Surgery for aortic coarctation: a 30 years experience

Long-term outcomes of surgical repair of isolated coarctation of the aorta in different age groups

BACKGROUND

Coarctation of the aorta (CoA) is one of the most common congenital heart defects (5-8% of all CHD). Treatment of native CoA may be accomplished surgically, or through an interventional approach. Surgical repair of CoA remains an important option for treatment of aortic coarctation during childhood, although it is mostly performed in neonates and young infants.

OBJECTIVES

In this retrospective study, we sought to share the long-term outcomes of different surgical techniques for repair of coarctation of the aorta in different age groups.

MATERIALS AND METHODS

This is a retrospective single-center clinical study that included 228 consecutive patients (age: 1 day- 41years) in whom surgical repair of isolated native coarctation of the aorta was performed with different surgical techniques.

RESULTS

Immediate results were excellent; however, the mortality rate were higher in the infants. Complications rate and incidence of recoarctation, both were comparable between different age groups and different surgical techniques.

CONCLUSIONS

Surgical repair of CoA remains an important option for treatment of aortic coarctation in different age groups with low morbidity and mortality. We did not find any significant difference between different surgical techniques regarding the development of recoarctation.

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.

Early and midterm outcomes of bare metal stenting in small children with recurrent aortic coarctation

AIMS

The aim of this study was to report our experience with the Cook Formula stent in the treatment of (recurrent) coarctation of the aorta in children below 12 kg.

METHODS AND RESULTS

In vitro study of the Cook Formula 418 (8 mm) and 535 (8 and 10 mm) stents demonstrated successful down-crimping on smaller balloons and predictable fracturing patterns. Between November 2012 and January 2019, one patient with native, one patient with post-interventional and thirteen patients with post-surgical coarctation of the aorta underwent implantation of a Cook Formula stent. Patient and procedural characteristics were obtained as well as procedural success, complications, and follow-up. Median age was 4.3 months and median weight 5.5 kg. Arterial sheath size ranged from 5 to 7 Fr. In-stent diameters of 3.7 to 8.8 mm were obtained with a median residual gradient of 0 mmHg. Major complications consisted of periprocedural haemodynamic instability (n=1), dissection of the iliac artery (n=1) and non-deployment with surgical removal (n=1). Re-dilations were performed after a median interval of 24.3 months. Median follow-up was 31.7 months.

CONCLUSIONS

The bare metal Cook Formula stent provides a durable and effective alternative to reoperation and balloon dilatation for native as well as post-surgical aortic coarctation in children below 12 kg.

Application of Modified Sliding Anastomosis in the Repair of Aortic Coarctation

Objectives

To evaluate the early and midterm results of a modified sliding anastomosis technique in patients with aortic coarctation.

Materials and Methods

In this study, we reported a new repair method and compared the early and midterm outcome(s) with a conventional surgical approach for the management of patients with aortic coarctation. Forty-eight aortic coarctation patients with a narrowed segment length longer than 2 cm were operated at our department's pediatric surgical division. Excision of the coarctation and end-to-end anastomosis was carried out in twenty-five patients (control group). In contrast, a modified sliding technique was used for twenty-three cases in the observation group. Other accompanying cardiac anomalies simultaneously repaired included ventricular septal defect and patent ductus arteriosus. All patients received 1.5-10 years of postoperative echocardiographic follow-up.

Results

This is a retrospective study carried out between January 2005 and June 2018. The study population consisted of forty-eight patients, which included twenty-six male and twenty-two female patients, with an average age of 5.2 ± 1.9 months (range, 28 days to 1 year). There was no mortality. The operative time, the number of intercostal artery disconnection, the drainage volume, and arm-leg systolic pressure gradient postoperation were less in the observation group as compared to the control group (p < 0.05). Also, cases with an anastomotic pressure gradient exceeding 10 mmHg during follow-up were less in the observation group as compared to the control group (p < 0.05). The postoperative complications encountered were chylothorax (control group 2 cases vs. observation group 0) and pulmonary atelectasis (control group 4 cases vs. observation group 1). They all, however, recovered after conservative treatment. Three patients in the control group underwent balloon angioplasty (reintervention) postoperative 2-4 years due to an increase in the anastomotic pressure gradient (>20 mmHg). After reintervention, the anastomotic pressure gradient reduced to 14 mmHg, 15 mmHg, and 17 mmHg, respectively.

Conclusions

For long segment aortic coarctation patients (longer than 2 cm), the use of the modified sliding anastomotic technique effectively helps to retain more autologous tissues, enlarge the diameter of the anastomosis, and decrease anastomotic tension and vascular injury. Therefore, this technique provides a new idea for the surgical treatment of aortic coarctations.

Follow-up after biventricular repair of the hypoplastic left heart complex

OBJECTIVES

In hypoplastic left heart complex patients, biventricular repair is preferred over staged-single ventricle palliation; however, there are too few studies to support either strategy. Therefore, we retrospectively characterized our patient cohort with hypoplastic left heart complex after biventricular repair to measure left-sided heart structures and assess our treatment strategy.

METHODS

Patients with hypoplastic left heart complex who had biventricular repair between 2004 and 2018 were retrospectively reviewed. Operative results were evaluated and echocardiographic mitral valve (MV) and aortic valve (AoV) dimensions, left ventricular length and left ventricular internal diastolic diameter (LVIDd) were measured preoperatively and during follow-up after 0.5, 1, 3, 5 and 10 years.

RESULTS

In 32 patients, the median age at surgery was 10 (interquartile range 5.0) days. The median follow-up was 6.19 (interquartile range 6.04) years. During the 10-year follow-up, the mean Z-scores increased from -2.82 to -1.49 and from -2.29 to 0.62 for MV and AoV, respectively. Analysis of variance results with post hoc paired t-tests showed that growth of left-sided heart structures was accelerated in the first year after repair, but was not equal, with the MV lagging behind the AoV (P = 0.033), resulting in significantly smaller MV Z-scores compared with AoV Z-scores at 10-year follow-up (P < 0.001). There were 2 (6%) early deaths. The major adverse events occurred in 4 (13%) patients. The surgical or catheter-based reintervention was required in 14 (44%) patients.

CONCLUSIONS

The growth rate of heart structures was most prominent during the first year after biventricular repair with lower growth rate of the MV compared with the AoV.

Mission-based cardiac surgery and catheter treatment of coarctation of aorta in the young and older children: a facility based review of cases in Addis Ababa

INTRODUCTION

Coarctation of the aorta is a congenital narrowing of the descending aorta. Hemodynamic derangement will be corrected with reopening of the narrowing either by surgery or catheter ballooning. There are few reports of post-operative cases in developing countries. The goal of this review is to describe the follow-up profile of cases in a setting with limited resource.

METHODS

Data from a retrospective facility-based chart review of cases within a single institution in Addis Ababa, were analyzed to quantify procedure, timing and post-operative blood pressure outcomes.

RESULTS

Thirty-two locally, and seven abroad operated cases, for a total of thirty-nine post-operative cases were analyzed. Balloon angioplasty with or without stent insertion, resection with end-to-end anastomosis and patch arthroplasty accounted for twenty, fourteen, and five cases respectively. Rebound hypertension occurred more frequently in the surgical group compared to the catheter group (P value < 0.01). The mean systolic blood pressures between pre and post-intervention differed significantly (P value = 0.001). Post-operative hypertension was observed in one-third of cases. Diagnosis and intervention time were late in majority of cases. A high rate of loss to follow-up was also observed.

CONCLUSION

Delayed diagnosis of cases coupled with a delay in intervention after diagnosis, is hypothesized to account at least in part for the findings. The challenges related to early diagnosis and intervention of case with congenital heart disease was discussed. Early diagnosis and referral of cases is recommended.

Long-Term Survival of Patients With Coarctation Repaired During Infancy (from the Pediatric Cardiac Care Consortium)

Patients who undergo coarctation repair during infancy have excellent early survival but long-term survival is unknown. We aimed to describe the long-term survival of patients with coarctation repaired during infancy and determine predictors of mortality. We performed a retrospective cohort study using data from the Pediatric Cardiac Care Consortium for patients with coarctation who underwent surgical repair before 12 months of age between 1982 and 2003. Long-term transplant-free survival was obtained by linkage with the National Death Index and the Organ Sharing Procurement Network. Kaplan Meier survival plots were constructed, and univariate and multivariable analyses were performed to determine predictors of mortality. We identified 2,424 coarctation patients who met inclusion criteria. At 20 years postoperatively, 94.5% of all patients and 95.8% of those discharged after initial operation remained alive, respectively. Significant multivariable predictors of mortality included surgical weight <2.5 kg (hazard ratio [HR] 3.70, 95% confidence interval [CI] 2.19 to 6.24), presence of a genetic syndrome (HR 2.40, 95% CI 1.13 to 5.10), and repair before 1990 (HR 1.91, 95% CI 1.09 to 3.34). None of the other factors examined including age at repair, gender, coarctation type, or surgical approach were found to be statistically significant. Over half of the deaths were due to the underlying congenital heart disease or other cardiovascular etiology. Overall long-term survival of patients who undergo coarctation repair during infancy is excellent. However, patients do experience small continued survival attrition throughout early adulthood. Ongoing monitoring of this cohort is necessary to assess late mortality risk.

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.

Repair of aortic coarctation in infancy: A 10-year clinical experience

Background

Coarctation of the aorta is a congenital narrowing of the upper descending aorta. The approximate incidence is 4% in live-born children with congenital heart disease. This study aimed to describe the surgical outcome and survival of patients undergoing congenital aortic coarctation repair via subclavian flap aortoplasty (group 1) or resection with end-to-end anastomosis (group 2).

Methods

We retrospectively reviewed the clinical outcomes of 105 infants who underwent repair of aortic coarctation between 2000 and December 2012. Fifty patients (group 1) underwent subclavian flap aortoplasty and 55 (group 2) underwent resection with end-to-end anastomosis. Procedure details and early results were collected by retrospective review of hospital and clinic data.

Results

The mean age of patients in group 1 was 6.73 ± 1.1 vs. 6.76 ± 1.2 months in group 2, and the mean weight was 6.01 ± 1.3 vs. 5.9 ± 1.0 kg, respectively. There were no significant differences among the intra- and postoperative variables in the 2 groups. Six patients in group 1 had a peak systolic gradient >20 mm Hg. The recurrence rate in group 1 was 12% vs. 1.8% in group 2 ( p < 0.05). Overall mortality was 2.8%. Survival in group 1 was 96% vs. 98.2% in group 2.

Conclusion

Repair of aortic coarctation in infancy by resection with end-to-end anastomosis can be performed with a low mortality rate and a low incidence of recoarctation, and it provides the optimal prognosis for coarctation in infancy.

One stage surgical treatment of aortic valve disease and aortic coarctation with aortic bypass grafting through the diaphragm and aortic valve replacement

OBJECTIVES

To validate ascending aorta-lower abdominal aorta bypass grafting treatment for patients with descending aortic coarctation and an aortic valve disease.

METHODS

The three patients in whom a descending atypical aortic coarctation was associated with an aortic valve disease were treated with one stage surgical treatment with aortic bypass grafting through the diaphragm and aortic valve replacement in our heart center. Operative technique consisted of performing ascending aorta-lower abdominal aorta bypass grafting through diaphragm muscle and implementing aortic valve replacement. The mean time for extracorporeal circulation and occluding clamp of aorta was recorded. Blood pressure data for pre- and post-operation was measured in the limbs. Computer-enhanced transvenous angiograms of pre- and post-operation were applied for detection of aortic stenosis. The other adverse events were noticed in outpatient service during a follow-up period.

RESULTS

The mean extracorporeal circulation time was 54 ± 11 min. The mean time for occluding clamp of aorta was 34 ± 6 min. An arterial pressure gradient was totally corrected after surgical treatment. Post-operation computer-enhanced transvenous angiograms showed the grafts to be open with a fluent flow. The patients had no gastrointestinal tract complications. No adverse event was noticed during a follow-up period in outpatient service.

CONCLUSIONS

Treatment of ascending aorta-lower abdominal aorta bypass is advisable for patients with descending aortic coarctation and an aortic valve disease.

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.

Acquired post-traumatic aortic coarctation presenting as new-onset congestive heart failure: treatment with endovascular repair

Acquired coarctation of the thoracic aorta is a rare phenomenon in adults. The etiology is often idiopathic, but severe stenosis can develop from prior surgery, blunt thoracic aortic injuries, or severe atherosclerotic/atheroembolic disease. Common symptomatic presentations include refractory upper extremity hypertension and new-onset congestive heart failure. We present the case of a 52-year-old man who developed acquired thoracic aortic coarctation 30 years after a blunt trauma and deceleration injuries to the aorta requiring open surgical aortic repair. He presented with poorly controlled hypertension and new-onset heart failure and was treated surgically with endovascular repair.

Prevalence and prognostic implication of restenosis or dilatation at the aortic coarctation repair site assessed by cardiovascular MRI in adult patients late after coarctation repair

BACKGROUND

Cardiovascular magnetic resonance (CMR) is ideal for assessing patients with repaired aortic coarctation (CoA). Little is known on the relation between long-term complications of CoA repair as assessed by CMR and clinical outcome. We examined the prevalence of restenosis and dilatation at the repair site and the long-term outcome in patients with repaired CoA.

METHODS AND RESULTS

CMR imaging and clinical data for adult CoA patients (247 patients aged 33.0 ± 12.8 years, 60% male), were analyzed. The diameter of the aorta at the repair site was measured on CMR and its ratio to the aortic diameter at the diaphragm (repair site-diaphragm ratio, RDR) was calculated. Restenosis (RDR≤70%) was present in 31% of patients (and significant in 9% [RDR<50%]), and dilatation (RDR>150%) in 13.0%. A discrete aneurysm at the repair site was observed in 9%. Restenosis was more likely after resection and end-end anastomosis, whereas dilatation after patch repair. Systemic hypertension was present in 69% of patients. Of the hypertensive patients, blood pressure (133 ± 20/73 ± 10 mm Hg) was well controlled in 93% with antihypertensive therapy. Mortality rate over a median length of 5.9 years was low (0.69% per year, 95% CI: 0.33-1.26), but significantly higher than age-matched healthy controls (standardised mortality ratio 2.86, CI 1.43-5.72, p<0.001).

CONCLUSION

Restenosis or dilatation at the CoA repair site as assessed by CMR is not uncommon. Medium term survival remains good, however, albeit lower than in the general population. Life-long follow-up and optimal blood pressure control are likely to secure a good longer term outlook in these patients.

Continuous cerebral and myocardial perfusion during one-stage repair for aortic coarctation with ventricular septal defect

Controversy still exists concerning the use of deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (SACP) for repair of aortic coarctation (CoA) with ventricular septal defect (VSD). This report therefore describes outcomes of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia compared with DHCA and SACP. Retrospective analysis was performed for 110 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Patients repaired under CCMP with mild hypothermia (32 °C) (group A, n = 60) were compared with those repaired under DHCA (18 °C) and SACP (group B, n = 50). In group A, the single arterial cannula perfusion technique was used for 15 patients (25 %), and the dual arterial cannula perfusion technique was used for 45 patients (75 %). The preoperative data were similar in the two groups. Group A had no hospital mortalities, compared with two mortalities (4 %) in group B. Group A had shorter myocardial ischemic and cardiopulmonary times, fewer delayed sternal closures, a shorter time to extubation, lower postoperative lactate levels, and fewer patients with low cardiac output requiring extracorporeal membrane oxygenation or with multiorgan failure than group B. During the postoperative course, no clinical or electrical neurologic events occurred in either group. The mean follow-up period was 5.2 ± 3.2 years for group A and 7.5 ± 3.1 years for group B (P = 0.048). One late death occurred in group B and no late deaths in group A. The actuarial survival for the two groups was similar (100 % for group A vs 96 % for group B; P = 0.264). The freedom from all types of cardiac reintervention was 96.7 % in group A and 89.6 % in group B (P = 0.688). All the patients were free of neurologic symptoms. The authors' perfusion strategy using CCMP with mild hypothermia for repair of CoA with VSD is feasible, safe, and associated with improved postoperative recovery and should be the method of choice.

Outcome of continuous cerebral and myocardial perfusion under mild hypothermia for aortic coarctation with ventricular septal defect repair

BACKGROUND

Controversy still exists on the use of the optimal cardiopulmonary bypass (CPB) management in aortic coarctation (CoA) with ventricular septal defect (VSD) repair. We report the outcome of patients undergoing continuous cerebral and myocardial perfusion (CCMP) under mild hypothermia.

METHOD

This is a retrospective analysis of 60 consecutive patients undergoing anatomic reconstruction of CoA with VSD closure between 1999 and 2011. Single arterial cannula perfusion technique was used in 15 (25%) patients, and a dual arterial cannula perfusion technique was used in 45 (75%) patients.

RESULTS

There were no hospital or late mortalities. Average CPB time was 105 ± 28 minutes, aortic clamp 27 ± 7 minutes, and descending aortic cross-clamp time 24 ± 5 minutes. Average continuous cerebral perfusion flow was 64 ± 8 mL/kg per minute. No patient needed delayed sternal closure. Average duration of ventilation was 38 ± 20 hours, ICU stay 7 ± 3 days, and hospital stay 14 ± 6 days. No patient required revision for bleeding and/or extracorporeal membrane oxygenation support. No neurologic complications were noted.

CONCLUSION

A perfusion strategy using CCMP with mild hypothermia for CoA and VSD repair is feasible and safe.

Retraction: Selective cerebro-myocardial perfusion under mild hypothermia during primary repair for aortic coarctation with ventricular septal defect

The following article from Artificial Organs, "Selective Cerebro-Myocardial Perfusion Under Mild Hypothermia During Primary Repair for Aortic Coarctation With Ventricular Septal Defect" by Huiwen Chen, Haifa Hong, Zhongqun Zhu and Jinfen Liu, published online on 2 November 2012 in Wiley Online Library (wileyonlinelibrary.com), has been retracted by agreement between the authors, the journal Editor-in-Chief, Paul S. Malchesky, the International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc. The retraction has been agreed due to simultaneous publication of a substantially similar article, "Continuous Cerebral and Myocardial Perfusion During One-Stage Repair for Aortic Coarctation With Ventricular Septal Defect", by Huiwen Chen, Haifa Hong, Zhongqun Zhu and Jinfen Liu, in Pediatric Cardiology 7 November 2012 [Epub ahead of print].

Stent placement versus surgery for coarctation of the thoracic aorta

BACKGROUND

Coarctation of the aorta (CoA) accounts for 5% to 7% of congenital heart disease, with an incidence of 0.3 to 0.4 per 1000 live births. Surgery was the only choice of therapy for CoA until 1982 when balloon angioplasty became an available alternative for its treatment. Re-coarctation, aneurysm and aortic dissection remain the disadvantages of both treatments. To avoid those disadvantages, in 1990 endovascular stents were introduced for native coarctation and re-coarctation and since then they have become an alternative approach to surgical repair. The best approach to treat the CoA, whether open surgery or by stent placement, is not clear.

OBJECTIVES

To analyze the effectiveness and safety of stent placement compared with open surgery in patients with coarctation of the thoracic aorta.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched September 2011) and CENTRAL (2011, Issue 3). We also searched MEDLINE, EMBASE, CINAHL, AMED, Web of Science and LILACS (last searched in September 2011). We evaluated the located references and applied the inclusion criteria to selected studies. There was no restriction on language.

SELECTION CRITERIA

Randomized or quasi-randomized controlled clinical trials that compared patients with CoA undergoing open surgery or stent placement.

DATA COLLECTION AND ANALYSIS

The review authors independently assessed the studies identified for eligibility for inclusion. We excluded studies after a consensus meeting.

MAIN RESULTS

All identified studies were screened and had the selection criteria applied to the title and abstract. In total, we selected five studies for full-text analysis. After detailed evaluation, we excluded all studies because there was no comparison between stent placement and open surgery.

AUTHORS' CONCLUSIONS

There is insufficient evidence with regards to the best treatment for coarctation of the thoracic aorta. This review suggests a need to perform a randomized controlled clinical trial with emphasis on the allocation method, evaluation of primary outcomes, size and quality of the sample, and long-term follow-up.

Recurrence rate of different techniques for repair of coarctation of aorta: A 10 years experience

Background and Aim:

The main goal of this study was to assess the frequency of recurrent coarctation after repair using different surgical methods.

Methods:

Surgical results of repairs for coarctation of aorta (Co-A) in 188 patients under the age 14 years who were treated in Rajaee Heart Center, Tehran, Iran, were evaluated retrospectively. The most common methods included patch-graft aortoplasty (59%), resection with end-to-end anastomosis (20.7%) and subclavian flap aortoplasty (SCFA) (16.5%). The remaining patients underwent bypass tube graft and excision with placement of a tube graft. Seventy eight percent had discrete stenosis while 22% had long segment narrowing. The patients were followed for 81.6±32.8 months.

Results:

The overall mortality rate was 2.6%. The highest incidence rate of recoarctation was found in the patch-graft aortoplasty group (12.7%) and the lowest was found in SCFA (3.2%). The incidence of recoarctation in long-segment lesions was significantly higher than that in the discrete ones (30% vs. 4%, P<0.001). In patients <1 year, the incidence of recoarctation was lower than that in the other age groups.

Conclusion:

The patch-graft aortoplasty technique had the highest incidence of recoarctation and SCFA had the lowest rate. Long-segment Co-A had a higher chance of recoarctation. In contrast to some previous reports, the incidence of recoarctation was not higher in the age below 1 year.

Emergency surgical intervention after unsuccessful percutaneous transluminal angioplasty and stenting of aortic coarctation

Coarctation of thoracic aorta is an uncommon diagnosis in adults. Catheter-based intervention consisting of primary ballooning and stenting is becoming one of the methods of choice for the treatment of native coarctation. We describe the case of a young adult with coarctation of the aorta treated unsuccessfully with percutaneous transluminal angioplasty and stent implantation that resulted in stent migration into the aortic arch and led to an urgent operative intervention. In one step, we performed the evacuation of the foreign body from the aortic arch as well as the treatment of the aortic coarctation through an extra-anatomical vascular graft interposition between the ascending and descending thoracic aorta. In this article, we discuss the need for emergency surgical intervention in this case.

Repair of aortic coarctation in an adult by direct aortoplasty

Various techniques have been proposed for surgical correction of aortic coarctation in adults. We describe direct aortoplasty repair in a 28-year-old woman with native coarctation. Four-year follow-up with magnetic resonance angiography confirmed a good result. This is a safe and effective technique that provides enlargement of the aortic lumen by avoiding extensive anastomotic suture lines or interposition of prosthetic graft material.

Coarctation of the Aorta: A Secondary Cause of Hypertension

Coarctation of the aorta is a constriction of the aorta located near the ligamentum arteriosum and the origins of the left subclavian artery. This condition may be associated with other congenital disease. The mean age of death for persons with this condition is 34 years if untreated, and is usually due to heart failure, aortic dissection or rupture, endocarditis, endarteritis, cerebral hemorrhage, ischemic heart disease, or concomitant aortic valve disease in uncomplicated cases. Symptoms may not be present in adults. Diminished and delayed pulses in the right femoral artery compared with the right radial or brachial artery are an important clue to the presence of a coarctation of the aorta, as are the presence of a systolic murmur over the anterior chest,bruits over the back, and visible notching of the posterior ribs on a chest x-ray. In many cases a diagnosis can be made with these findings. Two-dimensional echocardiography with Doppler interrogation is used to confirm the diagnosis. Surgical repair and percutaneous intervention are used to repair the coarctation; however, hypertension may not abate. Because late complications including recoarctation, hypertension, aortic aneurysm formation and rupture, sudden death, ischemic heart disease, heart failure, and cerebrovascular accidents may occur, careful follow-up is required.

Aortic coarctation: an overview

In severe aortic coarctation in the neonatal period, surgical repair is required soon after clinical stabilization. Elective repair of isolated aortic coarctation is nowadays indicated at 3-6 months of life or at the time of diagnosis. At present, no single operation appears to have a clear superiority. However, during the first months of life, an extended end-to-end anastomosis is considered the best option by most authors, even though weight at operation and anatomy of the aortic arch are also significant determinants of late recoarctation. In cases of aortic arch hypoplasia, which occurs in up to 70% of neonatal and infant coarctations, especially when associated anomalies are present, surgery seems the treatment of choice. After 3 months of age and in the adult population, balloon angioplasty and stent placement are considered a suitable option. Recently, we adopted a median sternotomy approach without the use of extracorporeal circulation for the treatment of aortic coarctation with a hypoplastic aortic arch. We treated 11 patients with satisfactory results at an average follow-up of 40 months.

Repair of coarctation of the aorta in infants weighing less than 2 kilograms

BACKGROUND

We retrospectively reviewed our experience in aortic coarctation repair on infants weighing less than 2 kg to evaluate the results and assess the rate of recoarctation in this group of patients.

METHODS

Twenty-four consecutive babies weighing 2 kg or less were operated on over a period of 15 years. Median gestational age was 33 weeks (range, 30 to 36), and median weight was 1.6 kg (range, 1.0 to 2.0). Seventeen of them had associated cardiac anomalies. The methods of repair undertaken were resection with extended end-to-end anastomosis (n = 13), subclavian flap angioplasty (n = 9), carotid flap angioplasty (n = 1), and patch repair using pulmonary homograft tissue (n = 1).

RESULTS

Mean follow-up was 52.5 months (range, 0.5 to 151). There were 3 in-hospital deaths and 2 late deaths. Recoarctation developed in 7 babies. Four underwent balloon dilatation; 1 of them required further surgery; 3 others have mild recoarctation, but have not required further intervention. Risk factor analyses revealed that the presence of preoperative congestive cardiac failure, and coexisting noncardiac lesions as well as the duration of descending aortic cross-clamp and postoperative ventilation had a significant influence on mortality after repair.

CONCLUSIONS

Coarctation repair in infants less than 2 kg can be performed safely. The incidence of recoarctation is acceptable and comparable with that of other pediatric cohorts that have been reported. Preoperative cardiac function and associated noncardiac lesions may influence the incidence of mortality after repair. Delaying the timing of surgical repair to achieve growth is not necessary.

Subclavian flap repair: review of 399 patients at median follow-up of fourteen years

BACKGROUND

Conflicting results have been obtained for the same operation for repair of coarctation of the aorta by different institutes. The purpose of this study was to assess the results of subclavian flap aortoplasty (SFA) alone, performed on 399 patients in a single institute between 1966 and 1995.

METHODS

Data were collected retrospectively from the congenital cardiac surgical database at the institute.

RESULTS

The median age at operation was 22 days (3 days-49 months). One hundred thirty-four patients had isolated coarctation while 265 children had complex coarctation. Maximum follow-up was 24 years (median, 14 years). Overall mortality over the whole duration of follow-up was 24.8%. Mortality for isolated coarctation at first intervention was 7.4% (operative mortality, 2.6%) while it was 12.8% for complex coarctation. At second intervention the mortality for isolated coarctation was 5%. For the second, third, and fourth interventions the mortality for complex coarctation was 25%, 25%, and 27%, respectively. The survival for isolated coarctation at 1, 5, 10, and 20 years was 94%, 93.2%, 92.4%, and 88.4%, respectively, while it was 74.6%, 66.3%, 63%, and 61.4%, respectively, for complex coarctation. Of the total patients, 15.3% had interventions for recoarctation. The incidence of recoarctation was 13.6% on those patients operated on in the first month of life, while it was 3.6% in older children. A percentage of 3.3% of patients continue to be hypertensive and require medication. There was a significant difference between the systolic blood pressure and anthropometric measurements between the arms. Despite this none of the patients complained of effect on lifestyle.

CONCLUSIONS

Despite improved early results the long-term mortality for coarctation remains high. Mortality is higher for complex coarctation as compared with isolated procedures. The incidence of recoarctation after SFA at long term is acceptable and is higher in patients operated on in the first month of life. The overall incidence of hypertension is quite low. Patients remained normotensive when operated upon at the age of 0.9 months. The SFA, no doubt, effects the limb development; however it does not cause limitation in the lifestyle.

Repair of aortic coarctation using temporary ascending to descending aortic bypass in children with poor collateral circulation

Aortic coarctation can now be repaired surgically with excellent results. Even though rare, injury to the spinal cord resulting in paraplegia remains a major concern. Preoperative evaluation showing the absence of collateral circulation is valuable in order to introduce protective actions. This report describes our experience using a temporary bypass from the ascending to the descending aorta bypass in children undergoing surgical correction of aortic coarctation in the setting of poorly developed collateral circulation. Between 1990 and 2002, we undertook direct surgical repair in 56 patients with isolated aortic coarctation, 20 as neonates, 11 as infants, and 25 during childhood. From 1998 onwards, we introduced preoperative evaluation of the collateral circulation with magnetic resonance imaging. From that time, we placed a temporary bypass from the ascending to the descending aorta, using a polytetrafluoroethylene tube of 4 to 8 mm diameter, whenever distal pressures were shown to be 25 mmHg or less after test clamping, or when magnetic resonance imaging revealed absence of collateral circulation. We found excellent correlations between the direct intra-operative measurements of distal pressure and the findings at magnetic resonance imaging. Following introduction of the temporary bypass, we observed no neurological complications, nor were there any complications related to bypass. Freedom from restenosis was 96%. Preoperative magnetic resonance imaging, therefore, can accurately visualize poor collateral circulation in children with aortic coarctation. The use of a temporary bypass can possibly eliminate the risk of neurological sequels following direct repair of coarctation in children with poorly developed collateral circulation. The temporary bypass is both easy to apply and safe.