The course and prognosis of coarctation of the aorta

Analysis of the formation mechanism and occurrence possibility of Post-Stenotic Dilatation of the aorta by CFD approach

BACKGROUND AND OBJECTIVE

Post-Stenotic Dilatation (PSD), the common complication of coarctation of the aorta (COA), is a progressive disease involving aortic aneurysm and even rupture. However, there has been no definitive method that could investigate the mechanism of PSD formation, progression and rupture. The purpose of the present work is to analyze the mechanism behind PSD formation and to further assess the risk of COA patients with different coarctation degrees deteriorating into PSD.

METHOD

Three-dimensional non-Newtonian (Carreau-Yasuda) hemodynamic simulations are performed throughout the cardiac cycle, and a novel parameter (λ_ci¯ intensity) is proposed to evaluate the intensity of vortices within the aorta. The PSD geometry is reconstructed from Computed Tomography scans. To analyze the formation mechanism and occurrence possibility of PSD, the computer technology is utilized to restore the expansive and/or narrow regions to obtain its previous state (COA) and control group (Normal), and to modify the minimum diameter to obtain the aortas with different coarctation degrees. The clinical cases of pre- and post-operation are further introduced to verify the analysis.

RESULTS

Compared with the Normal, the vortical structures with higher swirling strength are generated and accumulated at the downstream of the coarctation segment after COA occurrence, and partially disappear in the wake of PSD formation. The sequence of λ_ci¯ intensity is COA > PSD > Normal and pre-operation > post-operation. With increasing the degree of coarctation, the λ_ci¯ intensity is higher and the jet-flow becomes more drastic.

CONCLUSIONS

The formation of PSD is caused by the vortical structures with higher swirling strength accumulating at the downstream of the coarctation segment. An increase in coarctation degree elevates the risk of PSD occurrence and even aneurysmal dilatation.

Perioperative and Anesthetic Management of Coarctation of the Aorta

Isolated coarctation of the aorta is a relatively common form of congenital heart disease that is characterized by variable degrees of obstruction to aortic outflow. The clinical presentation varies from asymptomatic arterial hypertension to cardiogenic shock. The treatment options include surgical repair or interventional therapy with aortic balloon dilation and stent placement. This article will summarize the pathophysiology as well as describe the surgical and interventional procedures. The anesthetic management for those interventions will be reviewed.

An overview of concepts and approaches used in estimating the burden of congenital disorders globally

Congenital disorders are an important cause of pregnancy loss, premature death and life-long disability. A range of interventions can greatly reduce their burden, but the absence of local epidemiological data on their prevalence and the impact of interventions impede policy and service development in many countries. In an attempt to overcome these deficiencies, we have developed a tool—The Modell Global Database of Congenital Disorders (MGDb) that combines general biological principles and available observational data with demographic data, to generate estimates of the birth prevalence and effects of interventions on mortality and disability due to congenital disorders. MGDb aims to support policy development by generating country, regional and global epidemiological estimates. Here we provide an overview of the concepts and methodological approach used to develop MGDb.

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.

Balloon angioplasty for native coarctation of the aorta in neonates and infants with congestive heart failure

BACKGROUND

Balloon angioplasty (BA) is an alternative to surgical repair for coarctation of the aorta (CoA) in children. However, its role in the treatment of native CoA in neonates and infants remains controversial. The purpose of this study was to report the midterm outcomes of BA for native CoA in neonates and infants with congestive heart failure (CHF).

METHODS

Between July 2000 and March 2007, 18 neonates and infants with native CoA and CHF who underwent BA were enrolled. Patients without recoarctation were designated as group A, while those with recoarctation or CHF were designated as group B. The clinical presentations, laboratory data, and outcomes were compared between groups.

RESULTS

There were 10 patients in group A and eight in group B. The mean age was 2.8 +/- 3.1 months (range, 0.7-11 months). Mean body weight was 4.0 +/- 1.9 kg (range, 2.1-8.0kg). CHF improved markedly in all patients immediately after BA, with a reduction in systolic pressure gradient from 36.4 +/- 12.0 to 5.6 +/- 6.0 mmHg (p < 0.001). The recoarctation rate was 44% (8/18). The risk factors for restenosis were post-BA systolic pressure gradient >10 mmHg (p = 0.007) and CoA diameter <3 mm (p = 0.013).

CONCLUSIONS

The outcomes of BA for native CoA in neonates and infants with CHF remain poor. The incidence of recoarctation is high in neonates and patients whose post-BA systolic pressure gradient is >10 mmHg or whose CoA diameter is <3 mm.

MR imaging of adult patients with congenital heart disease

Although the incidence of congenital heart disease remains constant among newborns, improved medical and surgical techniques have dramatically prolonged life expectancy and produced a new, growing group of patients harboring these lesions: adults with congenital heart disease. Conventional imaging techniques in these patients may be limited because of patient size, chest configuration, or poor ventricular function. MR imaging provides a noninvasive means of directly demonstrating their developmental abnormalities and the sequelae of pathophysiologic changes caused by these lesions. Combined use of spin echo and gradient reversal echo acquisition techniques allows complete evaluation of cardiac morphology and function in these patients. An new medical and surgical therapies prolong the lives of these patients, the role of MR imaging for physiologic assessment and surgical planning will expand further.

Stent implantation in an adult with coarctation of the aorta in the presence of advanced secondary heart failure

We report the case of a 56-year-old woman with congenital coarctation of the aorta, who presented in critical clinical condition with advanced secondary cardiomyopathy and heart failure. We successfully applied an unusual technique to pass the aortic obstruction, and then implanted a PALMAZ stent. The procedure resulted in prompt clinical improvement and completely resolved the coarctation. The patient's improved clinical condition was still evident 11 months after the procedure.

Aortic coarctation: a rare and unexpected cause of secondary arterial hypertension in the elderly

We present a 72-year-old man with long-standing moderate hypertension, due to an aortic coarctation, who presented with a myocardial infarction. In view of his advanced age the aortic coarctation was treated conservatively.

Stroke in a 24-year-old man

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Coarctation of the aorta life and health 20-44 years after surgical repair

OBJECTIVE

To examine the health and lifestyle of a group of patients who had repair of coarctation of the aorta 20-44 years ago (these were the first such operations in the United Kingdom) and to see how the results would influence current management strategies.

DESIGN

Attempts were made to contact all patients by questionnaire. They were then requested to attend for a clinical examination.

SETTING

Patients had their initial surgery at the Westminster Hospital (by Charles Drew) and the follow up examination at the same hospital.

PATIENTS

149 operations were performed. 70 of the 106 patients presumed to be alive were traced and 62 replied. 42 attended for examination. Only patients with the diagnosis of simple coarctation were included. Some patients had had coincidental ligation of a patent ductus arteriosus but none had any other cardiac abnormality requiring surgical or medical treatment. Those who died during the follow up period were described in paper by Bobby et al (Br Heart J 1991;65:271-6).

MAIN OUTCOME MEASURES

Current symptoms and life situations, evidence of cardiac disease, further cardiac surgery, current and retrospective blood pressures, and Doppler echocardiographic examination.

RESULTS

29 (69%) had cardiovascular disorder. Doppler echocardiography did not show previously unrecognised major recoarctation. 19 (46%) had hypertension at follow up and there was evidence of enlargement of the aortic root or arch in seven (16%) patients, who tended to have had surgery at a later age. No evidence of cerebrovascular accident was found.

CONCLUSIONS

In this group of patients with surgically repaired simple coarctation, late morbidity (particularly aortic aneurysm, aortic valve disease, and ischaemic heart disease) was common. The incidence of intracranial haemorrhage seemed to have been reduced by surgical repair. The integrity of the surgery remained good. Many patients did not have any regular cardiovascular review. Long-term anxiety related to early surgical experiences was evident. Even after apparently successful surgical repair of aortic coarctation. It would be prudent for all patients to have long-term review.

Changing trends of congenital heart disease in adults: a catheterization laboratory perspective

Advances in cardiac surgery now enable many children with congenital heart disease (CHD) to survive to adulthood. The influence of such advances on the frequency of various lesions among adult patients undergoing cardiac catheterization (CC) has not previously been addressed. This retrospective analysis of 329 adults with CHD undergoing CC at an adult and at a pediatric referral center demonstrates that when compared to 20 years ago, adults with CHD who now undergo CC are more likely to have complex cardiac disease, and more have had prior surgery. In addition, despite more aggressive surgical management, ventricular dysfunction and dysrhythmias are now commonly encountered residua of CHD in adults who require diagnostic CC. Premature coronary artery disease appears uncommon. These changing characteristics of adults with CHD require consideration in the planning of future health care for these patients.

Coarctation of the aorta

Coarctation of the aorta is a cause of hypertension that can present dramatically in the severely ill infant or appear incidentally in the asymptomatic young adult. Coarctation is easily detected and there is good evidence that the extremely poor natural history can be altered favorably by surgical correction. The elevated blood pressure can be lowered in the majority of patients, and there is every expectation that the incidence of known complications of coarctation can be decreased. However, in about three fourths of the patients, significant residual cardiovascular defects persist, with their potential for future problems as yet incompletely defined. For this reason, patients who have undergone surgery for coarctation will need to be followed carefully for an indefinite period.

Considerations in the surgical management of infantile coarctation of aorta

The results of a recent 5 year experience with resection of coarctation of the aorta in infants less than 1 year of age are compared with those of an earlier series from the same institution. The significant improvement in mortality and morbidity statistics is attributed to modifications in operative and postoperative care. Operative mortality has decreased from 38 to 17 percent and the incidence rate of significant restenosis has diminished from 60 to 33 percent. It is suggested that in patients with large associated intracardiac shunt banding of the main pulmonary artery should be performed before resection of the coarctation. Three of five patients have survived procedures performed in this sequence. Microsurgical techniques and careful approximation of the aortic lumen with interrupted sutures are the major factors responsible for the reduced incidence of recoarctation. Prolonged ventilatory support postoperatively with the occasional addition of controlled positive airway pressure and continued aggressive medical therapy for heart failure are recommended.

Congenital mitral valve disease associated with coarctation of the aorta: a spectrum that includes parachute deformity of the mitral valve

Fifty-three specimens in which the primary diagnosis in life was coarctation of the aorta were examined; only nine had a mitral valve of normal size and configuration. Ten specimens had a normally formed valve mechanism which was small in comparison to both tricuspid valve and left ventricle. Three other specimens had a normally formed but small valve which exhibited a short free margin of the anterior leaflet. The remaining 31 specimens demonstrated various anomalies which included some forms of parachute mitral valve. The spectrum of malformations may be divided into three basic types: some showed fused or closely apposed chordae tendineae, due to nondevelopment of the intervening space; in others the space between the papillary muscles and the ventricular wall was underdeveloped, which prevented the papillary muscles from moving independently of the ventricular wall. The third type was found in a case of parachute mitral valve, where the chordae tendineae were attached solely to the anterolateral papillary muscle, and the posteromedial papillary muscle was inserted directly into the valve, near the annulus. Although the spectrum of congenital anomalies reported here does not include all forms of mitral stenosis, it does indicate that mitral valve disease probably occurs more frequently in coarctation of the aorta than previously was recognized.

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.

Coarctation in the Elderly

The clinical presentation and operative results have been assessed of a series of patients with coarctation over the age of 40, and have been compared with a larger group of all ages.

Long-standing hypertension increased markedly the incidence of symptoms due to left ventricular strain and cerebral hypertension. There was little increase in symptoms due to poor peripheral blood flow and no case of subacute bacterial endarteritis.

The preoperative systolic blood pressures, when related to the normal for the age and sex of the patient, were higher and the diastolic pressures lower than an average group but signs of left ventricular strain were more common.

At operation the aortic narrowing was found to be of usual severity. Grafts were necessary because of poor anastomotic tissue rather than long narrow segments as in the larger group. The operative mortality was doubled in the elderly, due entirely to hemorrhage from friable aortas. Morbidity was increased as a result of pulmonary and pleural complications.

Postoperative blood pressures were almost exactly comparable with those of the over-all group when related to normal for age and sex. Symptoms were usually relieved but there was relatively slight radiologic or electrocardiographic change. The operative mortality and morbidity are acceptable in view of the risks of inaction and the satisfactory results of operation in the survivors.