An unusual presentation of coarctation of the aorta in infancy: role of balloon angioplasty in the critically ill infant

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.

Progressive changes in residual gradient after aortic coarctation repair and its role in the prediction of reintervention: A longitudinal data analysis

Background

Repair of aortic coarctation through left thoracotomy is the standard treatment when anatomically feasible. Long-term outcomes are well studied, including the need for reintervention. However, the timely variation in residual gradients across the repaired segment is ill-defined. The aim of this work was to study the progressive changes of estimated peak gradient (ePG) acquired by transthoracic continuous-wave Doppler echocardiography across the aortic arch after repair and to assess the role of timing of assessment and values of ePG in prediction of reintervention.

Materials and Methods

All eligible patients for this study who underwent aortic coarctation repair through left thoracotomy from 2001 to 2017 were reviewed. Details of the aortic arch dimensions and associated lesions were obtained by transthoracic echocardiography (TTE). The primary outcome was the ePG across the aortic arch after repair. Longitudinal data analyses with mixed effect modeling were used to determine independent predictors for ePGs.

Results

A total of 312 patients were included. Median age and weight were 30 days and 4 kg, respectively. Associated lesions included ventricular septal defect (VSD) (53%), bicuspid aortic valve (53%) and mitral stenosis (25%). Over 15-years follow-up the freedom from reintervention was 92.3%, while 24 out of the 312 patients underwent reintervention (7.7%). Longitudinal data analyses of serial 2566 TTE studies were done. The graphical display showed that the ePG across coarctation area in the first postoperative TTE was the most notable difference between those who underwent reintervention and those who did not. Further testing with proportional hazard and logistic regression modeling confirmed this finding. The area under receiver operating curve statistics showed that an ePG of 25 mmHg is an optimal cutoff value for the prediction of the reintervention.

Conclusions

The ePG acquired in the first postoperative TTE is the most important predictor for reinterventions. The presence of VSD is associated with decreased ePGs. We propose that an ePG in the first postoperative TTE of 25 mmHg or more is a strong predictor for the need of reintervention.

Troponin T Mutation as a Cause of Left Ventricular Systolic Dysfunction in a Young Patient with Previous Surgical Correction of Aortic Coarctation

Coarctation of the aorta is a leading cause of morbidity and mortality among adults with congenital heart disease (ACHD). Lifelong surveillance is mandatory to screen for possible long-term cardiovascular events. Left ventricular systolic dysfunction has been reported in association with recoarctation, and association with dilated cardiomyopathy (DCMP) is very rare. Herein, we report the case of a 19-year-old boy with coarctation of the aorta who complained of mild exertional dyspnea. Cardiac magnetic resonance revealed a moderately dilated, hypokinetic left ventricle (LV), with mildly reduced EF (45%), and residual isthmic coarctation was excluded. Genetic tests revealed a heterozygous missense variant in TNNT2 (NM_001001430.2): c.518G>A (p. Arg173Gln). This case highlights the role of careful history taking: a family history of cardiomyopathy should not be overlooked even when the clinical setting seems to suggest a predisposition to hemodynamic factors for LVSD.

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.

Genetic testing for coarctation of aorta

Coarctation of the aorta (CoA) is an inherited narrowing of the proximal descending thoracic aorta. Histological features include localized medial thickening and infolding with superimposed neointimal tissue. CoA is diagnosed by detection of a murmur or hypertension during routine examination. Typical clinical features are delayed or absent femoral pulses and difference in blood pressure between the arm and legs. These symptoms may appear in the first weeks of life or after the neonatal period. CoA accounts for 4-6% of all congenital heart defects and has a reported prevalence of about 4 per 10,000 live births. It is more common in males than females (59% vs 41%). This Utility Gene Test was developed on the basis of an analysis of the literature and existing diagnostic protocols. It is useful for confirming diagnosis, as well as for differential diagnosis, couple risk assessment and access to clinical trials.

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.

Stent angioplasty: an effective alternative in selected infants with critical native aortic coarctation

Management of native aortic coarctation during early months of life poses therapeutic challenges, and there is no consensus among medical professionals regarding a management plan. Much can be argued about the benefits, limitations, and/or complications of transcatheter versus surgical intervention in such cases. Occasionally, the complexity of the lesions limits management options. Therefore, each patient requires individual management decisions because there is no one therapeutic plan that satisfies all patients. In this report, four critically ill infants who had complex native coarctation are presented. Surgical repair was not possible because of relative contraindications. The patients underwent transcatheter stent implantation (six procedures and seven stents) as a nondefinitive procedure with acceptable results. Three patients improved. One patient did not survive, mainly due to other major complications. Multiple reexpansions of the stents were carried out when indicated. After a mean follow-up of 45 months (range, 41-49), the three survivors were doing fine and had gained an average weight of 9.7 kg (range, 6.6-13.3). At the time of reporting, the relative contraindications no longer exist and the final surgical repair can be carried out. Our experience suggests that in certain situations and in critically ill infants with complex form of coarctation, stent angioplasty can be used as a life-saving palliative procedure. Further reexpansions can be done when required. This may serve as a bridge to major surgical repair in the future.

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.