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Kasar T, Erkut O, Tanidir İC, Şahin M, Topkarci MA, Guzeltas A. Balloon-expandable stents for native coarctation of the aorta in children and adolescents. Medicine (Baltimore) 2022; 101:e32332. [PMID: 36595787 PMCID: PMC9794334 DOI: 10.1097/md.0000000000032332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Although balloon-expandable stent implantation for native aortic coarctation is a preferred method in the adolescent age group, there are insufficient data about indications for and the efficacy of the procedure in a younger age group. The aim of this study was to compare and evaluate the data of young pediatric and adolescent patients who underwent balloon-expandable stent implantation because of native aortic coarctation. The retrospective analysis included the demographic characteristics and data related to the procedure and follow-up of patients who underwent stent implantation for native aortic coarctation between August 2010 and November 2017. Patients with re-coarctation were excluded from the study. The patients were separated into 2 groups as the adolescent group (Group I: 10-18 years) and the pediatric group (Group II: ≤ 9.9 years). Group-I comprised of 18 patients and Group-II, 32 patients. Covered stent was implanted to 32 (73%) patients and uncovered stent to 12 (27%) patients. The procedural success rate was 100%. Following stent implantation, peak systolic gradient decreased significantly in both groups (P < .0001) (Group-I: from 35.9 ± 16.6 mm Hg-2.2 ± 3.4 mm Hg, Group II: from 34 ± 13.3 mm Hg-3 ± 4.09 mm Hg). Complications developed in 3 patients, and all in Group I. Femoral hematoma developed in 1 patient, balloon rupture occurred during the procedure in 1 patient, and there was temporary loss of pulse in 1 patient. All the complications were treated successfully. All the patients were taking anti-hypertensive drugs before intervention and during the mean 23-month follow-up period (range, 2-84 months), hypertension recovered in 35 (80%) patients and drugs were terminated. Stent implantation for aortic coarctation in the pediatric age group may provide pleasing results, reducing the coarctation gradient, providing effective dilatation in the lesion area and eliminating hypertension.
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Affiliation(s)
- Taner Kasar
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
- * Correspondence: Taner kasar, Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istasyon Mah.Turgut Ozal Bulvari No:11 Kucukcekmece, Istanbul 34303, Turkey (e-mail: )
| | - Ozturk Erkut
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - İ. Cansaran Tanidir
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Murat Şahin
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - M. Akin Topkarci
- Department of Anesthesia, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
| | - Alper Guzeltas
- Department of Pediatric Cardiology, Istanbul Saglik Bilimleri University Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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Arya B, Maskatia SA. Coarctation of the aorta: Prenatal assessment, postnatal management and neonatal outcomes. Semin Perinatol 2022; 46:151584. [PMID: 35422354 DOI: 10.1016/j.semperi.2022.151584] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Coarctation of the aorta (Coa) is a potentially life threatening diagnosis. It occurs in 0.3 per 1000 live births and accounts for 6-8% of all infants with congenital heart defects. Neonates with severe Coa may be completely asymptomatic at birth, as the ductus arteriosus can provide flow to the lower body. Those who are not diagnosed prenatally may be diagnosed only after constriction of the ductus arteriosus, when they present in cardiogenic shock. This group has a higher risk for mortality and morbidity relative to those diagnosed prenatally. Despite the increasing practice of universal pulse oximetry screening, many cases with significant coarctation of the aorta still go undiagnosed in the newborn period. In this article, we present the pathophysiology, diagnosis, presentation, treatment and outcomes of Coa.
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Affiliation(s)
- Bhawna Arya
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA, United States.
| | - Shiraz A Maskatia
- Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, United States
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Sherif NEE, Taggart NW. Covered Stents in the Management of Aortic Coarctation and Right Ventricular Outflow Tract Obstruction. Curr Cardiol Rep 2022; 24:51-58. [PMID: 35028814 DOI: 10.1007/s11886-021-01623-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW To review the use of covered stents in the treatment of coarctation of the aorta (CoA) and right ventricle to pulmonary artery (RV-PA) conduit obstruction. RECENT FINDINGS The only commercially available covered stent approved for treatment of CoA and dysfunctional RV-PA conduits is the covered Cheatham-Platinum stent (CCPS). Early outcomes have demonstrated its safety and have suggested its efficacy in treating or preventing aortic wall injury (AWI) or conduit disruption. A recent study of CCPS use for CoA reported a progressive risk of stent fracture over time and a risk of AWI despite the purported protection that the CCPS provides. The use of other covered stents has been reported, but large, systematic studies are lacking. CCPS use may reduce but does not eliminate the risk of conduit disruption or AWI. Structural limitations of the CCPS may predispose it to stent fracture. Access to a broad range of covered stents continues to be an unmet need in the field of congenital interventional cardiology.
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Affiliation(s)
- Nibras E El Sherif
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nathaniel W Taggart
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA.
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O'Byrne ML, Glatz AC. Managing confounding and effect modification in pediatric/congenital interventional cardiology research. Catheter Cardiovasc Interv 2021; 98:1159-1166. [PMID: 34420250 DOI: 10.1002/ccd.29925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/27/2021] [Accepted: 08/01/2021] [Indexed: 11/08/2022]
Abstract
Measuring the effect of a treatment on outcomes is an important goal for research in pediatric/congenital interventional cardiology. The breadth of anatomic and physiologic variations, patient ages, and genetic syndromes and noncardiac comorbid conditions all represent sources of potential confounding and effect modification that are major obstacles to this goal. If not accounted for, these factors can obscure the "true" treatment effect and lead to spurious conclusions about the relative efficacy and/or safety of therapies. In this review, we discuss the importance of confounding and effect modification in pediatric/congenital interventional cardiology research. We define these terms and discuss strategies (both in study design and data analysis) to mitigate error introduced by confounding and effect modification. The importance of confounding by indication in pediatric/congenital cardiology is discussed along with specific methods to address it.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Marcus BS, Rubio A, Deen JF. Transcatheter relief of coarctation of the aorta in a persistent fifth aortic arch anatomy. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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6
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Agasthi P, Pujari SH, Tseng A, Graziano JN, Marcotte F, Majdalany D, Mookadam F, Hagler DJ, Arsanjani R. Management of adults with coarctation of aorta. World J Cardiol 2020; 12:167-191. [PMID: 32547712 PMCID: PMC7284000 DOI: 10.4330/wjc.v12.i5.167] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Andrew Tseng
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Joseph N Graziano
- Division of Cardiology, Phoenix Children's Hospital, Children's Heart Center, Phoenix, AZ 85016, United States
| | - Francois Marcotte
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - David Majdalany
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, United States
| | - Reza Arsanjani
- Department of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ 85259, United States
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Epidurals for Coarctation Repair in Children Are Associated with Decreased Postoperative Anti-Hypertensive Infusion Requirement as Measured by a Novel Parameter, the Anti-Hypertensive Dosing Index (ADI). CHILDREN-BASEL 2019; 6:children6100112. [PMID: 31658735 PMCID: PMC6826390 DOI: 10.3390/children6100112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/10/2019] [Accepted: 09/27/2019] [Indexed: 11/18/2022]
Abstract
Background: Sympathetically-associated hypertension after coarctation repair is a common problem often requiring anti-hypertensive infusions in an intensive care unit. Epidurals suppress sympathetic output and can reduce blood pressure but have not been studied following coarctation repair in children. We sought to determine whether epidurals for coarctation repair in children were associated with decreased requirement for postoperative anti-hypertensive infusions, if they were associated with changes in hospital course, or with complications. Methods: In this observational retrospective cohort study, we evaluated all patients age 1–18 years undergoing coarctation repair at our institution during a 10-year period and compared the requirement for postoperative anti-hypertensive infusions in patients with and without epidurals using an anti-hypertensive dosing index (ADI) incorporating total dose-hours of all anti-hypertensive infusions (primary outcome). We also assessed intensive care unit (ICU) and hospital length of stay, discharge on oral anti-hypertensive medication, and complications potentially related to epidurals (secondary outcomes). Results: Children undergoing coarctation repair with epidurals had decreased requirements for postoperative anti-hypertensive infusions compared to children without epidurals (cumulative ADI 65.0 [28.5–130.3] v. 157.0 [68.6–214.7], p = 0.021; mean ADI 49.0 [33.3–131.2] v. 163.0 [66.6–209.8], p = 0.01). After multivariable cumulative logit mixed-effects regression analysis, mean ADI was decreased in patients with epidurals throughout the postoperative period (p < 0.001). Patients with epidurals were 1.6 years older and weighed 10.6 kg more than patients without epidurals but were otherwise comparable. Epidural complications included pruritus (three patients), agitation (one patient), somnolence (one patient), and transient orthostatic hypotension (one patient). Duration of intensive care unit admission, duration of hospital stays, and requirement for anti-hypertensive medication at discharge were similar in patients with and without epidurals. Conclusions: This is the first study of children receiving an epidural for surgical repair of aortic coarctation via open thoracotomy. In this small, single-institution, observational retrospective cohort study, epidurals for coarctation repair in children were associated with decreased postoperative anti-hypertensive infusion requirements. Epidurals were not associated with length of ICU or hospital stay, or with discharge on anti-hypertensive medication. No significant epidural complications were noted. Prospective study of larger populations will be necessary to confirm these associations, address causality, verify safety, and assess other effects.
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Abstract
PURPOSE OF REVIEW Aortic coarctation is a common congenital abnormality causing significant morbidity and mortality if not corrected. Re-coarctation or restenosis of the aorta following treatment is a relatively common long-term problem and the optimal therapy has not been elucidated. In this review, we identify the challenges associated with and the optimal management for recurrent aortic coarctation and the most appropriate therapy for different patient cohorts. RECENT FINDINGS Open surgery provides a durable long-term aortic repair, however, given the complex nature of the procedure, has a somewhat higher rate of serious complications. Endovascular repair, although less invasive and relatively safe, has limitations in treated complex anatomy and is more likely to require repeat intervention. Open surgical repair is more appropriate for infants that have not been intervened on and endovascular therapy should be reserved for older children and adults and those that require repeat intervention.
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9
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Fox EB, Latham GJ, Ross FJ, Joffe D. Perioperative and Anesthetic Management of Coarctation of the Aorta. Semin Cardiothorac Vasc Anesth 2019; 23:212-224. [PMID: 30614372 DOI: 10.1177/1089253218821953] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Eric B Fox
- 1 Seattle Children's Hospital, Seattle, WA, USA
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10
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Abstract
Congenital heart disease (CHD) is the most common birth defect, occurring in approximately 0.8% to 1.0% of neonates. Advances in medical and surgical therapies for children with CHD have resulted in a growing population of patients reaching adulthood, with survival rates exceeding 85%. Many of these patients, especially if managed inappropriately, face the prospect of future complications including heart failure and premature death. For adults with uncorrected or previously palliated CHD, percutaneous therapies have become the primary treatment for many forms of CHD. In this article, we discuss the role of transcatheter interventions in the treatment of adults with CHD.
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Affiliation(s)
- Hussam S Suradi
- Interventional Cardiology, Structural Heart & Valve Center, St. Mary Medical Center, 1500 South Lake Park Avenue, Suite 100, Hobart, IN 46342, USA; Department of Cardiology, Community Hospital, Munster, IN 46321, USA; Rush Center for Structural Heart Disease, Rush University Medical Center, Chicago, IL 60612, USA.
| | - Ziyad M Hijazi
- Sidra Cardiac Program, Department of Pediatrics, Sidra Medical & Research Center, Weill Cornell Medicine, PO Box 26999, Doha, Qatar
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11
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Wu Y, Jin X, Kuang H, Lv T, Li Y, Zhou Y, Wu C. Is balloon angioplasty superior to surgery in the treatment of paediatric native coarctation of the aorta: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 28:291-300. [PMID: 30060099 DOI: 10.1093/icvts/ivy224] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 06/12/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Yuhao Wu
- Department of Cardiothoracic Surgery, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xin Jin
- Department of Cardiothoracic Surgery, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hongyu Kuang
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Tiewei Lv
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Department of Cardiology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yonggang Li
- Department of Cardiothoracic Surgery, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuehang Zhou
- Department of Cardiothoracic Surgery, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chun Wu
- Department of Cardiothoracic Surgery, Children’s Hospital of Chongqing Medical University, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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Impact of different coarctation therapies on aortic stiffness: phase-contrast MRI study. Int J Cardiovasc Imaging 2018; 34:1459-1469. [DOI: 10.1007/s10554-018-1357-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/13/2018] [Indexed: 11/25/2022]
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13
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Sen S, Garg S, Rao SG, Kulkarni S. Native aortic coarctation in neonates and infants: Immediate and midterm outcomes with balloon angioplasty and surgery. Ann Pediatr Cardiol 2018; 11:261-266. [PMID: 30271015 PMCID: PMC6146845 DOI: 10.4103/apc.apc_165_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background Native aortic coarctation in young infants can be treated surgically or with balloon angioplasty, although the latter approach remains controversial. We sought to compare midterm outcomes of balloon and surgical coarctoplasty at our center and to review the current practices in literature. Methods The study design was a retrospective record review. Patients with coarctation aged <1 year who underwent balloon or surgical coarctoplasty at our center (January 2010-January 2016) with >6-month post-procedure follow-up were studied. Patients with significant arch hypoplasia or interruption, long-segment coarctation, and associated intracardiac lesions were excluded from the study. Clinical, echocardiographic, and procedural details were recorded at initial presentation and follow-up. Need for reintervention was noted. Results Out of a total of 75 patients, 28 underwent balloon (Group A) and 47 underwent surgical coarctoplasty (Group B). There were two deaths in Group B (mortality 4.2%) and none in Group A. In neonates, 63.6% of Group A and 17.4% of Group B patients required reintervention (P = 0.007). Beyond the neonatal age, 29.4% of Group A and 41.6% of Group B patients required reintervention (not statistically significant). On univariate analysis, residual coarctation on predischarge echocardiogram was the only significant predictor of reintervention (P = 0.04). On Kaplan-Meier analysis, with neonatal presentation, freedom from reintervention in Group B was significantly higher than Group A (P = 0.028). Conclusion In neonates with native aortic coarctation, surgery unequivocally yields better immediate and midterm results and is the preferred treatment modality. In older infants, balloon coarctoplasty has good early and midterm outcomes with acceptable reintervention rates and should be considered a viable alternative to surgery, especially in critical patients with high surgical risk.
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Affiliation(s)
- Supratim Sen
- Department of Pediatric Cardiology, SRCC Children's Hospital, Mumbai, Maharashtra, India
| | - Sandeep Garg
- Children's Heart Centre, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
| | - Suresh G Rao
- Children's Heart Centre, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
| | - Snehal Kulkarni
- Children's Heart Centre, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
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Pathirana D, Johnston B, Johnston P. The effects of tapering and artery wall stiffness on treatments for Coarctation of the Aorta. Comput Methods Biomech Biomed Engin 2017; 20:1512-1524. [PMID: 29119836 DOI: 10.1080/10255842.2017.1382483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Coarctation of the Aorta is a congenital narrowing of the aorta. Two commonly used treatments are resection and end-to-end anastomosis, and stent placements. We simulate blood flow through one-dimensional models of aortas. Different artery stiffnesses, due to treatments, are included in our model, and used to compare blood flow properties in the treated aortas. We expand our previously published model to include the natural tapering of aortas. We look at change in aorta wall radius, blood pressure and blood flow velocity, and find that, of the two treatments, the resection and end-to-end anastomosis treatment more closely matches healthy aortas.
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Affiliation(s)
- Dilan Pathirana
- a School of Natural Sciences and Queensland Micro- and Nanotechnology Centre , Griffith University , Nathan , Australia
| | - Barbara Johnston
- a School of Natural Sciences and Queensland Micro- and Nanotechnology Centre , Griffith University , Nathan , Australia
| | - Peter Johnston
- a School of Natural Sciences and Queensland Micro- and Nanotechnology Centre , Griffith University , Nathan , Australia
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15
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Noly PE, Legris-Falardeau V, Ibrahim R, El-Hamamsy I, Cartier R, Lamarche Y, Bouchard D, Dorval JF, Poirier N, Demers P. Results of a multimodal approach for the management of aortic coarctation and its complications in adults. Interact Cardiovasc Thorac Surg 2017; 25:335-342. [DOI: 10.1093/icvts/ivx039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 01/23/2017] [Indexed: 01/23/2023] Open
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Taggart NW, Minahan M, Cabalka AK, Cetta F, Usmani K, Ringel RE. Immediate Outcomes of Covered Stent Placement for Treatment or Prevention of Aortic Wall Injury Associated With Coarctation of the Aorta (COAST II). JACC Cardiovasc Interv 2016; 9:484-93. [PMID: 26896890 DOI: 10.1016/j.jcin.2015.11.038] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/04/2015] [Accepted: 11/19/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVES This study aimed to describe the safety and short-term efficacy of the Covered Cheatham-Platinum stent (CCPS) in treating or preventing aortic wall injury (AWI) in patients with coarctation of the aorta (CoA). BACKGROUND The COAST II trial (Covered Cheatham-Platinum Stents for Prevention or Treatment of Aortic Wall Injury Associated with Coarctation of the Aorta Trial) is a multicenter, single-arm trial using the CCPS for the treatment and/or prevention of AWI in patients with CoA and pre-existing AWI or increased risk of AWI. METHODS Patients were enrolled if they had a history of CoA with pre-existing AWI (Treatment group) or with increased risk of AWI (Prevention group). Pre/post-implant hemodynamics and angiography were reported. A core laboratory performed standardized review of all angiograms. One-month follow-up was reported. RESULTS A total of 158 patients (male = 65%; median age 19 years) underwent placement of CCPS. Eighty-three patients had pre-existing AWI. The average ascending-to-descending aorta systolic gradient improved from 27 ± 20 mm Hg to 4 ± 6 mm Hg. Complete coverage of pre-existing AWI was achieved in 66 of 71 patients (93%) with AWI who received a single CCPS. Ultimately, complete coverage of AWI was achieved in 76 of 83 patients (92%); 7 patients had minor endoleaks that did not require repeat intervention. Four patients experienced important access site vascular injury. There were no acute AWI, repeat interventions, or deaths. CONCLUSIONS The CCPS can effectively treat and potentially prevent AWI associated with CoA. Access site arterial injury is the most common important complication. Longer-term follow-up is necessary to define mid- and late-term outcomes.
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Affiliation(s)
- Nathaniel W Taggart
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Matthew Minahan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Allison K Cabalka
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Frank Cetta
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kudret Usmani
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Richard E Ringel
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Suradi H, Hijazi ZM. Current management of coarctation of the aorta. Glob Cardiol Sci Pract 2015; 2015:44. [PMID: 26779519 PMCID: PMC4710863 DOI: 10.5339/gcsp.2015.44] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 08/27/2015] [Indexed: 01/16/2023] Open
Abstract
Coarctation of the aorta (C) is the sixth most common lesion in congenital heart disease and represents a spectrum of aortic narrowing that varies from a discrete entity to tubular hypoplasia. This condition was once thought to be a relatively simple lesion that would be "cured" upon repair of the narrowing, however, despite relief of the anatomical obstruction the subsequent risk of early morbidity and death persists. This review outlines the optimal management strategy of this disease from neonatal to adult life and provides insights to approach this straightforward but challenging condition.
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Affiliation(s)
- Hussam Suradi
- Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, ChicagoIL, USA; St Mary Medical Center, Community Healtare Network, HobartIN, USA
| | - Ziyad M Hijazi
- Rush Center for Congenital & Structural Heart Disease, Rush University Medical Center, ChicagoIL, USA; Sidra Cardiovascular Center of Excellence, Sidra Medical & Research Center, Doha, Qatar
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Forbes TJ, Gowda ST. Intravascular stent therapy for coarctation of the aorta. Methodist Debakey Cardiovasc J 2015; 10:82-7. [PMID: 25114759 DOI: 10.14797/mdcj-10-2-82] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Intravascular stent therapy is considered a primary therapeutic option for most adults and adolescents with coarctation of the aorta. This review highlights the indications, technical considerations, procedural aspects, and limited long-term outcome data when using this intervention. Stent technology has continued to evolve with potential for further modifications since its inception in the early 1990s. The best therapeutic approach, e.g., stenting versus surgery, in the treatment of native coarctation continues to be debated due to the paucity of long-term clinical and imaging data in both groups.
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Lara-Rojas CM, Bernal-Lopez MR, Lopez-Carmona MD, Gomez-Huelgas R. Familial aortic coarctation: a rare cause of refractory hypertension in the elderly: a case report. Medicine (Baltimore) 2015; 94:e467. [PMID: 25634191 PMCID: PMC4602944 DOI: 10.1097/md.0000000000000467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report the first case of late presentation of familial aortic coarctation, a rare cause of hypertension. Diagnosis of familial aortic coarctation in the elderly is exceptional, given that in the absence of endovascular or surgical repair patients do not usually survive beyond 50 years of age. Our case concerns a 72-year-old woman with hypertension of long evolution, control of which improved markedly after endovascular repair of the coarctation. Her son had undergone surgery for repair of aortic coarctation at the age of 23 years.
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Affiliation(s)
- Carmen M Lara-Rojas
- From the Internal Medicine Department, Biomedical Institute of Malaga (IBIMA), Regional University Hospital of Malaga, Spain (CML-R, MDL-C, G-H); Ciber Fisiopatología de la Obesidad y Nutrición (CB06/003) Instituto de Salud Carlos III, Madrid, Spain (MRB-L, RG-H); and Biomedical Research Laboratory, Internal Medicine Department, Biomedical Institute of Malaga (IBIMA), Regional University Hospital of Malaga, Spain (MRB-L)
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Charlton-Ouw KM, Codreanu ME, Leake SS, Sandhu HK, Calderon D, Azizzadeh A, Estrera AL, Safi HJ. Open repair of adult aortic coarctation mostly by a resection and graft replacement technique. J Vasc Surg 2014; 61:66-72. [PMID: 25041987 DOI: 10.1016/j.jvs.2014.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/01/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND We report on our experience with treatment of adults requiring de novo or redo open aortic coarctation repair mostly by a resection and interposition graft technique. METHODS We retrospectively reviewed all patients older than 16 years requiring open repair of aortic coarctation. Indications for repair, operative details, and outcomes were analyzed. RESULTS Between 1996 and 2011, we treated 29 adult aortic coarctation patients with open repair. The mean age was 42 years (range, 17-69 years), and there were 15 men. Nine patients had previous repair with recurrence; the remaining 20 had native coarctation. Thoracic aortic aneurysms were present in 22 patients (76%), ranging in size from 3.0 to 9.6 cm (mean, 4.8 cm). Four patients had intercostal artery aneurysms (range, 1.0-2.5 cm), four had left subclavian artery aneurysms, and four had ascending/arch aneurysms. The most common repair was resection of aortic coarctation with interposition graft replacement (93%). Two patients without aneurysm had bypasses from the proximal descending thoracic aorta to the infrarenal aorta without aortic resection. There was no in-hospital mortality, stroke, or paraplegia. Long-term survival was 89% during a median follow-up of 81 months (interquartile range, 47-118 months), with no patient requiring reoperation on the repaired segment. CONCLUSIONS Open repair of native and recurrent adult aortic coarctation has acceptable morbidity and low mortality. Especially in patients with concomitant aneurysm, resection with interposition graft replacement provides a safe and durable repair option.
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Affiliation(s)
- Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Texas Medical Center, Houston, Tex.
| | - Maria E Codreanu
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Texas Medical Center, Houston, Tex
| | - Samuel S Leake
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex
| | - Harleen K Sandhu
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex
| | - Daniel Calderon
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex
| | - Ali Azizzadeh
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Texas Medical Center, Houston, Tex
| | - Anthony L Estrera
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Texas Medical Center, Houston, Tex
| | - Hazim J Safi
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Houston, Tex; Memorial Hermann Heart and Vascular Institute, Texas Medical Center, Houston, Tex
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21
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Cardoso G, Abecasis M, Anjos R, Marques M, Koukoulis G, Aguiar C, Neves JP. Aortic Coarctation Repair in the Adult. J Card Surg 2014; 29:512-8. [DOI: 10.1111/jocs.12367] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Goncalo Cardoso
- Department of Cardiology; Santa Cruz Hospital, CHLO; Carnaxide Portugal
| | - Miguel Abecasis
- Department of Cardio-Thoracic Surgery; Santa Cruz Hospital, CHLO; Carnaxide Portugal
| | - Rui Anjos
- Department of Pediatric Cardiology; Santa Cruz Hospital, CHLO; Carnaxide Portugal
| | - Marta Marques
- Department of Cardio-Thoracic Surgery; Santa Cruz Hospital, CHLO; Carnaxide Portugal
| | - Giovanna Koukoulis
- Department of Cardio-Thoracic Surgery; Santa Cruz Hospital, CHLO; Carnaxide Portugal
| | - Carlos Aguiar
- Department of Cardiology; Santa Cruz Hospital, CHLO; Carnaxide Portugal
| | - José Pedro Neves
- Department of Cardio-Thoracic Surgery; Santa Cruz Hospital, CHLO; Carnaxide Portugal
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22
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Vergales JE, Gangemi JJ, Rhueban KS, Lim DS. Coarctation of the aorta - the current state of surgical and transcatheter therapies. Curr Cardiol Rev 2014; 9:211-9. [PMID: 23909637 PMCID: PMC3780346 DOI: 10.2174/1573403x113099990032] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 01/20/2013] [Indexed: 12/11/2022] Open
Abstract
Aortic coarctation represents a distinct anatomic obstruction as blood moves from the ascending to the descending aorta and can present in a range of ages from infancy to adulthood. While it is often an isolated and discrete narrowing, it can also be seen in the more extreme scenario of severe arch hypoplasia as seen in the hypoplastic left heart syndrome or in conjunction with numerous other congenital heart defects. Since the first description of an anatomic surgical repair over sixty years ago, an evolution of both surgical and transcatheter therapies has occurred allowing clinicians to manage and treat this disease with excellent results and low morbidity and mortality. This review focuses on the current state of both transcatheter and surgical therapies, paying special attention to recent data on long-term follow-up of both approaches. Further, current thoughts will be explored about future therapeutic options that attempt to improve upon historical long-term outcomes.
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Affiliation(s)
- Jeffrey E Vergales
- Children’s Hospital Heart Center, Department of Pediatrics, University of Virginia, USA.
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23
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Hijazi ZM, Kenny DP. Covered stents for coarctation of the aorta: treating the interventionalist or the patient? JACC Cardiovasc Interv 2014; 7:424-5. [PMID: 24630877 DOI: 10.1016/j.jcin.2013.12.200] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/20/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Ziyad M Hijazi
- Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, Illinois.
| | - Damien P Kenny
- Rush Center for Congenital and Structural Heart Disease, Rush University Medical Center, Chicago, Illinois
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24
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Hu ZP, Wang ZW, Dai XF, Zhan BT, Ren W, Li LC, Zhang H, Ren ZL. Outcomes of Surgical versus Balloon Angioplasty Treatment for Native Coarctation of the Aorta: A Meta-Analysis. Ann Vasc Surg 2014; 28:394-403. [DOI: 10.1016/j.avsg.2013.02.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Revised: 01/14/2013] [Accepted: 02/17/2013] [Indexed: 12/12/2022]
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25
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Luijendijk P, Bouma BJ, Groenink M, Boekholdt M, Hazekamp MG, Blom NA, Koolbergen DR, de Winter RJ, Mulder BJM. Surgical versus percutaneous treatment of aortic coarctation: new standards in an era of transcatheter repair. Expert Rev Cardiovasc Ther 2014; 10:1517-31. [DOI: 10.1586/erc.12.158] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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26
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Holzer R, Cao QL, Hijazi ZM. State of the art catheter interventions in adults with congenital heart disease. Expert Rev Cardiovasc Ther 2014; 2:699-711. [PMID: 15350171 DOI: 10.1586/14779072.2.5.699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Catheter interventions in adults with congenital heart disease have rapidly advanced. Transcatheter valve repair and replacement techniques have been added to the existing spectrum of well-established procedures. This review summarizes current transcatheter management strategies for congenital cardiac anomalies seen in the adult population.
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Affiliation(s)
- Ralf Holzer
- Pediatric Cardiology, The University of Chicago Children's Hospital, 5841 S. Maryland Avenue, MC 4051, Chicago, IL 60637, USA.
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27
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Butera G, Manica JL, Chessa M, Piazza L, Negura D, Micheletti A, Arcidiacono C, Carminati M. Covered-stent implantation to treat aortic coarctation. Expert Rev Med Devices 2014; 9:123-30. [DOI: 10.1586/erd.12.2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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28
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Ringel RE, Vincent J, Jenkins KJ, Gauvreau K, Moses H, Lofgren K, Usmani K. Acute outcome of stent therapy for coarctation of the aorta: Results of the coarctation of the aorta stent trial. Catheter Cardiovasc Interv 2013; 82:503-10. [DOI: 10.1002/ccd.24949] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/01/2013] [Accepted: 04/07/2013] [Indexed: 11/08/2022]
Affiliation(s)
- Richard E. Ringel
- Division of Pediatric Cardiology; Department of Pediatrics; Johns Hopkins University School of Medicine; Baltimore; MD
| | - Julie Vincent
- Division of Pediatric Cardiology; Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York-Presbyterian; New York; New York
| | - Kathy J. Jenkins
- Department of Cardiology; Boston Children's Hospital; Boston; MA
| | | | - Heidi Moses
- Department of Cardiology; Boston Children's Hospital; Boston; MA
| | - Kimberly Lofgren
- Department of Cardiology; Boston Children's Hospital; Boston; MA
| | - Kudret Usmani
- Department of Cardiology; Boston Children's Hospital; Boston; MA
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Bozzani A, Arici V, Ragni F. Thoracic aorta coarctation in the adults: open surgery is still the gold standard. Vasc Endovascular Surg 2013; 47:216-8. [PMID: 23393085 DOI: 10.1177/1538574413477218] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aortic coarctation (CoA) is the fifth most common congenital heart defect, accounting for 6% to 8% of live births with congenital heart disease. Traditional treatment for CoA consists of open surgical repair, and the endovascular procedures have been proposed as an alternative treatment. We describe the case of a 50-year-old man presented to our department with mild lower limbs claudication and hypertension. The computed tomography scan diagnosed an aortic postductal coarctation, which we treated with aortoplasty with Dacron patch. The open surgery, in our opinion, is nowadays still preferable due to the time-stable and effective outcome.
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Affiliation(s)
- Antonio Bozzani
- Division ofVascular Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, 27100 Pavia, Italy.
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30
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Oi K, Yoshida T, Takeshita M, Tsuruta G. False aneurysm on distal part of coarctation of the aorta in a parous Turner syndrome patient. Gen Thorac Cardiovasc Surg 2012. [PMID: 23207878 DOI: 10.1007/s11748-012-0189-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
False aneurysm associated with untreated coarctation of the aorta (CoA) is an uncommon vascular complication. We present a 41-year-old woman with mosaic Turner syndrome who had CoA complicated with a small false aneurysm on descending aorta just distal to the coarctation. The patient had not been diagnosed with Turner syndrome despite several physical characteristics of the syndrome because she had histories of natural childbirth. The false aneurysm was resected with the coarctation through a thoracotomy and proximal aorta was directly anastomosed to distal aorta. Endovascular therapy has become preferred method in recent years in treatment for coarctation of the aorta. However, careful consideration should be given to the irregularities on the aorta with the coarctation for diagnosis of false aneurysm.
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Affiliation(s)
- Keiji Oi
- Department of Cardiovascular Surgery, Hokushin General Hospital, 1-5-63 Nishi, Nakano-shi, Nagano 383-8505, Japan.
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Ringel RE, Gauvreau K, Moses H, Jenkins KJ. Coarctation of the Aorta Stent Trial (COAST): study design and rationale. Am Heart J 2012; 164:7-13. [PMID: 22795276 DOI: 10.1016/j.ahj.2012.04.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 04/22/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Coarctation of the aorta (CoA) accounts for 4% to 5% of congenital cardiac abnormalities. Stent therapy has become an accepted alternative to surgery for older children and adults, although there are no balloon-expandable stents approved by the Food and Drug Administration for use in the aorta. The Cheatham-Platinum (CP) stent was designed for CoA therapy and is widely used outside the United States. We have designed the first prospective trial of stent therapy for CoA to serve as the pivotal trial for Food and Drug Administration approval of the CP stent. METHODS The COAST study is a prospective, multicenter, single-arm clinical study. The population includes patients with native or recurrent CoA. Four primary outcome variables were defined. For each variable, the stent will be compared to performance guidelines derived from surgical experience. The first efficacy outcome is reduction in arm-leg systolic blood pressure gradient, and the second is reduction in hospital length of stay. Safety outcomes include the following: the occurrence of any serious or somewhat serious adverse event attributed to the stent or implantation procedure and the occurrence of postprocedure paradoxical hypertension. A total of 105 patients treated with the CP stent will be enrolled. DISCUSSION To ascertain the effectiveness and safety of an interventional device, randomized controlled trials have been offered as the criterion standard. However, these trials are not well suited to study rare conditions such as CoA, especially once the therapy in question has received acceptance within the medical community. New clinical trial and statistical approaches are needed to evaluate such therapies. The COAST study is an example of this kind of innovative trial design.
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Pádua LMS, Garcia LC, Rubira CJ, de Oliveira Carvalho PE. Stent placement versus surgery for coarctation of the thoracic aorta. Cochrane Database Syst Rev 2012:CD008204. [PMID: 22592728 DOI: 10.1002/14651858.cd008204.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Forbes TJ, Kim DW, Du W, Turner DR, Holzer R, Amin Z, Hijazi Z, Ghasemi A, Rome JJ, Nykanen D, Zahn E, Cowley C, Hoyer M, Waight D, Gruenstein D, Javois A, Foerster S, Kreutzer J, Sullivan N, Khan A, Owada C, Hagler D, Lim S, Canter J, Zellers T. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: an observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol 2012; 58:2664-74. [PMID: 22152954 DOI: 10.1016/j.jacc.2011.08.053] [Citation(s) in RCA: 197] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 08/03/2011] [Accepted: 08/09/2011] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the safety and efficacy of surgical, stent, and balloon angioplasty (BA) treatment of native coarctation acutely and at follow-up. BACKGROUND Controversy surrounds the optimal treatment for native coarctation of the aorta. This is the first multicenter study evaluating acute and follow-up outcomes of these 3 treatment options in children weighing >10 kg. METHODS This is a multicenter observational study. Baseline, acute, short-term (3 to 18 months), and intermediate (>18 months) follow-up hemodynamic, imaging data, and complications were recorded. RESULTS Between June 2002 and July 2009, 350 patients from 36 institutions were enrolled: 217 underwent stent, 61 underwent BA, and 72 underwent surgery. All 3 arms showed significant improvement acutely and at follow-up in resting systolic blood pressure and upper to lower extremity systolic blood pressure gradient (ULG). Stent was superior to BA in achieving lower ULG acutely. Surgery and stent were superior to BA at short-term follow-up in achieving lower ULG. Stent patients had shorter hospitalization than surgical patients (2.4 vs. 6.4 days; p < 0.001) and fewer complications than surgical and BA patients (2.3%, 8.1%, and 9.8%; p < 0.001). The BA patients were more likely to encounter aortic wall injury, both acutely and at follow-up (p < 0.001). CONCLUSIONS Stent patients had significantly lower acute complications compared with surgery patients or BA patients, although they were more likely to require a planned reintervention. At short-term and intermediate follow-up, stent and surgical patients achieved superior hemodynamic and integrated aortic arch imaging outcomes compared with BA patients. Because of the nonrandomized nature of this study, these results should be interpreted with caution.
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Romfh A, Pluchinotta FR, Porayette P, Valente AM, Sanders SP. Congenital Heart Defects in Adults : A Field Guide for Cardiologists. ACTA ACUST UNITED AC 2012. [PMID: 24294540 DOI: 10.4172/2155-9880.s8-007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Advances in cardiology and cardiac surgery allow a large proportion of patients with congenital heart defects to survive into adulthood. These patients frequently develop complications characteristic of the defect or its treatment. Consequently, adult cardiologists participating in the care of these patients need a working knowledge of the more common defects. Occasionally, patients with congenital heart defects such as atrial septal defect, Ebstein anomaly or physiologically corrected transposition of the great arteries present for the first time in adulthood. More often patients previously treated in pediatric cardiology centers have transitioned to adult congenital heart disease centers for ongoing care. Some of the more important defects in this category are tetralogy of Fallot, transposition of the great arteries, functionally single ventricle defects, and coarctation. Through this field guide, we provide an overview of the anatomy of selected defects commonly seen in an adult congenital practice using pathology specimens and clinical imaging studies. In addition, we describe the physiology, clinical presentation to the adult cardiologist, possible complications, treatment options, and outcomes.
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Affiliation(s)
- Anitra Romfh
- Department of Cardiology, Children's Hospital Boston, Boston, MA 02115, USA ; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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Bugami SA, Motairi MA, Zahrani AA, Zahrani AA. The unusual hypertensive patient. J Saudi Heart Assoc 2012; 24:41-5. [PMID: 23960667 PMCID: PMC3727539 DOI: 10.1016/j.jsha.2011.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022] Open
Abstract
Many young patients with systemic hypertension have secondary causes which if identified early could lessen the cardiovascular complications associated with long standing hypertension. Coarctation of the aorta is one of those rare causes. We describe a 40 year old male with hypertension, coarctation of the aorta, bicuspid aortic valve, PDA and an adrenal mass.
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Affiliation(s)
- Saad Al Bugami
- King Saud Bin Abdulaziz University, King Abdulaziz Medical City, king Khalid National Guard Hospital, Jeddah 21423, Saudi Arabia
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Abstract
Untreated thoracic aortic coarctation leads to early death predominantly because of hypertension and its cardiovascular sequelae. Surgical treatment has been available for > 50 years and has improved hypertension and survival. More recently, endovascular techniques have offered a minimally invasive alternative to traditional open repair. Early and intermediate results suggest angioplasty and stenting have an important role in the management of aortic coarctation, particularly in adults and older children.
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Affiliation(s)
- D R Turner
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, United Kingdom
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37
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Fraisse A, Kammache I. Traitement interventionnel des vaisseaux. ARCHIVES OF CARDIOVASCULAR DISEASES SUPPLEMENTS 2011. [DOI: 10.1016/s1878-6480(11)70347-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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38
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Angtuaco MJ, Vyas HV, Morrow WR, Imamura M, Jaquiss RDB, Sachdeva R. Aortopulmonary index as a novel morphologic correlate of early recurrence of coarctation of aorta after surgical repair in infancy. J Am Soc Echocardiogr 2011; 24:841-6. [PMID: 21570255 DOI: 10.1016/j.echo.2011.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to determine morphologic correlates of early reintervention for recurrent coarctation in infants undergoing surgical repair in the current era. METHODS Medical records of infants who underwent repair of coarctation were retrospectively reviewed. Z scores for aortic segments, relative aortic arch segmental dimensions (indexed to ascending or descending aortic dimension), and aortopulmonary index (the ratio of aortic to pulmonary annular diameter) were derived from preoperative echocardiograms. RESULTS Eighty-seven patients underwent repair (median age, 13 days). Early arch reintervention (<1 year after surgery) was performed in 11. Lower aortopulmonary index and Z scores of the aortic annulus and sinotubular junction were associated with early reintervention. Aortopulmonary index < 0.6 was the best correlate (sensitivity, 72.7%; specificity, 73.7%; area under the curve, 0.732). Aortic arch dimensions were not correlated with early reintervention. CONCLUSION In the current era, aortopulmonary index rather than aortic arch hypoplasia is correlated with the need for reintervention for recurrent coarctation within 1 year of surgery.
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Affiliation(s)
- Michael J Angtuaco
- Department of Pediatrics, Division of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas
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Früh S, Knirsch W, Dodge-Khatami A, Dave H, Prêtre R, Kretschmar O. Comparison of surgical and interventional therapy of native and recurrent aortic coarctation regarding different age groups during childhood. Eur J Cardiothorac Surg 2010; 39:898-904. [PMID: 21169030 DOI: 10.1016/j.ejcts.2010.09.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 09/21/2010] [Accepted: 09/22/2010] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The aim of the study was to analyze immediate results, rate of complications and re-interventions during medium-term outcome in pediatric patients with native or recurrent aortic coarctation. We focused on an age-related therapeutic approach comparing surgical and trans-catheter treatment. METHODS This is a retrospective, single-centre, clinical observational trial including 91 consecutive patients (age: 1 day-18 years) treated for native coarctation in 67 and recurrent aortic coarctation in 24 patients. Surgical treatment was performed in 56, trans-catheter treatment with balloon dilatation in 17, and by stent implantation in 18 patients. According to the age groups, we treated 48 children in group A (<6 months of age), 16 in group B (6 months-6 years), and 27 in group C (>6 years). A total of 41 patients in group A were operated (85%), patients in group B received either surgical or trans-catheter treatment (50% vs 50%), and 16 patients in group C were treated by stent implantation (62%). RESULTS Immediate results were excellent with a significant release of pressure gradient in all three age groups (64.7% in group A, 69.1% in group B, and 63.3% in group C). Complication rate and re-intervention rate (surgical and interventional) both were [corrected] comparable between the three age groups (complications: group A 8.3%, group B 6.3%, and group C 3.7%, [corrected] re-interventions: group A 16.6%, group B 18.8%, and group C 14.8%). [corrected] Midterm outcome after a median follow-up period of 17.5 months was satisfactory with a re-intervention-free survival after 17.5 months of 83.4%, 81.2%, and 81.5% in group A, group B, and group C, respectively. CONCLUSIONS The current strategy of an age-related therapy for native and recurrent aortic coarctation in our institution is surgery in infants <6 months (group A), either surgery or balloon dilatation in younger patients <6 years (group B), while in older children >6 years of age (group C) the trans-catheter treatment with stent implantation is an excellent alternative to surgery. Balloon dilatations showed limited results with an overall re-intervention rate of 53% and, therefore, should mainly be performed as a rescue procedure or in recurrent aortic coarctation in neonates.
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Affiliation(s)
- Seraina Früh
- Division of Pediatric and Congenital Cardiac Surgery, University Children's Hospital Zurich, Zurich, Switzerland
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Yoo YS, Woo HY, Choi JH, Cho KR, Oh YT, Heo G. Balloon catheter assisted excision of benign cervical cyst. Auris Nasus Larynx 2010; 37:504-7. [DOI: 10.1016/j.anl.2009.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Revised: 11/24/2009] [Accepted: 12/01/2009] [Indexed: 10/20/2022]
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Mohan UR, Danon S, Levi D, Connolly D, Moore JW. Stent implantation for coarctation of the aorta in children <30 kg. JACC Cardiovasc Interv 2009; 2:877-83. [PMID: 19778777 DOI: 10.1016/j.jcin.2009.07.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Revised: 05/15/2009] [Accepted: 07/08/2009] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Our aim was to determine key characteristics of stents commonly implanted in the aorta through bench testing and to describe our technique and acute results in patients weighing <30 kg. BACKGROUND Despite the increasing use of stents for interventional treatment for coarctation of the aorta (CoA) in larger patients, use of large stents is controversial in small children. METHODS Methods included bench testing of large stents, and retrospective review of all patients over 1 year of age who had stent implantation for treatment of CoA. Patients were divided into 2 groups based on weight. Paired comparisons were made before and after stent implantation, and group outcomes were compared. RESULTS Sixty patients comprised the entire sample, with 22 patients assigned to group I (<30 kg) and 38 patients assigned to group II (>or=30 kg). The mean minimum diameters of the CoA (group I 5.0 to 10.7 mm; group II 8.0 to 15.0 mm) and the ratio of the coarctation diameter to the descending aorta diameter measured at the level of the diaphragm (CoA/DAo ratio) (group I 0.4 to 0.93; group II 0.46 to 0.94) increased significantly in both groups (all p < 0.05). The mean systolic gradient decreased significantly in both groups (group I 23.0 to 2.0 mm Hg; group II 24.0 to 2.8 mm Hg; both p = 0.001). No difference was found between the groups in the CoA/DAo ratio, residual systolic gradients, or the decrease in systolic gradient after stent implantation. There were no significant complications in patients under 30 kg. CONCLUSIONS As in larger patients, use of large stents for treatment of CoA in small children is effective and safe in the short term. In these patients, stent redilations will be required, and follow-up is ongoing.
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Affiliation(s)
- Uthara R Mohan
- Rady Children's Hospital and UCSD, San Diego, California 92123, USA
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Coartación aórtica en el adulto. CIRUGIA CARDIOVASCULAR 2009. [DOI: 10.1016/s1134-0096(09)70134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Rao PS. Transcatheter interventions in critically ill neonates and infants with aortic coarctation. Ann Pediatr Cardiol 2009; 2:116-9. [PMID: 20808623 PMCID: PMC2922658 DOI: 10.4103/0974-2069.58312] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- P Syamasundar Rao
- Address for correspondence: Dr. P Syamasundar Rao, Division of Pediatric Cardiology, The University of Texas/Houston Medical School, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA. E-mail:
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Simultaneous Presentation of Coarctation of the Thoracic Aorta and Aneurysm of the Superior Mesenteric Artery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009; 4:113-6. [DOI: 10.1097/imi.0b013e3181a39077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A 34-year-old woman presented with both coarctation of the thoracic aorta and aneurysm of the superior mesenteric artery. The former was managed by open surgical repair, the latter by stent-graft. This case illustrates the need for facility with both percutaneous and open approaches to diseases of the aorta and its branches.
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Karmy-Jones R, Bloch R, Martin MA. Simultaneous Presentation of Coarctation of the Thoracic Aorta and Aneurysm of the Superior Mesenteric Artery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2009. [DOI: 10.1177/155698450900400210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Riyad Karmy-Jones
- Heart and Vascular Institute, Southwest Washington Medical Center, Vancouver, WA, USA
| | - Robert Bloch
- Heart and Vascular Institute, Southwest Washington Medical Center, Vancouver, WA, USA
| | - M. Alan Martin
- Heart and Vascular Institute, Southwest Washington Medical Center, Vancouver, WA, USA
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Controversy about coarctation. Cardiol Young 2008; 18:361-2. [PMID: 18577306 DOI: 10.1017/s1047951108002473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Balloon angioplasty for native coarctation of the aorta in infants and children is gaining acceptance as an alternative to surgery in discrete membranous obstruction. The aim of this study was to assess the immediate and intermediate-term effectiveness and safety of balloon angioplasty in infants and children with discrete membranous obstruction and mild complex arch anomalies. We performed a retrospective study evaluating the immediate and intermediate-term results of balloon angioplasty in 46 consecutive patients with native coarctation of the aorta done between March 1998 and June 2003. Isolated discrete fibromembranous obstruction occurred in 32 patients, and 14 patients had mild complex arch anomalies. Follow-up was obtained in 40 patients. There was no early mortality. The procedure was initially successful in 43 patients (93%). There were three immediate failures. Of the 40 patients who were followed, 32 (80%) had maintained a cuff pressure gradient of 20 mmHg across the dilated area. Four patients developed restenosis, which was successfully treated by repeated balloon angioplasty. The other four patients continued to have mild gradient (20-22 mmHg) with systolic hypertension and without angiographic evidence of restenosis but with isthmus hypoplasia; they received atenolol and captopril. Serial echocardiographic measurement of left ventricular dimension and function revealed significant improvement after balloon angioplasty of aortic coarctation in patients with the echocardiographic picture of hypertensive cardiomyopathy. Balloon angioplasty may be considered as a tool in the armamentarium of management of aortic coarctation in different anatomic variants, taking into consideration the clinical presentation and patient age.
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Abstract
OBJECTIVE We sought to use techniques of decision analysis to compare values or preferences for balloon angioplasty versus surgery for treatment of aortic coarctation in children. BACKGROUND Balloon angioplasty and surgery for aortic coarctation have a differing spectrum and prevalence of outcomes and complications, making direct comparison difficult. METHODS From articles reporting treatment outcomes of native aortic coarctation from 1984 through 2005, we determined the baseline probabilities of successful treatment, complications, recoarctation and aneurysmal formation. Decision trees with baseline probabilities of these outcomes were formulated. Standard gamble interviews of medical professionals determined the preferences for the various outcomes. Final cumulative preference scores were further adjusted for both perceived mortality and procedural disutility. Sensitivity analyses determined threshold probabilities at which the score advantage changed. RESULTS Final preference scores for balloon angioplasty, with a mean of 0.8999, and standard deviation of 0.0236, were significantly higher than for surgery, at a mean of 0.8873, and standard deviation of 0.0246. The score advantage for balloon angioplasty did not change when adjusted for disutility, or mortality. Sensitivity analysis showed that even if the probability of periprocedural death or major complications for surgery was reduced to none, balloon angioplasty would still be preferred, expect for neonates, where if surgical mortality were reduced below 4%, then surgery would be preferred. Probabilities for periprocedural death or major complications associated with balloon angioplasty would have to exceed plausible thresholds before surgery would be preferred. CONCLUSIONS After accounting for preference-weighted probabilities of outcomes, balloon angioplasty is preferred over surgery for all plausible situations as the initial treatment for native aortic coarctation in children.
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What is the preferred therapy for patients with aortic coarctation--the standard gamble and decision analysis versus real results? Cardiol Young 2008; 18:18-21. [PMID: 18093361 DOI: 10.1017/s1047951107001771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Almashham Y, Dahdah N, Miro J. Use of radiofrequency then stent implantation for recanalization of complete aorta coarctation. Pediatr Cardiol 2008; 29:207-9. [PMID: 17885781 DOI: 10.1007/s00246-007-9090-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 06/26/2007] [Accepted: 06/26/2007] [Indexed: 10/22/2022]
Abstract
Recanalization of a complete coarctation with isthmus occlusion was successfully accomplished in a 16-year-old patient using radiofrequency. This allowed the insertion and deployment of a covered stent to reestablish flow continuity across the isthmus. No complications were encountered. To the authors' knowledge this is the first case of radiofrequency use for complete coarctation, and among the rare cases of complete coarctation addressed primarily percutaneously to be reported.
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Affiliation(s)
- Y Almashham
- Pediatric Cardiology, Sainte-Justine Hospital, 3175 Cote Sainte-Catherine, Qc H3T 1C5 Montreal, Canada
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