Perioperative and Anesthetic Management of Coarctation of the Aorta

Evaluation of short and mid-term clinical outcomes in patients with aortic coarctation treated with self-expandable stents

The present study aimed to evaluate the outcomes of percutaneous treatment of aortic coarctation using self-expandable uncovered Nitinol stents. We conducted a retrospective clinical data review of all patients with aortic coarctation and treated with self-expandable uncovered Nitinol stents at our institution between 2009 and 2019. The gradient pressure across the coarctation site was measured using aortography. Follow-up echocardiography and computed tomography angiography were performed to assess possible stent complications. A total of 127 stents were successfully implanted in 125 patients (64.8% males) with a mean age of 35.36 ± 11.9 years. The gradient across the coarctation site decreased significantly from 67.48 ± 14.79 to 5.04 ± 3.01 mmHg (P < 0.001) after self-expandable stent implantation. Systolic blood pressure (SBP) decreased significantly from 175.53 ± 15.99 to 147.22 ± 12.83 mmHg (P < 0.001) after self-expandable stenting. There were no major technical or clinical complications, including balloon rupture, aneurysmal formation, infection, secondary stent migration, thrombosis, death during the procedure, and in-hospital mortality. On a mean follow-up of 48 ± 23.6 months (12-120 months), the gradient [from 59.43 ± 15.42 to 3.72 ± 1.38 mmHg (P < 0.001)] and SBP [from 175.53 ± 15.99 to 127.99 ± 7.82 mmHg (P < 0.001)] decreased significantly. There was no mortality, aneurysmal formation in the stent site, dislocation, or aortic re-stenosis requiring intervention during mid-term follow-up. Treatment of aortic coarctation using a self-expandable uncovered nitinol stent is safe and effective with promising mid-term outcomes.

Single-Lung Ventilation in Infants for Surgical Repair of Coarctation of The Aorta Without Cardiopulmonary Bypass

OBJECTIVE

To investigate the effect of improving the operative field and postoperative atelectasis of single-lung ventilation (SLV) in the surgical repair of coarctation of the aorta (CoA) in infants without the use of cardiopulmonary bypass (CPB).

METHODS

This was a retrospective cohort study. The clinical data of 28 infants (aged 1 to 4 months, weighing between 4.2 and 6 kg) who underwent surgical repair of CoA without CPB from January 2019 to May 2022 were analyzed. Fourteen infants received SLV with a bronchial blocker (Group S), and the other 14 infants received routine endotracheal intubation and bilateral lung ventilation (Group R).

RESULTS

In comparison to Group R, Group S exhibited improved exposure of the operative field, a lower postoperative atelectasis score (P<0.001), reduced prevalence of hypoxemia (P=0.01), and shorter durations of operation, mechanical ventilation, and ICU stay (P=0.01, P<0.001, P=0.03). There was no difference in preoperative information or perioperative respiratory and circulatory indicators before SLV, 10 minutes after SLV, and 10 minutes after the end of SLV between the two groups (P>0.05). Intraoperative bleeding, intraoperative positive end-expiratory pressure (PEEP), and systolic pressure gradient across the coarctation after operation were also not different between the two groups (P>0.05).

CONCLUSION

This study demonstrates that employing SLV with a bronchial blocker is consistent with enhanced operative field, reduced operation duration, lower prevalence of intraoperative hypoxemia, and fewer postoperative complications during the surgical repair of CoA in infants without the use of CPB.

Perioperative and Anesthetic Considerations in Shone's Complex

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Surgical Considerations in Shone Complex

Shone complex is defined by 4 anomalies: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and coarctation of the aorta. Establishing a clear definition is one of the principal challenges in the study of Shone complex as not all patients have all lesions. The essential feature of Shone complex is multilevel left-sided obstruction involving both the left ventricular inflow and outflow. This anatomic variability is reflected in the clinical presentation as signs of left ventricular inflow obstruction are often masked by outflow obstruction and the multilevel nature of the condition is thus underappreciated. Surgical treatment is often stepwise addressing the outflow obstruction first. In this review, geared to the pediatric cardiac anesthesiologist, we review the pathophysiology, diagnosis, treatment, and outcomes of Shone complex.

The Choice of Optimally Necessary Devices for Endovascular Treatment of Coarctation of the Aorta

The aim. To determine the optimally necessary devices for endovascular stenting of coarctation of the aorta (CoA), considering the anatomical features of the defect and the age of the patient. Materials and methods. Examination and endovascular treatment of 189 patients aged 5 to 60 years with CoA of different anatomical and morphological variants was performed. Results and discussion. We presented the clinical features of different anatomical andmorphological variants of CoA. Endovascular treatment of CoA with stenting is considered the best method for adolescents and adults, due to the lower risk of aneurysm formation compared to balloon angioplasty. We were able to successfully reduce the invasive pressure gradient in patients of different ages and to establish dependence of the frequency of complications on the type of the stent used. There were no cases of in-hospital death. The effectiveness of the intervention was 99.4 %. All the patients were discharged from the hospital in good condition 3-7 days (3.3 ± 1.9 days) after the procedure. Currently, 95.7 % are being followed up. During the 5-year follow-up period, 1 patient died due to concomitant heart failure, heart rhythm disturbances (atrial fibrillation) and mitral insufficiency. There were 10.1 % patients (n = 19) with complications: 4.9 % (n = 4) with open-cell stents, 12.1 % (n = 13) with closed-cell stents, 2.2 % (n = 4) with stent-grafts, 7.9 % (n = 16) with uncovered stents. The frequency of reinterventions was 45.0 % in patients older than 25 years, 37.2 % in those aged 5-18 years and 17.6 % in those aged 19-25 years. Conclusions. The choice of optimally necessary devices for endovascular stenting of the aorta is recommended to be carried out considering the anatomical features of the defect and the age of the patient.

Study on the Mechanism of Cardiac Intensive Care after Thoracoscopic Surgery

Objective

To explore the mechanism of intensive care of the heart after thoracoscopic surgery.

Methods

104 patients with severe cardiac disease were selected after thoracoscopic surgery in our hospital, received nursing care after surgery, and divided into control group (n = 53) and research group (n = 51) according to different nursing methods. Before nursing, the research group carried out targeted nursing and prevention of postoperative complications. The quality of life, complications, anxiety, depression and satisfaction scores, 6-minute walking distance, self-care ability scores, and cardiac function were compared between the two groups.

Results

Patients' quality of life scores improved significantly in both groups after treatment, but the increase was greater in the study group than in the control group (P < 0.05); the incidence of complications was 18.9% and 5.9% in the study and control groups, respectively, and the incidence of complications was lower in the study group than in the control group (P < 0.05); and the incidence of complications was lower in the study group than in the control group (P < 0.05). After care, patients' anxiety and depression scores were significantly lower, and satisfaction scores were significantly higher in both groups, with a greater change in the study group than in the control group (P < 0.05); after care, patients' 6-minute walking distance was significantly higher in both groups, with a greater change in the study group than in the control group (P < 0.05); after care, LVEF indicators were significantly higher, and LVESD and LVED indicators were significantly higher, with a greater change in the study group than in the control group. After care, LVEF indexes increased significantly in both groups, while LVESD and LVED indexes decreased significantly in the study group, with a greater change than in the control group (P < 0.05); after care, systolic blood pressure and heart rate increased significantly in both groups, with a greater increase in the study group than in the control group (P < 0.05); after care, systolic blood pressure and heart rate increased significantly in both groups, with a more significant increase.

Conclusion

Targeted nursing for patients with severe cardiac disease after thoracoscopic surgery has a significant effect, which can improve patients' anxiety and depression, significantly improve patients' self-care ability and quality of life, and at the same time improve patients' cardiac function, heart rate, and blood pressure, with high patient satisfaction.

Management of percutaneous treatment of aorta coarctation diagnosed during pregnancy

Management of coarctation of the aorta (CoA) during pregnancy is complicated by increased procedural risks to the pregnant woman and her fetus. The aim of this research was to analyze 10-years of experience of CoA treatment diagnosed during pregnancy. During 2010–2020 we performed percutaneous stents implantations (SI) in 4 women during 15–23 weeks of pregnancy and in 6 women 48 hours – 5 years after delivery. In all presented cases, successful CoA repair was achieved. There was a significant decrease of peak-to-peak invasive systolic pressure gradient across the CoA (60.0±31.2 and 11.8±7.3 mmHg, p=0.001) and mean noninvasive systolic arterial pressure (163.0±46.2 and 120.5±9.2 mmHg, p=0.01) after SI. All percutaneously treated women during pregnancy (n=4) delivered healthy full-term babies. At follow-up (from 2 months to 10 years), all 10 women are alive without significant Doppler gradient across CoA with no signs of aortic aneurysm formation. To the best of our knowledge, we presented the largest published cohort of CoA percutaneous treatment during pregnancy. We categorized our experience in managing aortic coarctation diagnosed during pregnancy in one algorithm. Our experience demonstrates that excellent maternal and neonatal pregnancy outcomes can be obtained in women after CoA percutaneous repair, diagnosed during pregnancy. An aortic stent implantation is effective and safe for both mother and fetus.