Stenting of critical aortic coarctation in neonates between 600 and 1,350 g. Using a transfemoral artery approach. A single center experience

Follow-up outcomes and effectiveness of stent implantation for aortic coarctation: A systematic review and meta-analysis

BACKGROUND

The authors aim to investigate the clinical implications of stent use for the management of CoA.

METHODS

All observational studies on stent implantation for the treatment of aortic coarctation and the relevant RCTs were systematically retrieved. Outcomes included the immediate success rate, pre- and post-stent gradient, survival, minor and major complications, restenosis, post-stent systolic blood pressure, and reintervention rate. The analysis was further stratified by CoA type, stent type, and the mean age of the patients.

RESULTS

Our meta-analysis incorporated 66 eligible studies involving 3,880 patients. The success rates for stent placement, defined as achieving post-treatment gradients of ≤20 mmHg and 10 mmHg, 0.96 (95% CI: 0.95 - 0.97; I2 = 59.83%) and 0.92 (95% CI: 0.89 - 0.95, I2 = 77.63%) respectively. The complication rates were quite low, with minor and major complication rates of 0.017 (95% CI: 0.013 - 0.021) and 0.007 (95% CI: 0.005 - 0.009), respectively. Unplanned reinterventions were required at a rate of 0.021 (95% CI: 0.015 - 0.026). At a mean follow-up of 2.9 years, 97% of the patients survived and 28% remained on antihypertensive therapy. While immediate effectiveness was consistent across age groups, complications were more prevalent in patients aged <20 years, and long-term efficacy was lower in those aged >20 years. Encouragingly, in neonates and infants, CoA stenting yielded results comparable to those observed in older children.

CONCLUSION

These findings underscore the overall favorable outcomes of stent placement for aortic coarctation, with considerations for age-related variations in complications and long-term efficacy.

Alternative technique for femoral access in neonates undergoing cardiac catheterization

We report an alternative technique for femoral access in neonates <3.5 kg undergoing cardiac catheterization. By modifying a 0.014" Balance middleweight Elite wire and using a 24-gauge Galt introducer needle, we have noted increased ease and success in obtaining vascular access in this challenging cohort.

Results of Aortic Coarctation Repair in Low- and Normal Birth-Weight Neonates: A Propensity Score-Matched Analysis

INTRODUCTION

Surgical treatment of aortic coarctation in low-birth-weight (LBW) neonates is associated with risks of higher hospital mortality rates and recoarctation development in the long-term. The goal of our study was to compare the results of surgical treatment of aortic coarctation in LBW neonates and normal-weight patients, to identify predictors of recoarctation in the long-term among LBW patients.

MATERIALS AND METHODS

A retrospective study was performed to analyse the patients who had undergone resection of isolated aortic coarctation between 2005 and 2022. Overall analysis included 521 patients under the age of 30 days, 89 LBW patients and 432 patients with normal body weight. Propensity score matching (PSM) was performed at a ratio of 1:1 for the statistical adjustment of original patients' data in both groups.

RESULTS

All patients underwent standard resection of aortic coarctation with extended end-to-end anastomosis. Hospital mortality among LBW patients was 8% and in patients with normal weight the mortality amounted to 1% (p = 0.030). LBW patients were transferred to other hospitals more often than normal-weight patients who were more often discharged (p < 0.001). In the long-term, period mortality was not statistically significantly different (p = 0.801). The freedom from reoperation in the group of normal-weight children was 87%, whereas in the LBW patients the rate was 63% (log rank test, p = 0.104). In the multivariate regression model, the most significant risk factors for reoperation were as follows: preoperative inotropes administration (OR (95% CI) 4.369 (1.316-14.51)) and pressure gradient across aortic arch before discharge (OR (95% CI) 1.081 (1.014-1.153)).

CONCLUSIONS

Hospital mortality was higher among LBW patients (p = 0.030). There was a statistical trend of differences in reoperation rates: in the long-term among LBW patients, a higher reintervention probability remains. Moreover, the LBW group initially had more severe clinical condition in terms of cardiac failure and impaired renal function. Factors associated with the risk of recoarctation were preoperative inotropes infusion and pressure gradient across aortic before discharge.

Outcomes after aortic coarctation repair in neonates weighing less than 2000 g

BACKGROUND

Preterm birth is common in children with congenital heart disease. However, data on how to manage low-birth-weight infants with aortic coarctation are scarce and outcomes are poorly reported. Surgery is often delayed in these infants because gaining weight is supposed to improve mortality and to reduce the risk for recoarctation.

METHODS

All infants weighing less than 2000 g who underwent repair for aortic coarctation at our institution between January 2017 and December 2020 were included in a retrospective study. Baseline characteristics, medical and surgical management, and outcomes, including recoarctation, death, and complications of preterm birth, were analyzed.

RESULTS

A total of 15 patients had coarctation repair at a median age of 15 days and at a median weight of 1585 g. Infants with a birth weight <1200 g were operated on later and did not have higher recoarctation rates compared to those with a birth weight >1200 g. The recoarctation rate was 26.6% and one infant died of an extracardiac cause. Concerning prematurity-related complications, we observed 40% of bronchopulmonary dysplasia, 40% of intraventricular hemorrhage, and 27% of retinopathy of prematurity. These complications were more prevalent in children with a birth weight of <1200 g.

CONCLUSION

Delaying surgery beyond 15 days to gain weight does not appear to decrease the risk of recoarctation and may be deleterious in low-birth-weight infants who are exposed for a longer period to risk factors of prematurity-related complications.

Percutaneous closure of simple congenital heart diseases under echocardiographic guidance

Congenital heart disease (CHD), birth defect with the highest incidence rates worldwide, and is mainly characterized by the abnormal internal structure of the heart or/and the anatomical structure of great vessels. In the past few decades, CHD repair surgery through standard median sternotomy incision combined with cardiopulmonary bypass (CPB) technology has been considered the gold standard for surgical correction of heart and great vessels. With the promotion and clinical application of interventional catheterization technology, transcatheter closure of CHD under radioactive radiation has gradually been recognized and applied. However, its radiation exposure and potential complications related to arteriovenous vessels still face challenges. In recent years, an increasing number of surgeons have explored new surgical procedures, for the safe and effective treatment of CHD, as far as possible to reduce surgical trauma, avoid radiation exposure, and improve the cosmetic effect. Therefore, on the premise of satisfactory exposure or guidance, how to integrate ultrasound and percutaneous interventional technology remained the focus of the exploration. This mini-review highlights and summarizes the signs of progress of ultrasound intervention in the last decade that have proven the effectiveness and operability of a well-established procedure for percutaneous closure of congenital heart diseases under echocardiographic guidance only. We discuss potential diseases that will benefit from this emerging procedure based on this progress. Owing to the crucial advantages played by this strategy in the treatment of CHD, better understanding and promotion of this less exploited field may contribute to the development of therapeutics targeting CHD, improve medical utilization rate, promote the optimization of medical resources, and ultimately achieve precise and efficient medical treatment.

Fluoroscopy-free, echocardiography-guided hybrid stenting of native aortic coarctation in a 920-grams premature infant

Therapeutic options are limited for the management of extremely low-birth-weight infants with critical aortic coarctation despite high doses of prostaglandin infusion. We report successful hybrid, fluoroscopy-free, echocardiography-guided primary stenting of native aortic coarctation in a 920-grams premature infant.

Transcatheter Interventions for Neonates with Congenital Heart Disease: A Review

Newborns with congenital heart disease often require interventions linked to high morbidity and mortality rates. In the last few decades, many transcatheter interventions have become the first-line treatments for some critical conditions in the neonatal period. A catheter-based approach provides several advantages in terms of procedural time, length of hospitalization, repeatability and neurodevelopmental issues (usually related to cardiopulmonary bypass). The main transcatheter procedures will be reviewed, as they are now valid alternatives to conventional surgical management.