arch, and for the latter, despite the "successful" repair of the aortic coarctation, the intrinsic vascular anomaly remains a significant long-term morbidity.

The Journey of an Indian Pediatric Cardiologist : Dr. K. C. Chaudhuri Lifetime Achievement Award/Oration at AIIMS, New Delhi, September 2017

The life journey of an Indian pediatric cardiologist, who bestowed considerable attention to the development of new knowledge and train/teach physicians around the world while providing care of patients with heart disease over a 45-y period, is reviewed. This appraisal focuses particular attention on the scientific contributions to the literature. These include spontaneous closure of physiologically advantageous ventricular septal defects, various issues related to a congenital heart defect namely, tricuspid atresia and transcatheter and, interventional pediatric cardiac procedures.

Recurrent coarctation: interventional techniques and results

Coarctation of the aorta (CoA) accounts for 5% to 8% of all congenital heart defects. With all forms of interventions for native CoA, repeat intervention may be required due to restenosis and/or aneurysm formation. Restenosis rates vary from 5% to 24% and are higher in infants and children and in those with arch hypoplasia. Although repeat surgery can be done for recurrent CoA, guidelines from a number of professional societies have recommended balloon angioplasty with or without stenting as the preferred intervention for patients with isolated recoarctation. For infants and young children with recurrent coarctation, balloon angioplasty has been shown to be safe and effective with low incidence of complications. However, the rates of restenosis and reinterventions are high with balloon angioplasty alone. Endovascular stent placement is indicated, either electively in adults or as a bailout procedure in those who develop a complication such as dissection or intimal tear after balloon angioplasty. Conventionally bare metal stents are used; these can be dilated later if required. Covered stents, introduced more recently, are best reserved for those who have aneurysm at the site of previous repair or who develop a complication such as aortic wall perforation or tear. Stents produce complete abolition of gradients across the coarct segment in a majority of cases with good opening of the lumen on angiography. The long-term results are better than that of balloon angioplasty alone, with very low rates of restenosis. However, endovascular stenting is a technically demanding procedure and can be associated with serious complications rarely.

Stent implantation for coarctation of the aorta in children <30 kg

OBJECTIVES

Our aim was to determine key characteristics of stents commonly implanted in the aorta through bench testing and to describe our technique and acute results in patients weighing <30 kg.

BACKGROUND

Despite the increasing use of stents for interventional treatment for coarctation of the aorta (CoA) in larger patients, use of large stents is controversial in small children.

METHODS

Methods included bench testing of large stents, and retrospective review of all patients over 1 year of age who had stent implantation for treatment of CoA. Patients were divided into 2 groups based on weight. Paired comparisons were made before and after stent implantation, and group outcomes were compared.

RESULTS

Sixty patients comprised the entire sample, with 22 patients assigned to group I (<30 kg) and 38 patients assigned to group II (>or=30 kg). The mean minimum diameters of the CoA (group I 5.0 to 10.7 mm; group II 8.0 to 15.0 mm) and the ratio of the coarctation diameter to the descending aorta diameter measured at the level of the diaphragm (CoA/DAo ratio) (group I 0.4 to 0.93; group II 0.46 to 0.94) increased significantly in both groups (all p < 0.05). The mean systolic gradient decreased significantly in both groups (group I 23.0 to 2.0 mm Hg; group II 24.0 to 2.8 mm Hg; both p = 0.001). No difference was found between the groups in the CoA/DAo ratio, residual systolic gradients, or the decrease in systolic gradient after stent implantation. There were no significant complications in patients under 30 kg.

CONCLUSIONS

As in larger patients, use of large stents for treatment of CoA in small children is effective and safe in the short term. In these patients, stent redilations will be required, and follow-up is ongoing.

Tratamiento no quirúrgico de la coartación y recoartación de aorta

OBJECTIVES

To analyze the results of nonsurgical treatment of aortic coarctation and recoarctation by evaluating the results of each technique, and its complications and outcome.

PATIENTS AND METHODS

The results were as follows: 51 children underwent balloon dilatation due to recoarctation (86.5 %); two underwent dilation of a native coarctation (3.3 %) and six underwent stent implantation for recoarctation (10 %). Age ranged from 2 to 236 months (109 +/- 63.45 months) with a follow-up of between 1 and 156 months (38.87 +/-32.96 months).

RESULTS

The mean predilatation gradient in children with recoarctation was 34 +/- 11.62 mmHg, which decreased to 11 +/- 5.38 mm Hg (p < 0.0001). In 12 patients (20.3 %) effective dilatation was not achieved. The size of the stenosis was 6.7 +/- 2.35 mm predilatation, which increased to 9.3 +/- 3.10 mm (p < 0.0001) after dilatation with a percentage increase of 50.97. There were very few complications. Six children required subsequent redilatation. The experience with stent showed a mean gradient of 32.83 +/- 10.62 mm Hg, which decreased to 7.3 +/- 3.8 mm Hg (p < 0.0001) with a balloon/stenosis ratio of 1.94.

CONCLUSIONS

We conclude that the interventionist technique is highly effective in both native coarctation and recoarctation in the short term, as well as subsequently, with very few complications. The stent technique produces equally good results in older children, which is promising for the future.

Percutaneous recanalization and balloon angioplasty of congenital isolated local atresia of the aortic isthmus in adults

Congenital isolated local atresia of the aortic isthmus is anatomically similar and morphogenetically related to congenital coarctation of the aorta and was encountered in 4 out of 26 consecutive adult patients selected for coarctation angioplasty at our center. Anterograde recanalization of the atresia was safely and successfully accomplished in all four patients, using a brachial approach. Balloon dilation in the four patients, with ancillary stent implantation in one patient, resulted in reduction of translesion gradient from 84 +/- 11 mm Hg to 9 +/- 7 mm Hg without complications. Angiography in the three non-stented patients after a mean follow-up of 13 months showed no evidence of restenosis, dissection or aneurysm formation, though one patient had mild dilatation of the posterior aspect of the aortic isthmus. The clinical presentation of patients with isolated local aortic atresia, and their short- to mid-term response to percutaneous treatment, is similar to that of patients with isolated severe coarctation of aorta.

Tricuspid Atresia

Untreated, the prognosis for patients with tricuspid atresia (TA) is poor. Recent advances in medical and surgical therapy, particularly the application of Fontan principle, have markedly improved the long-term outlook for children with this condition. Palliative procedures to normalize the pulmonary blood flow and to relieve interatrial or interventricular obstruction should be undertaken promptly. Staged total cavopulmonary connection to bypass the right atrium and right ventricle by an initial bidirectional Glenn procedure and followed by extracardiac conduit diversion of inferior vena caval flow into the pulmonary arteries appears to be the current procedure of choice in the surgical management of TA. Total cavopulmonary diversion appears to be superior to conventional Fontan-Kreutzer operations, but long-term follow-up results are needed to confirm this impression.

Combined brachial and femoral approach to balloon angioplasty in coarctation of aorta

Transfemoral balloon angioplasty of native aortic coarctation was initially not feasible in two patients, because of inability to cannulate the femoral artery percutaneously in one, and to cross the coarctation in the other. The percutaneous brachial approach helped overcome both these problems, after which utilization of intravascular snares allowed successful transfemoral completion of angioplasty.

Balloon angioplasty for aortic coarctation--report of a questionnaire survey by the Japanese Pediatric Interventional Cardiology Committee

The aim of this study was to analyze the results of a questionnaire survey regarding acute and late effects of balloon angioplasty for aortic coarctation in Japan. Considerable controversy still exists regarding the effectiveness and safety of balloon angioplasty in native coarctation. Moreover, little information about this mode of treatment is available from Japan. A questionnaire was sent to 55 Japanese institutions with pediatric cardiology units. A total of 208 patients from 35 institutions were reported and analyzed for indications for balloon angioplasty, acute and late results, and complications. Balloon angioplasty was performed in 56 patients with native coarctation (group I) and in 152 patients with postoperative recoarctation (group II). In group I, the pressure gradient across the coarcted site decreased significantly from 34 +/- 19 to 16 +/- 21 mmHg (p < 0.001), and the diameter of the coarcted site increased significantly from 3.7 +/- 1.7 to 6.0 +/- 2.5 mm (p < 0.001). In group II the pressure gradient significantly decreased from 41 +/- 20 to 15 +/- 15 mmHg (p < 0.001) and the diameter of the coarcted site significantly increased from 4.2 +/- 2.2 to 6.8 +/- 3.1 mm (p < 0.001). The restenosis rate was significantly higher in group I (19/41, 46%) than in group II (25/139, 18%) (p = 0.0006). Redilation was successfully performed in 27 of 29 of the patients with restenosis. Major complications included femoral pulse loss, transient bradycardia, and arrhythmia. No patient died of a cardiac event related to the procedure. The significant risk factors for late restenosis included type of coarctation, age under 4 months, balloon size used, pressure gradient and coarctation diameter before the procedure. Balloon angioplasty is a suitable treatment for aortic coarctation in both native coarctation and postoperative recoarctation. Restenosis was significant after initial balloon angioplasty in native coarctation but redilation was effective in most cases. The most significant risk group for restenosis is young children with native coarctation.

Quantitative echocardiographic analysis of the aortic arch predicts outcome of balloon angioplasty of native coarctation of the aorta

BACKGROUND

The use of balloon angioplasty for treatment of native aortic coarctation is controversial. Cineangiographic data suggest that aortic arch hypoplasia and isthmic narrowing are associated with angioplasty failure. This study of echocardiographic measurements of preangioplasty aortic arch morphology was performed to identify potential anatomic predictors of outcome noninvasively.

METHODS AND RESULTS

The preangioplasty echocardiograms of 105 patients 3 days to 17 years old with native coarctation of the aorta were analyzed off-line. Angioplasty was considered successful if the residual coarctation gradient was < 20 mm Hg and no intervention for recoarctation occurred. Univariate analysis identified young age at angioplasty, presence of a patent ductus arteriosus, and the diameters of the aortic isthmus, distal transverse arch, and aortic valve as predictors of early and late outcomes. Multivariate analysis showed that the preangioplasty aortic isthmus z value was the best independent predictor of outcome, eliminating the effect on outcome of age and associated cardiac defects. An isthmus z value < or = -2.16 predicted early failure with 91% sensitivity and 85% specificity. Kaplan-Meier analysis demonstrated that 90% of patients with an isthmus z value > -1.0 remained free of recoarctation at late follow-up, whereas 89% of patients with a preangioplasty isthmus z value < or = -2.0 developed recoarctation within 36 months.

CONCLUSIONS

Echocardiographic measurements of the aortic arch predict both early and late outcomes of balloon angioplasty for native aortic coarctation, and the preangioplasty aortic isthmus z value was the best independent predictor. Quantitative aortic arch analysis may improve selection of angioplasty candidates who are likely to benefit from the procedure.

Balloon angioplasty for native coarctation of the aorta

Balloon angioplasty of native coarctations of the aorta is one of the most controversial facets of the pediatric interventional cardiologist's practice. We have evaluated the history and experimental rationale of this technology. Presently accepted techniques are outlined and controversies intrinsic in performance of this procedure are discussed. Acute, short-term, and long-term results are reviewed with particular emphasis on differences in success of the procedure as related to patient age. Common and significant complications are discussed and in some cases compared to analogous surgical complications. Newer technologies and approaches to interventional therapy for coarctation of the aorta are also discussed.

Validation of risk factors in predicting recoarctation after initially successful balloon angioplasty for native aortic coarctation

Despite gratifying immediate results, significant recoarctation at follow-up has been observed after balloon angioplasty of native aortic coarctation. Risk factors for such recurrences have been identified in one of our previous studies. In this study we examined the value of these risk factors in the prediction of recoarctation after balloon angioplasty. During a 6-year period ending in September 1993, 37 infants and children aged 2 days to 15 years underwent balloon angioplasty of native coarctation with resultant reduction in coarctation gradient from 45 +/- 17 (mean +/- SD) to 12 +/- 9 mm Hg (p < 0.001). On the basis of results of 4- to 48-month follow-up catheterization in 30 children, recoarctation developed in 8 (27%) children. The data from these patients were scrutinized to identify subjects that exhibited the previously determined risk factors, namely age < 12 months, size of aortic isthmus less than two thirds the size of the ascending aorta, coarcted aortic segment < 3.5 mm before angioplasty, and coarcted segment < 6.0 mm after angioplasty. Then, thirty variables (Table I) were examined by logistic regression to identify factors responsible for recoarctation; the data from both study groups were combined for this analysis. The prevalence of recoarctation in each subgroup with a given number of risk factors is similar (p < 0.1) to that observed in the initial study identifying the risk factors. In addition, logistic regression identified age (p = 0.014), size of isthmus (p = 0.006), preangioplasty coarcted segment (p = 0.01), and postangioplasty coarcted segment (p = 0.006) as risk factors.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical versus balloon therapy for aortic coarctation in infants < or = 3 months old

OBJECTIVES

This study compared the efficacy and safety of balloon angioplasty with surgical correction of native aortic coarctation in infants < or = 3 months old.

BACKGROUND

There is a controversy with regard to the role of balloon angioplasty in the treatment of aortic coarctation, especially in young infants.

METHODS

Data from 29 infants < or = 3 months old undergoing therapy for aortic coarctation during the decade ending 1992 were analyzed. Fourteen infants underwent surgery, and 15 had balloon angioplasty. The sole criterion for allotment to the balloon group was the availability of an interventional cardiologist at the time of presentation of the infant.

RESULTS

The surgical and balloon groups were comparable (p > 0.1) with regard to age (27 +/- 35 [mean +/- SD] vs. 29 +/- 27 days), weight (3.5 +/- 0.9 vs. 3.8 +/- 1.0 kg) and prevalence (7 of 14 vs. 8 of 15) and type of associated defects. Operative (1 of 14 vs. 1 of 15) and late (3 of 13 vs. 3 of 14) mortality, immediate gradient relief (36 +/- 25 to 10 +/- 9 mm Hg vs. 41 +/- 14 to 6 +/- 6 mm Hg) and follow-up gradient (27 +/- 27 vs. 24 +/- 19 mm Hg) were similar (p > 0.1). Infants with a gradient > 20 mm Hg at follow-up (6 of 13 vs. 7 of 14) and need for reintervention (6 of 13 vs. 7 of 14) were also similar (p > 0.1) in both groups. Duration of hospital stay during the first intervention was higher (p < 0.05) in the surgical (32 +/- 37 days) than the balloon (7 +/- 6 days) group. Similarly, duration of endotracheal intubation and mechanical ventilation was longer (p < 0.05) in the surgical (12 +/- 16 days) than the balloon (2 +/- 3 days) group. Complications after surgical intervention (0.86 events/patient) were higher (p < 0.01) than those seen after balloon angioplasty (0.27 events/patient). However, the lack of significant differences observed for mortality rates and residual gradients may be due to low statistical power to detect differences (16% to 49%), implying that this may be due to either actual lack of statistical difference or small sample size.

CONCLUSIONS

The data indicate that the degree of relief from aortic coarctation and the frequency with which reintervention is needed are similar in both groups. However, the morbidity and complication rates are lower with balloon than with surgical therapy. These data suggest that balloon angioplasty may be an acceptable alternative to surgical correction in the treatment of symptomatic aortic coarctation in infants < or = 3 months old.

Comparison of angioplasty and surgery for unoperated coarctation of the aorta

BACKGROUND

The use of balloon coarctation angioplasty instead of surgery as treatment for unoperated coarctation of the aorta is controversial. The efficacy and complications of the two procedures have not been studied before in a prospective fashion.

METHODS AND RESULTS

Thirty-six patients were prospectively randomized to either angioplasty (20 patients) or surgery (16 patients). Immediate results and patient follow-up, including physical examination, angiograms, and magnetic resonance imaging, were compared between groups. Reduction in peak systolic pressure gradient across the coarctation was similar (86%) immediately after both balloon coarctation angioplasty and surgery. On follow-up, aneurysms were seen only in the angioplasty group (20%) and not in the surgery group (0%). No aneurysms have shown progression or required surgery. The incidence of other complications was similar in both groups, although two patients experienced neurological complications after surgery. Although not statistically different, the incidence of restenosis (peak systolic pressure gradient > or = 20 mm Hg) tended to be greater in the angioplasty group (25%) than in the surgery group (6%). Restenosis after angioplasty occurred more frequently in patients with an aortic isthmus/descending aorta diameter ratio < 0.65 and was associated with an immediate catheterization residual peak systolic pressure gradient across the coarctation > or = 12 mm Hg.

CONCLUSIONS

Immediate gradient reduction is similar after balloon coarctation angioplasty and surgical treatment of unoperated coarctation of the aorta. The risks of aneurysm formation and possibly restenosis after angioplasty are higher than after surgery, although the risks of other complications are similar. Balloon coarctation angioplasty may provide an effective initial alternative to surgical repair of unoperated coarctation of the aorta in children beyond infancy, particularly in patients with a well-developed isthmus. Further follow-up is necessary to determine the long-term risks of postangioplasty aneurysms.

Repair of coarctation of the aorta in infancy: comparison of surgical and balloon angioplasty

Surgical repair of coarctation of the aorta in infancy has recently been challenged by some investigators who suggest that balloon angioplasty results in a lower mortality rate and similar risk of restenosis. Over a 44-month period, 37 consecutive infants with a mean age of 33 days (median, 15 days; range, 1 to 200 days) and mean and median weight of 3.7 kg (range, 2.4 to 5.4 kg) underwent surgical repair of coarctation of the aorta with either an end-to-end anastomosis (24 patients) or subclavian flap angioplasty (13 patients). There were no operative deaths (95% confidence interval, 0% to 10%). Four patients died late (> 30 days) after surgery (11%). Four patients (11%) (95% confidence interval, 3% to 25%) had residual gradients greater than 20 mm Hg. A review of the recent literature on treatment of native coarctation in infants with surgical repair (18 reports, 1189 patients) and balloon angioplasty (8 reports, 57 patients) reveals a similar early mortality rate but a much higher rate of recoarctation in infants who were treated with balloon dilation (57%) as compared with those who underwent surgical repair (14%). Because of the incidence of restenosis, balloon dilation as compared with surgical repair does not yet offer an improved outcome for native coarctation of the aorta in infancy.

Percutaneous balloon coarctation angioplasty: long-term results

One hundred and ten patients, age 2 days to 35 years (mean 7.0 +/- 7.0 years), have undergone 118 percutaneous balloon angioplasty procedures for discrete coarctation of the aorta since April 1982. The mean systolic gradient was significantly decreased from 48 +/- 22 to 8 +/- 7 mmHg after angioplasty (P less than 0.0001). Long-term results were evaluated in 95 patients, by follow-up catheterization in 30 and Doppler echocardiography in 65 patients. The follow-up period was 1-9 years (4.2 +/- 2.1). At follow-up the mean residual gradient was 9 +/- 8 mmHg. On the basis of follow-up data, four groups of patients were identified: group I consisted of 53 patients over 3 months of age with native coarctation of the aorta; group II consisted of 13 patients with postoperative coarctation restenosis; group III consisted of 21 infants 3 months of age or younger with native coarctation of the aorta; and group IV consisted of eight infants who developed postdilatation restenosis. Patients in groups I and II had good results and required no redilatation or surgical repair. In group III successful redilatation in eight and surgical repair in seven infants were performed 1 month to 5 years after the initial dilatation. There were no mortalities related to the 118 dilatation procedures. Of the seven patients who had surgical repair of the coarctation and the associated cardiac anomalies, four expired in the immediate postoperative period.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon angioplasty of native coarctation of the aorta in adolescents and young adults

Balloon angioplasty of native coarctation of the aorta was performed in 35 consecutive adolescents and young adults, aged 14 to 37 years (mean 22.6 +/- 7.1). Twenty-eight (80%) patients had isolated discrete coarctation, six (17.1%) had tubular hypoplasia of the aortic isthmus, and one (2.9%) had hypoplasia of the post-coarctation aorta. The peak systolic pressure gradient decreased from 78.5 +/- 23.9 to 15.7 +/- 11.6 mm Hg (p less than 0.001), and the mean coarctation diameter increased from 4.7 +/- 2.4 to 13.1 +/- 2.7 mm (p less than 0.001) immediately after angioplasty. Patients with discrete-type coarctation had significantly less residual gradient than patients with long-segment tubular coarctation (12.3 +/- 10.7 vs 27.2 +/- 6.6 mm Hg, p less than 0.01). On recatheterization and angiography in 26 patients at 12.6 +/- 1.5 months after dilatation, there was no significant change in gradient (15.5 +/- 13.3 mm Hg) and diameter (13.1 +/- 1.8 mm) from the immediate post-angioplasty results. However, two patients had an increase in gradient and three had small aortic aneurysms with no change in appearance on restudy after 2 years. After 3 to 67 months' (mean 32.7 +/- 19.2) follow-up, all patients showed continued clinical improvement. Hypertension was relieved in 37.5% (12/32) and improved in 59.4% (19/32). Our experience suggests that balloon angioplasty of native aortic coarctation in adolescents and young adults is safe and highly effective with sustained improvement on intermediate-term follow-up.

Role of balloon angioplasty in the treatment of aortic coarctation

Since the initial report of coarctation balloon angioplasty in 1982, several groups have used this technique for native coarctations in neonates, infants, and children and for postoperative recoarctations. However, recommendations for use of balloon angioplasty as a treatment procedure of choice are clouded by reports of aneurysm development at the site of coarctation. Here we review our experience as well as that published in the literature, including Valvuloplasty and Angioplasty of Congenital Anomalies Registry data, and present evidence in support of balloon angioplasty as a therapeutic procedure of choice for treating native and recurrent postoperative aortic coarctations. Balloon angioplasty of native aortic coarctations in 20 neonates and infants 1 year old or less reduced peak systolic pressure gradient across the coarctation from 40 +/- 12 mm Hg (mean +/- standard deviation) to 11 +/- 8 mm Hg (p less than 0.001); no patient required immediate surgical intervention. The residual gradient at follow-up (mean follow-up, 12 months) in 16 infants was 18 +/- 16 mm Hg, a significant improvement (p less than 0.01) compared with preangioplasty values. In none of the patients did an aneurysm develop. Recoarctation developed in 5 (31%) of the 16 infants and was successfully treated either by surgical resection (in 2) or by repeat balloon angioplasty (in 3). A comparison of mortality and recurrence rates between the balloon angioplasty and surgical groups was made with the help of data pooled from the literature published since 1980. The initial (7% versus 23%) and late (2% versus 25%) mortality and recoarctation (11% versus 18%) rates were higher (p less than 0.025) after surgical intervention than after balloon therapy. When only reports in which patients were operated on after 1979 were included in this type of analysis, the initial and late mortality rates remained higher (p less than 0.01) after operation than after angioplasty, and the recoarctation rates became similar (p greater than 0.1). Thirty-two children (greater than 1 year old) underwent balloon angioplasty of native coarctation with a resultant reduction in peak systolic pressure gradient from 48 +/- 19 mm Hg to 10 +/- 9 mm Hg (p less than 0.001), which continued to remain low (14 +/- 11 mm Hg; p less than 0.001) at follow-up catheterization in 24 children 13 months (mean) later. There were no immediate or late deaths. A small aneurysm developed in 1 patient (4%) but did not require intervention. Recoarctation developed in 2 patients (8%), and in both, repeat balloon angioplasty was performed with good results.(ABSTRACT TRUNCATED AT 400 WORDS)