COARCTATION OF THE AORTA WITH PARTICULAR EMPHASIS UPON IMPROVED TECHNIQUES OF SURGICAL REPAIR

Coarctation of the aorta

Controversy still exists in the literature regarding definitive therapy for repair of coarctation of the aorta. Major factors involve not only the timing of repair, but also the method of repair, whether surgical or by percutaneous transluminal balloon dilatation. Results and complications of coarctation repair using various methods of classification present a diversity of results. This report will focus on these issues and attempt to dispel the statement that either one method or the other is the "choice method" of repair for any and all types of coarctation. Also presented is a proposed classification we believe will assist in clarifying the choice of therapy and perhaps improve not only the reporting of results, but also the results themselves. Methods of repair are discussed to provide the surgeon with a complete armamentarium of operations that the surgeon would tailor to the individual anatomicopathological patterns of the patient who presents at the time of surgery. Copyright 2000 by W.B. Saunders Company

Venous patch aortoplasty for correction of experimental coarctation

Experimental chronic aortic coarctation in eight beagle dogs was repaired with a free autogenous vein patch graft. Seven sham-operated dogs were controls. One year later the aortic resting blood pressure proximal to the aortoplasty was 122/77 (SD 10/8) mmHg in the aortoplasty group and 112/76 (SD 11/10) in the control group. The strength of the venous patch was tested with intravenous infusion of phenylephrine 0.01 mg/kg/min for 10 min (total dose 0.1 mg/kg). The aortic blood pressure after this infusion was 240/167 (38/26) and 271/179 (27/19) mmHg, respectively. The systolic gradient across the aortoplasty site was 3.9 (6.9) mmHg at rest and 7.7 (16.6) after the phenylephrine infusion. The aortic cross-sectional area at the aortoplasty site was 46.8 (2.7) mm2 in the aortoplasty group and 43.7 (3.7) in the control group. Focal intimal smooth muscle cell hyperplasia was found in the venous patch and in the aortic wall beside the sutures, and the medial layer of the patch was fibrotic. A venous patch may be an option for treatment of coarctation.

Surgical treatment of isolated coarctation of the aorta: 18 years' experience

From March 1967 to February 1985 91 patients aged from 11 months to 53 years underwent surgical treatment of isolated coarctation of the aorta. The surgical procedures in descending order of frequency, were: resection with end to end anastomosis, resection with replacement by a tube graft, patch aortoplasty, and bypass graft. Resection with end to end anastomosis was achieved mainly in younger patients. The number of patients needing other procedures increased with advancing age. Eighty six patients have been followed up (mean 10 years). There were no hospital or late deaths and none of the patients suffered from spinal cord injury. There were three recurrences of the coarctation, all in patients who had had primary reconstruction below the age of one year. The patients were divided into three groups by age: group 1, 0-5 years; group 2, 6-15 years; and group 3, over 15 years. It was found that there was no late hypertension in group 1 while hypertension persisted in 7% of group 2 and in 28% of group 3. Fifty per cent of the patients with persistent hypertension were above the age of 20 years at the time of operation and had resection with replacement by a tube graft. It is recommended that elective surgery for coarctation of the aorta should be performed at the age of 3-5 years to avoid both recurrence of stenosis and persistent hypertension.

Pseudocoarctation and mid-arch aortic coarctation

A 21-year-old woman was found to have a mid-arch aortic coarctation in combination with pseudocoarctation. The angiographic disgnosis was established by left atrial injection after transseptal puncture.

Current management of coarctation of the aorta

A series of 55 surgically treated cases of coarctation of the thoracic aorta is presented with an operative mortality of 5-4%. The problems encountered in infants are discussed and postoperative complications in adults and children detailed. The advantages of patch graft aortoplasty over resection and end-to-end anastomosis are described.

Coarctation of the aorta. Longitudinal assessment of operated patients

One hundred and ninety patients over the age of two operated upon for coarctation of the aorta from 1957 to 1972 at one institution were followed for one to 15.5 years (mean, 6.6 years). There were eleven cardiovascular deaths in the follow-up period. The mean age at death was 32.5 years. Two-thirds of the patients had an associated cardiovascular anomaly; 74 had coexistent aortic valve disease, and 19 had mitral stenosis or insufficiency. Five patients had a significant central nervous system event in the late postoperative period. Left ventricular hypertrophy by electrocardiogram was noted in 45, and 72 had radiographic left ventricular hypertrophy. A significant persistent or residual hemodynamic abnormality, either congenital heart disease, residual coarctation or persistent diastolic hypertension, could account for the residual electrocardiographic or radiographic abnormality. The data indicate that this population requires continuing care despite correction of the coarctation.

Coarctation of the aorta

In a series of 70 patients who had surgical correction of coarctation of the aorta between 1952 and 1969, the operative mortality was 7% and the complication rate was 14%. The mortality was particularly high in adult males over 30, with pre-operative evidence of left ventricular ischaemia. Simple surgical procedures had satisfactory results, but the use of prostheses carried a high risk, and turning down the left subclavian artery failed to lower the blood pressure. The blood pressure score fell by 68% after operation, and by a further 8% following discharge from hospital. This result was maintained up to 17 years after operation, and may be expected in all groups of patients.

LATE RESULTS OF THE OPERATION FOR COARCTATION IN THE GROWING CHILD

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