Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children

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.

Surgery for aortic recoarctation in children less than 10 years old: A single-center experience in Siberia, Russia

BACKGROUND

Persistence or recurrence of stenosis is a complication of initial coarctation repair. This study aims to report short-term outcomes of surgical management of recurrent coarctation and initial repair analysis.

METHODS

We retrospectively reviewed our experience with 51 patients undergoing recoarctation surgical repair between 2008 and 2019 using antegrade cerebral perfusion (ACP) technique.

RESULTS

Surgical correction included prosthetic patch aortoplasty in 23 (45%), resection with wide end-to-end anastomosis in 15 (29%), and a tube interposition graft in 13 (25%) patients. The median age at initial correction and reintervention was 12 months and 9 years. The median interval from primary repair to reintervention was 60 months. Initial repair analysis revealed 33% of patients had initial correction in the neonatal period, 72.5% of patients were done via a left thoracotomy approach and 63% of patients had end-to-end anastomosis at initial surgery.

CONCLUSION

Our study demonstrates that surgical repair of recurrent coarctation of the aorta using ACP technique can be performed safely and with excellent results.

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.

Management of Congenital Heart Disease: State of the Art; Part I-ACYANOTIC Heart Defects

Since the description of surgery for patent ductus arteriosus in late 1930s, an innumerable number of advances have taken place in the management of congenital heart defects (CHDs). In this review the current status of treatment of seven of the most common acyanotic CHDs was reviewed. The discussion included indications for, and timing of, intervention and methods of intervention. The indications are, by and large, determined by the severity of the lesion. Pressure gradients in obstructive lesions and the magnitude of the shunt in left-to-right shunt lesions are used to assess the severity of the lesion. The timing of intervention is different for each lesion and largely dependent upon when the criteria for indications for intervention were met. Appropriate medical management is necessary in most patients. Trans-catheter methods are preferable in some defects while surgery is a better option in some other defects. The currently available medical, trans-catheter, and surgical methods to treat acyanotic CHD are feasible, safe, and effective.

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.

Consensus on timing of intervention for common congenital heart diseases: part I - acyanotic heart defects

The purpose of this review/editorial is to discuss how and when to treat the most common acyanotic congenital heart defects (CHD); the discussion of cyanotic heart defects will be presented in a subsequent editorial. By and large, the indications and timing of intervention are decided by the severity of the lesion. Balloon pulmonary valvuloplasty is the treatment of choice for valvar pulmonary stenosis and the indication for intervention is peak-to-peak systolic pressure gradient >50 mmHg across the pulmonary valve. For aortic valve stenosis, balloon aortic valvuloplasty appears to be the first therapeutic procedure of choice; the indications for balloon dilatation of aortic valve are peak-to-peak systolic pressure gradient across the aortic valve in excess of 70 mmHg irrespective of the symptoms or a gradient ≥ 50 mmHg with either symptoms or electrocardiographic ST-T wave changes indicative of myocardial perfusion abnormality. The indications for intervention in coarctation of the aorta are significant hypertension and/or congestive heart failure along with a pressure gradient in excess of 20 mmHg across the coarctation; the type of intervention varies with age at presentation and the anatomy of coarctation: surgical intervention for neonates and young infants, balloon angioplasty for discrete native coarctation in children, and stents in adolescents and adults. Long segment coarctations or those associated with hypoplasia of the isthmus or transverse aortic arch require surgical treatment in younger children and stents in adolescents and adults. For post-surgical aortic recoarctation, balloon angioplasty in young children and stents in adolescents and adults are treatment options. Transcatheter closure methods are currently preferred for ostium secundum atrial septal defects (ASDs); the indications for occlusion are right ventricular volume overload by echocardiogram. Ostium primum, sinus venosus and coronary sinus ASDs require surgical closure. For all ASDs elective closure around age 4 to 5 y is recommended or as and when detected beyond that age. For the more common perimembraneous ventricular septal defects (VSDs) of large size, surgical closure should be performed prior to 6 to 12 mo of age. Muscular VSDs may be closed with devices. Patent ductus arteriosus (PDA) may be closed with Amplatzer Duct Occluder if they are moderate to large and Gianturco coils if they are small. Surgical and video-thoracoscopic closure are the available options at some centers. In the presence of pulmonary hypertension appropriate testing to determine suitability for closure should be undertaken. The treatment of acyanotic CHD with currently available medical, transcatheter and surgical methods is feasible, safe and effective and should be performed at an appropriate age in order to prevent damage to cardiovascular structures.

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.

Balloon angioplasty of postoperative coarctation in the transverse arch in infants: protecting the common carotid artery

We performed balloon angioplasty in three patients with postoperative coarctation in the transverse arch adjacent to the left common carotid artery. The age at arch reconstruction was 5, 6, and 2 days, while the interval between operation and balloon dilatation was 59 days, 87 days, and 12 months, respectively. Two balloons, one in the stenosis and the other in the left common carotid artery, were introduced over a wire sequentially and inflated simultaneously until the waist of the balloon in the arch disappeared. After balloon dilatation, a significant reduction in the peak-to-peak pressure gradient and an increase in vessel diameters were observed in all patients. Further growth of the transverse arch was documented at follow-up in two patients. No aneurysm has been detected in any patients. We believe that placing a protective balloon in the neck vessel increases safety during balloon dilatation of coarctation in the transverse arch.

Recent advances in pediatric cardiology--electrophysiology, transcatheter and surgical advances

Whereas the medical advances were reviewed in the previous paper, electrophysiological, transcatheter and surgical advances will be the focus in this review. Greater understanding of the arrhythmias, development of non-pharmacological treatment, namely catheter ablation and internal cardioverter-defibrillator (ICD) and miniaturization pacemakers and IDs have occurred in the last decade so that the methods could be applied to smaller and more complex patient population. Surgery has been the traditional treatment option for palliation and correction of congenital and acquired heart defects in infants and children. During the last one to one and one-half decades, a remarkable number of transcatheter methods were developed and refined. These developments during the last decade were reviewed and include long-term results of balloon dilatation procedures, transcatheter closure of atrial septal defects, patent ductus arteriosus, and ventricular septal defect, percutaneous valve replacement, intravascular stents to manage vascular obstructive lesions that can not be satisfactorily balloon-dilated, catheter completion of Fontan procedure, myocardial reduction in hypertrophic cardiomyopathy and other miscellaneous procedures. Recent advances in the transcatheter modes of therapy have added a new dimension to the management of neonates, infants and children with heart disease. They should now be added to the armamentarium available to the Pediatrician and Pediatric Cardiologist in the management of cardiac problems in the pediatric patient. Surgical methods and concepts have been greatly refined such that surgery can be undertaken even in the sickest and most complex patient. The majority of congenital heart defects can be corrected by open heart surgery; some require prior palliation and others can be operated without prior palliation. Recent advances in various defects were reviewed.

Balloon angioplasty of coarctation of the aorta: a safe alternative for surgery in adults: immediate and mid-term results

Patients with coarctation of the aorta can be treated either with surgery or with balloon angioplasty. So far, the last method has proved to be successful in children, but results of this treatment in (young) adults are virtually unknown. The aim of this study was to evaluate the immediate and mid-term follow-up results of balloon angioplasty of native coarctation in (mainly young) adults. Coarctation of the aorta was diagnosed by means of ultrasound or angiography, and defined as a stenosis with a pressure gradient greater than 20 mm Hg. The balloon angioplasty-procedure was carried out under complete anesthesia, and was considered to be successful, if the pressure gradient was reduced to less than 20 mm Hg. Nineteen consecutive adults (12 males, 7 females; aged 14-67 years, median 29) with native coarctation were treated from 1995-99. Mean pressure gradient decreased from 49.3+/- 20.8 to 4.8+/-8.2 mm Hg (P<0.0001). One patient showed a suboptimal result with a residual pressure gradient of 28 mm Hg. In one other patient a stent was placed on request of the referring physician. Follow-up was 100% complete and ranged from 3-47 months (mean 20.2+/- 12.9). At 1-year follow-up mean systolic blood pressure was reduced from 159.4+/-19.5 to 132.5+/-17.6 mm Hg (n = 18; P<0.0001), and mean ankle-arm pressure index improved from 0.73+/-0.09 to 0.96+/-0.05 (n = 18; P<0.0001). Anti-hypertensive medication could either be reduced or stopped in 7 patients (53.8%). With ultrasound or angiography or MRI, no patients had signs of aneurysm formation or worsening restenosis during follow-up. In adult patients with uncomplicated native coarctation of the aorta, balloon angioplasty (without stenting) would seem to be an excellent and safe alternative for surgery. In our hospital it has completely replaced surgical correction in such patients.

Balloon angioplasty of postsurgical recoarctation in infants: the risk of restenosis and long-term follow-up

OBJECTIVES

This study was undertaken to evaluate the long-term results of balloon angioplasty (BA) for postsurgical recoarctation in infants.

BACKGROUND

Balloon angioplasty is a well-accepted modality for the treatment of recoarctation. However, infants remain a group of concern because of their size, risk for complications and the potential for restenosis with growth. Age <12 months has been determined to be a risk factor for the development of recoarctation after angioplasty for native coarctation. Although studies on postsurgical coarctation have found no relationship between age at angioplasty and the development of recoarctation, few studies specifically addressing infants have been performed.

METHODS

Clinical, echocardiographic, hemodynamic and angiographic data on 22 consecutive children <1 year of age who underwent BA between 1986 and 1996 were reviewed.

RESULTS

A successful result, defined as a postprocedure gradient of < or =20 mm Hg, was achieved in 20 of 22 (91%) infants with a reduction in the systolic peak pressure gradient from 48 +/- 27 to 9 +/- 10 mm Hg (p < 0.001) and an increase in coarctation diameter from 2.7 +/- 1.1 to 5.2 +/- 1.5 mm (p < 0.001). At long-term follow-up of a median of 56 months (0.6 to 12 years), the restenosis rate after an initial optimal result was 16% (3 of 19). Five (24%) infants required reintervention (2 initially unsuccessful; 3 recoarctation), with a success rate of 95% after two procedures. Suboptimal long-term outcome correlated with a lower infant weight.

CONCLUSIONS

Balloon angioplasty can be safely performed in infants, with good long-term results. The risk of restenosis is low and can be successfully managed with repeat angioplasty.

Long-term follow-up results after balloon dilatation of pulmonic stenosis, aortic stenosis, and coarctation of the aorta: a review

Although immediate and intermediate-term results after balloon dilatation of congenital stenotic lesions of the heart in children are well studied, long-term results have not been documented. Therefore, we reviewed our experience along with the limited published data to address this issue. Late follow-up after balloon pulmonary and aortic valvuloplasty shows low-residual gradients, reintervention-free rates in the mid-80s for pulmonic and in the mid-50s for aortic stenosis, and an increase in degree and prevalence of similunar valve insufficiency. Balloon angioplasty of aortic coarctation results in low-residual gradients, residual hypertension in a minority of patients, low prevalence of aneurysms, and high rates of recurrence in the neonate and young infant. Overall, balloon dilatation is a useful technique in relieving congenital obstructive lesions of the heart in the pediatric patient, but continued study of (1) late pulmonary and aortic insufficiency after valvuloplasty, (2) recurrence and aneurysms after balloon angioplasty of coarctations and, (3) femoral artery compromise in lesions requiring transfemoral artery approach is warranted.

Interventional cardiac catheterization

Over the past decade, transcatheter interventions have become increasingly important in the treatment of patients with congenital heart lesions. These procedures may be broadly grouped as dilations (e.g., septostomy, valvuloplasty, angioplasty, and endovascular stenting) or as closures (e.g., vascular embolization and device closure of defects). Balloon valvuloplasty has become the treatment of choice for patients in all age groups with simple valvar pulmonic stenosis and, although not curative, seems at least comparable to surgery for congenital aortic stenosis in newborns to young adults. Balloon angioplasty is successfully applied to a wide range of aortic, pulmonary artery, and venous stenoses. Stents are useful in dilating lesions of which the intrinsic elasticity results in vessel recoil after balloon dilation alone. Catheter-delivered coils are used to embolize a wide range of arterial, venous, and prosthetic vascular connections. Although some devices remain investigational, they have been successfully used for closure of many arterial ducts and atrial and ventricular septal defects. In the therapy for patients with complex CHD, best results may be achieved by combining cardiac surgery with interventional catheterization. The cooperation among interventional cardiologists and cardiac surgeons was highlighted in a report of an algorithm to manage patients with tetralogy of Fallot or pulmonary atresia with diminutive pulmonary arteries, involving balloon dilation, coil embolization of collaterals, and intraoperative stent placement. In this setting, well-planned catheterization procedures have an important role in reducing the overall number of procedures that patients may require over a lifetime, with improved outcomes.

Recurrent aortic coarctation: is surgical repair still the gold standard?

OBJECTIVE

We reviewed our experience with surgical repair compared with balloon aortoplasty of recurrent coarctations of the aorta.

METHODS

This is a retrospective review of 1 institution's 27-year experience with surgical repair of recurrent aortic coarctation. A thorough chart review was performed of all pediatric patients undergoing surgical repair for recurrent aortic coarctation (n = 56) from January 1970 through July 1996.

RESULTS

The vast majority of recoarctations were repaired with a prosthetic patch technique, with a greater than 96% success rate. No deaths or major complications occurred in the 56 patients. Although a direct comparison with balloon aortoplasty cannot be done, we have reviewed the data available in the literature and found higher complication rates and lower success rates than we obtained in our series.

CONCLUSIONS

Although the treatment of aortic coarctation has improved significantly during the past decades, persistent hypertension after repairs at an older age and recurrent coarctation after repairs in neonates occur in all institutions. Surgeons have not agreed on the optimal approach to primary coarctation repair, and invasive cardiologists have challenged operative intervention for both recurrent and primary coarctation. This study demonstrates that surgical repair of recurrent coarctation of the aorta can be performed safely and with excellent results. We believe it is still the gold standard in the management of recurrent coarctation of the aorta.

Long-term follow-up results of balloon angioplasty of postoperative aortic recoarctation

Immediate- and short-term follow-up results of balloon dilatation of aortic recoarctation following surgery have been well documented, but there is sparse data on long-term follow-up. During a 10-year period ending in August 1995, 33 children, aged 2 months to 14 years old, underwent balloon angioplasty of aortic recoarctation. Prior surgery included resection and end-to-end anastomosis (n = 9), subclavian flap (n = 16) or prosthetic (Dacron or Gore-Tex) patch (n = 5) angioplasty, and repair of an interrupted aortic arch (n = 3). Recoarctation developed 1 month to 14 years (mean +/- SD 29 +/- 44 months) after surgery. The indications for angioplasty were peak-to-peak systolic gradients > 20 mm Hg and systemic hypertension and/or congestive heart failure. After balloon angioplasty, the peak-to-peak systolic pressure gradient across the coarctation decreased from 48 +/- 22 to 13 +/- 15 mm Hg (p <0.01), and the size of the coarcted segment increased from 3.3 +/- 1.4 to 6.5 +/- 2.3 mm (p <0.01). Follow-up angiography and/or magnetic resonance imaging were performed in 20 children 17 +/- 12 months after angioplasty. No aneurysms were observed and improvement in the diameter of the coarcted aortic segment (9 +/- 3 mm) persisted. One- to 10-year (median 5) clinical follow-up was available in 32 children. During follow-up, 2 children required surgery to repair a long tubular isthmic narrowing. The residual gradients, determined by arm-leg systolic blood pressure difference, were 5 +/- 8 mm Hg. No patient was symptomatic and only 1 patient (3%) was hypertensive, controlled with antihypertensive medications. We conclude that balloon angioplasty of aortic recoarctation following all types of surgical repair is feasible, safe, and effective with good long-term results. We recommend balloon angioplasty as the procedure of choice in the management of postsurgical recoarctation with hypertension and/or congestive heart failure.

Use of balloon-expandable stents for coarctation of the aorta: initial results and intermediate-term follow-up

OBJECTIVES

In this study we report our preliminary results and intermediate-term follow-up (up to 3.5 years) of stent implantation for coarctation of the aorta (COA).

BACKGROUND

Balloon angioplasty has gained acceptance as a modality of treatment for COA. Some patients do not respond optimally to balloon angioplasty alone. Balloon-expandable stents have been used in pulmonary arteries and large systemic arteries such as the femoroiliac vessels, with a significant improvement in vessel patency and a reduction in the pressure gradient compared with balloon angioplasty alone.

METHODS

Nine patients (>10 years old) with COA in whom balloon dilation alone was thought to be ineffective underwent stent implantation. Seven patients had a previous operation or balloon dilation, or both, to relieve their coarctation but had a significant residual/recurrent gradient.

RESULTS

At the time of stent implantation, the systolic and mean gradients decreased from a mean (+/-SEM) of 37 +/- 7 and 14 +/- 3 mm Hg to 4 +/- 1 and 2 +/- 0.6 mm Hg, respectively (p < or = 0.002). The coarctation diameter increased from a mean of 9 +/- 1 to 15 +/- 1 mm (p < 0.002). The patients have been followed for up to 42 months (mean 18, median 13) with no complications; the stents remain in position with no fracture. One patient underwent further successful dilation 3 years after stent implantation because of an exercise-induced gradient. No other intervention has been required. The systolic gradient at latest follow-up is 7 +/- 2 mm Hg. Only two (a 44-year old with diabetes and a 50-year old with long-standing hypertension) of five patients previously requiring antihypertensive treatment still remain on medications for blood pressure control.

CONCLUSIONS

The use of stents in COA is a feasible alternative to surgical repair or balloon angioplasty in selected patients with an effective gradient reduction. Intermediate-term follow-up shows excellent gradient relief, with no complications in this group of patients.

Balloon angioplasty of recurrent coarctation: a 12-year review

OBJECTIVES

This study was undertaken to investigate the long-term outcome of balloon angioplasty for recurrent coarctation of the aorta in a large series of patients.

BACKGROUND

Balloon angioplasty has become the standard treatment for residual or recurrent aortic coarctation. Despite the widespread use of this treatment modality, there are few data outlining the long-term outcome of a large patient cohort.

METHODS

Clinical, echocardiographic, hemodynamic and angiographic data on 90 consecutive patients who underwent balloon angioplasty between January 1984 and January 1996 were reviewed.

RESULTS

Mean systolic pressure gradients were reduced from 31 +/- 21 to 8 +/- 9 mm Hg after dilation (p = 0.0001). The mean diameter of the stenotic site, measured in the frontal and lateral views, increased by 38% and 35%, respectively (p = 0.001). Neurologic events occurred in two patients, with one death. An aortic tear occurred in one patient, requiring surgical intervention. Optimal results were defined as a postprocedure gradient < 20 mm Hg and were obtained acutely in 88% of patients. At long-term follow-up (12 years), 53 (72%) of 74 patients with an early optimal result remained free from reintervention. Transverse arch hypoplasia, defined as an arch dimension < 2 SD below the mean for age, was the primary predictor of the need for reintervention.

CONCLUSIONS

Although the majority of patients undergoing percutaneous balloon angioplasty for recoarctation of the aorta will achieve long-term benefit, the need for further surgical intervention in those with transverse arch hypoplasia remains high.

Dilation mechanism, causes of restenosis and stenting in balloon coarctation angioplasty

This review focuses on the individual dilation mechanism, the possible cause of restenosis after balloon angioplasty and the clinical application of a stent in coarctation of the aorta. Balloon angioplasty is still not the first choice of therapy in neonates with native coarctation because of the potential risk of aortic disruption, the high incidence of restenosis and the satisfactory results of surgical coarctectomy. Intravascular ultrasound imaging provides the individual mechanism of aortic dilation by balloon, and this will be a new modality for assessing the relationship between restenosis and aortic luminal morphology after balloon dilation. Although the cause of restenosis after balloon angioplasty remains uncertain, it may be due to a combination of elastic recoil by ductal tissue constriction, intimal hyperplasia and arterial remodelling. A stent could be an effective alternative to conventional balloon angioplasty in native coarctation of the aorta, preventing ductal tissue constriction. However, the problematic relationship between patient growth and relative stenosis of the stent should be clarified before clinical application of a stent for this disease.

Evaluation of superficial femoral artery compromise and limb growth retardation after transfemoral artery balloon dilatations

BACKGROUND

Abnormalities of arterial pulse and limb growth after retrograde femoral arterial catheterization have been well documented. However, the magnitude of such complications after transfemoral artery balloon dilatation has not been thoroughly investigated. This study sought to evaluate the prevalence of these abnormalities in children who have undergone transfemoral artery balloon dilatation.

METHODS AND RESULTS

Data on 43 consecutive patients (1 day to 15.5 years old at the time of balloon dilatation) seen on follow-up (42 +/- 23 months) (group 1) were compared with those of 35 patients undergoing retrograde femoral arterial catheterization (group 2) and 47 control patients. Interventional ankle/control ankle blood pressure index (AAI), ratio of interventional/control lower limb length (LLI), and leg length difference (LLD) were measured. Ages and weights at study were similar in all three groups, as were the ages and weights at intervention and duration of follow-up in groups 1 and 2. The AAI was lower (P = .023) in group 1 (0.95 +/- 0.13) than in groups 2 (1.0 +/- 0.1) and 3 (1.01 +/- 0.09). The prevalence of subjects with AAI < or = 0.9 was higher (P = .003) in group 1 than in the other two groups. The LLI and LLD were similar (P > .1) in all three groups. AAI and LLD in the balloon group are not significantly associated with age and weight at intervention, duration of follow-up, or size of the balloon or balloon catheter shaft.

CONCLUSIONS

Transfemoral artery balloon dilatation procedures produce superficial femoral artery compromise, but there was no significant limb growth retardation at a 3.5-year mean follow-up, which may be related to development of collateral circulation. Study of a larger number of children at a longer follow-up interval may be necessary to further confirm these observations.

Balloon angioplasty for postoperative recurrent coarctation of the aorta

Surgical repair for recurrent or residual postoperative coarctation of the aorta is associated with some morbidity, mortality, and an incidence of recurrent coarctation that may be as high as 20%. Balloon angioplasty for recurrent or residual postoperative coarctation has become the standard treatment of choice for this condition. In this article, we review the protocol we use, and the acute and long-term results of this procedure. Since 1983, over 400 patients have undergone balloon angioplasty for recurrent coarctation with excellent immediate relief of the gradient and improvement in the diameter. On long-term follow-up, the majority of these patients enjoyed a lasting beneficial effect of the balloon angioplasty. We discuss the future use of stents for selected patients who are not amenable or failed balloon angioplasty of recurrent or residual postoperative coarctation.

Balloon angioplasty for aortic recoarctation in children: initial and follow up results and midterm effect on blood pressure

OBJECTIVE

To assess the direct and follow up results of balloon angioplasty for aortic recoarctation with respect to the type of initial operation and to determine the midterm effect on systolic blood pressure.

DESIGN

Prospective study of invasive haemodynamic and angiographic data and non-invasive data on upper body blood pressure.

SETTING

Tertiary referral centre for paediatric cardiology.

SUBJECTS

24 infants and children (age 0.3-16.2 years, mean 5.9 years) who had had surgical correction for coarctation (end to end anastomosis (14 patients) subclavian flap angioplasty (nine), patch angioplasty (one)).

MAIN OUTCOME MEASURES

Peak systolic gradient over the recoarctation and aortic diameters before and directly after angioplasty and at follow up. Upper body blood pressure before and after angioplasty and at latest follow up.

RESULTS

Mean peak systolic gradient initially decreased from 35 (15) to 12 (9) mm Hg (p < 0.001) and was 9 (10) mm Hg at follow up after 1.4 (0.5) years. Patients with a subclavian flap repair showed a slight further decrease in the residual gradient at follow up (p < 0.05). The coarctation diameter increased from 5.3 (2.6) to 7.7 (2.5) mm (p < 0.001), and a further increase to 9.3 (2.9) mm (p < 0.01) was present at follow up after 1.4 (0.5) years without significant changes in other aortic diameters. Upper body systolic blood pressure decreased from 138 (24) to 115 (17) mm Hg after balloon angioplasty, and the effect on blood pressure persisted at a mean follow up of 3.7 years. One patient died of ventricular failure. Femoral artery thrombosis occurred in three patients. In one patient a small aneurysm occurred that had not increased at follow up. In one patient restenosis after angioplasty was redilated successfully. In one patient dilatation of a residual stenosis after angioplasty failed.

CONCLUSION

Balloon angioplasty for recoarctation is effective and is associated with accelerated growth of the dilated segment at follow up in many patients. The complication rate is acceptable. Midterm follow up shows persistent relief of upper body hypertension in most patients.

Balloon angioplasty of the aorta in Takayasu's arteritis: Initial and long-term results

Percutaneous transluminal balloon angioplasty for stenosis of the aorta was performed in 36 patients with Takayasu's arteritis (age range, 8 to 36 years; mean, 19.1 +/- 7.7 years). Balloon dilatation was successful in 34 patients and resulted in a decrease in the mean peak systolic pressure gradient (PSG) from 75.2 +/- 29.1 mm Hg to 24.8 +/- 19 mm Hg (p less than 0.001) and a mean increase in the diameter of the stenosed segments from 4.5 +/- 2.2 mm to 9.6 +/- 3.8 mm (p less than 0.001). Hemodynamic and angiographic restudy, which was performed in 20 patients at a mean follow-up period of 7.7 +/- 4.1 months (range, 3 to 24 months), showed a further decrease in PSG (greater than or equal to 15 mm Hg) in seven patients (from 40.0 +/- 11.2 mm Hg to 15.7 +/- 10.2 mm Hg; p less than 0.01), no significant change in PSG in 12 patients (17.1 +/- 13.6 mm Hg vs 16.6 +/- 12.7 mm Hg; p = NS), and an increase in PSG from 15 mm Hg to 85 mm Hg in one patient. The patient who showed restenosis underwent successful redilatation. Six patients who underwent late recatheterization and angiography at 36 to 60 months (mean, 43 +/- 9.4 months) show continued relief of stenosis (mean PSG, 8.8 +/- 7.8 mm Hg). Patients with short-segment (less than 4 cm) stenosis experience more relief than patients with long-segment (greater than or equal to 4 cm) stenosis (residual PSG, 18.6 +/- 8.2 mm Hg vs 40 +/- 16 mm Hg; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical impact of balloon angioplasty for branch pulmonary arterial stenosis

The clinical impact of percutaneous balloon angioplasty on the management of patients with native or postoperative pulmonary arterial stenosis was reviewed. Seventy-four patients underwent 110 angioplasty procedures. Mean age at dilation was 6.7 +/- 5.3 years (range 0.2 to 18.1), 17 patients were aged less than 1 year, mean follow-up was 37.7 +/- 22.8 months (range 16 to 96), and 34 patients (44%) had follow-up angiography. Pulmonary artery dilation was acutely successful in 53% of patients, 17% had recurrent stenosis, and 5% had complications. The impact on subsequent care was favorably influenced in 26 of 74 patients (35%) with either complete resolution of stenosis (n = 7), optimizing future surgical conditions (n = 14), reduction in right ventricular pressure by greater than 20% (n = 3), or improvement of ipsilateral lung perfusion (n = 2). No patient previously considered inoperable was subsequently considered suitable for surgical repair owing to the intervention. No correlation was found between success and cardiac diagnosis (p = 0.48), site of stenosis (p = 0.78), balloon-vessel ratio (p = 0.42), or whether the stenotic area consisted of native or synthetic material (p = 0.22). No predictive factors for success could be defined, and often there was only a transient clinical impact. Due to the low complication risk and potential for a beneficial result, it still appears prudent to offer angioplasty as an initial therapeutic modality in this setting.

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.

Percutaneous transluminal angioplasty in Takayasu arteritis

Percutaneous transluminal balloon angioplasty (PTBA) was performed in 87 patients for 111 stenotic lesions due to Takayasu arteritis. Of the lesions attempted for dilatation, 35 were in the aorta, 64 in renal arteries, 9 in subclavian, and 3 in common iliac arteries. The stenosis of aorta could be successfully dilated in 33 of 35 (94.3%) patients with fall in peak systolic pressure gradient (PSG) from 77.7 +/- 28.4 mmHg to 26.4 +/- 20.6 mmHg (P < 0.001) and increase in luminal diameter from 4.7 +/- 2.4 mm to 10.1 +/- 4.1 mm (P < 0.001). On hemodynamic and angiographic restudy in 20 patients at 3-24 months (mean 7.7 +/- 4.1 months) further fall in PSG (> or = 15 mmHg) was observed in 7 patients, no significant change in 12 patients and restenosis with increase in PSG in one patient which could be successfully redilated. Late restudy at 36-60 months (mean 43 +/- 9.4) in six patients showed continued relief of stenosis (mean PSG 8.8 +/- 7.8 mmHg). Of the 64 stenotic lesions of the renal arteries, 58 (90.6%) could be successfully dilated with decrease in stenosis from 89.1 +/- 10.1% to 29.9 +/- 14.9% (P < 0.001). Follow-up intra-arterial digital subtraction angiography in 25 patients at a mean follow-up period of 13.1 months (range 3-29 months) showed restenosis in 5/36 (13.9%) lesions which could be successfully redilated. Angioplasty was also successful in dilating 8/9 (88.9%) subclavian and all 3 common iliac artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon angioplasty for recurrent coarctation of aorta. Immediate and long-term results

BACKGROUND

As angioplasty techniques have been refined and larger low-profile balloons developed, a nonsurgical approach to recoarctation has become available. Several reports have documented both the efficacy and safety of this procedure. However, there are little data available on the long-term follow-up of these patients. This report details the initial results and long-term evaluation of both the relief of obstruction and the presence of hypertension after balloon angioplasty for recurrent coarctation.

METHODS AND RESULTS

Balloon angioplasty for recurrent coarctation of the aorta was performed 29 times in 26 patients at a median age of 4 years and 9 months (range, 4 months to 29 years), with eight patients less than 1 year old. Initial surgical techniques were end-to-end anastomosis in 11 patients, subclavian flap aortoplasty in 11 patients, and patch aortoplasty in four patients. Angioplasty was performed at a median interval of 2 years and 7 months (range, 4 months to 23 years) after surgery. Mean peak systolic pressure difference across the coarctation decreased from 40.0 +/- 16.8 to 10.3 +/- 9.5 mm Hg (p less than 0.05) after the initial angioplasty, and mean diameter of the aortic lumen at the coarctation site increased from 5.8 +/- 3.5 to 9.0 +/- 4.3 mm (p less than 0.05). There was no mortality, and only one patient developed an aneurysm (4%). Three patients underwent repeat angioplasty for a pressure difference of more than 20 mm Hg. Long-term follow-up is available on 24 of 26 patients with a mean follow-up of 42 +/- 24 months (range, 12-88 months). Mean peak systolic pressure difference across the area of coarctation decreased from 40.3 +/- 17.4 before angioplasty to 8.5 +/- 8.3 mm Hg after final angioplasty (p less than 0.05) and 7.5 +/- 7.5 mm Hg at follow-up. Mean peak systolic blood pressure in the upper extremities decreased from 133.1 +/- 14.9 before angioplasty to 111.1 +/- 14.1 mm Hg at long-term follow-up (p less than 0.05).

CONCLUSIONS

Balloon angioplasty should be considered the treatment of choice for relief of recurrent aortic coarctation.

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)