Management of adults with coarctation of aorta

Late Outcomes of Ascending-to-Descending Bypass for Aortic Coarctation

BACKGROUND

Ascending-to-descending aortic bypass is a repair option for patients with complex aortic coarctation. This technique is reported to have minimal early morbidity and mortality; however, the long-term results of the procedure are unknown.

METHODS

This study analyzed the late outcomes of 81 consecutive patients with aortic coarctation who underwent ascending-to-descending aortic bypass through a median sternotomy from January 1985 to December 2012. The study was limited to this interval to allow for a minimum of 10-year follow-up. Fifty-two patients had recurrent coarctation after previous repair, and 44 patients had concomitant cardiac procedures at the time of ascending-to-descending bypass.

RESULTS

There was no perioperative mortality, and overall survival at 5, 10, and 20 years was 94%, 90%, and 85%, respectively, similar to an age- and sex-matched population. There were no interventions for the ascending-to-descending bypass during follow-up, and no deaths were known to be related to the bypass graft. Subsequent cardiac operations were performed through a median sternotomy in 7 patients (9%), and late imaging in 48 patients (59%) demonstrated no hemodynamically significant stenoses or pseudoaneurysms. At late follow-up, median systolic blood pressure was 124 mm Hg, and one-half of the patients were receiving either no or only 1 antihypertensive agent.

CONCLUSIONS

Ascending-to-descending aortic bypass is a safe operation with excellent long-term outcomes for adult patients with complex aortic coarctation. The procedure is durable and appears to improve systemic hypertension. Importantly, ascending-to-descending bypass does not hinder the safe performance of subsequent operations performed through a median sternotomy.

End-to-side anastomosis and autologous pulmonary artery patch for aortic coarctation and hypoplastic aortic arch

Background

Aortic coarctation (CoA) is a congenital heart disease that usually combines various cardiovascular malformations, including hypoplastic aortic arch (HAA). We explore end-to-side anastomosis (ESA) and autologous pulmonary artery patch (APAP) in CoA with HAA, to provide more clinical experience.

Methods

This is a single-center retrospective study. The target population is patients with aortic stenosis and HAA who underwent surgery between 2015 and 2021. All cases included were consecutive, and no instances were omitted due to absent data, lack of consent, or other factors. Collect information on gender, age, and weight at the time of the operation, detailed information on the constricted segment and pressure gradient evaluated by echocardiography and computed tomography (CT), and other factors of patients, and these data were analyzed by statistical methods.

Results

Ninety-six patients (67 males and 29 females) with median age of 76 (41.75, 128.50) days and median weight of 4.20 (3.70, 5.10) kg were enrolled. The follow-up period was 46.20 (34.40, 54.70) months. The patients were divided into two groups based on surgery: ESA (G1, 59) and APAP (G2, 37). The combined cardiovascular malformations were treated simultaneously. None of the patients had neurological events or renal failure, and three died early after the operation. Finally, 93 patients were successfully followed-up. Cox regression showed that ESA was a risk factor for aortic arch geometry is closer to Gothic (G-AAg), elevated blood pressure (EBp), and aortic recoarctation (reCoA) after surgery. In G1, 18 patients had G-AAg (P=0.03), 13 had EBp (P=0.041), and 12 had reCoA (P=0.041), all of which were significantly higher than those in G2 (three had G-AAg, one of whom had EBp and reCoA).

Conclusions

It is safe and effective to repair CoA and HAA and other cardiovascular malformations through one-stage median sternotomy. Compared with ESA, APAP can lower the risks of G-AAg, EBp, and reCoA. Although APAP takes longer, the proper application of selective antegrade cerebral perfusion may lower the risks. We recommend expanding the indications for APAP when circumstances allow, which will benefit patients.

Dislodgement of balloon expandable stent graft in aortic coarctoplasty, protector or proctor fault?: A case report

INTRODUCTION

Coarctation of the aorta is a congenital narrowing of the thoracic aorta associated with hypertension and significant pressure gradients across the coarctation site. Coarctoplasty by percutaneous approach is the preferred method of treatment. However, complications like stent dislodgement may result and must be immediately managed to prevent adverse outcomes.

CASE PRESENTATION

A 29-year-old male, who had previously undergone a mitral valve replacement, presents with exertional dyspnea and systemic hypertension. Blood pressure measurements revealed a 50 mmHg gradient between the upper and lower extremities. Imaging modalities revealed severe CoA with a 45 mmHg peak systolic gradient. During percutaneous coarctoplasty with a balloon-expandable stent, improper use of the yellow applicator resulted in stent dislodgment. A stent was partially deployed and, after post-dilation, the stenosis was resolved. The patient recovered uneventfully and remained asymptomatic with no evidence of recoarctation at six-month follow-up.

DISCUSSION

Coarctoplasty with stent implantation is a relatively safe yet effective treatment for CoA. However, this technique may be complicated by stent dislodgment due to technical error or device-related issues. The major cause of stent dislodgment in the present case was considered failure to use the yellow applicator. Fortunately, prompt corrective measures allowed uneventful deployment of the stent without major complications.

CONCLUSION

Strict adherence to procedural protocols is critical for minimizing complications and achieving optimal outcomes on CoA interventions.

An in silico analysis of heart rate impact on wall shear stress hemodynamic parameters in aortic coarctation

This study examines how heart rate (HR) affects hemodynamics in a South African infant with Coarctation of the Aorta. Computed tomography angiography segments aortic coarctation anatomy; Doppler echocardiography derives inlet flow waveforms. Simulations occur at 100, 120, and 160 beats per minute, representing reduced, resting, and elevated HR levels. Turbulence was analyzed over time and space using turbulence-resolving and pulsatile large-eddy simulations. Specifically, a 60% reduction in HR led to a reduction in maximum velocity by 45%, and a 57% decrease in pressure drop. The reduction in turbulence-related metrics was less significant. The ratio of turbulent kinetic energy to total kinetic energy decreased by 2%, while turbulent wall shear stress decreased by 3%. These results demonstrate that HR significantly affects velocity and pressure drop, while turbulence arising from the coarctation region is relatively unaffected. The balance between turbulent kinetic energy and total kinetic energy shows minimal enhancement due to the complex interplay among HR, turbulence, and geometry. This complexity prompts discussion on how HR-slowing medications, such as beta-blockers or ivabradine, could positively influence hemodynamic stresses. In particular, the results indicate that while HR modulation can influence flow dynamics, it may not significantly reduce turbulence-induced shear stresses within the coarctation zone. Therefore, further investigation is necessary to understand the potential impact of HR modulation in the management of CoA, and whether interventions targeting the anatomical correction of the coarctation may be more effective in improving hemodynamic outcomes.

Surgical revascularisation in an adult with coarctation of the aorta

One of the most common congenital cardiac anomalies is coarctation of the aorta (CoA) It accounts for 4%-6% of all congenital heart defects. A CoA case surviving into adulthood may result in hypertension, weak femoral pulse, limb and bowel ischaemia and heart failure. A man in his early 20s presented with severe lower limb and abdominal pain with long-standing hypertension, refractory to antihypertensives. Difference in upper and lower limb blood pressures, weak peripheral pulses and radiofemoral delay were noted. Angiogram showed adult CoA with total occlusion of the proximal aortic segment. The patient underwent left axillary artery to descending thoracic aorta bypass grafting, had a normal recovery and was put on life-long antihypertensives. An untreated case of CoA surviving into adulthood will result in complications. Any individual with unknown aetiology of hypertension and ischaemic symptoms must be screened for CoA.

The Unique Challenge of Coronary Artery Disease in Adult Patients with Congenital Heart Disease

Advances in medical and surgical interventions have resulted in a steady increase in the number of patients with congenital heart disease (CHD) reaching adult age. Unfortunately, this ever-growing population faces an added challenge: an increased risk of acquiring coronary artery disease. This review provides insight into the complex interactions between coronary artery disease and CHD in adults. We describe the peculiar features of cardiac anatomy in these patients, the possible role cardiac sequelae may play in an increased risk of myocardial ischemia, and the diagnostic challenges in this patient group. Furthermore, this review outlines the risk factors and potential mechanisms of accelerated atherosclerosis in adults with CHD by pointing out areas where current knowledge is incomplete and highlighting areas for further research. The review concludes by examining potential management strategies for this particular population, emphasizing the necessity for a multidisciplinary approach. Understanding the unique coronary risks that adults with CHD experience can enhance patient care and improve long-term results.

CT Angiography for Aortic Arch Anomalies: Prevalence, Diagnostic Efficacy, and Illustrative Findings

Aortic arch anomalies encompass a diverse spectrum of conditions. Elucidating the prevalence of these anomalies, their impact on patient wellbeing, and the most effective diagnostic tools are crucial steps in ensuring optimal patient care. This paper aims to explore the various presentations of aortic arch anomalies, emphasizing the remarkable utility of computed tomography (CT) angiography in their definitive diagnosis and characterization. We conducted a retrospective study on patients who were submitted to the CT angiography of the thoracic aorta or supra-aortic trunks, or the contrast-enhanced CT scans of the thorax and/or cervical region between January 2021 and February 2024 in our Hospital. Out of the total of 2350 patients, 18 were diagnosed with aortic arch anomalies, with an average age of approximately 55 years. The aortic arch anomalies identified in the study were as follows: left aortic arch with the aberrant origin of the right subclavian artery, right aortic arch (types I and II), double aortic arch, aortic coarctation, aortic pseudocoarctation, and ductus diverticulum. Although often asymptomatic, aortic arch anomalies require recognition and CT using advanced post-processing techniques is the optimal diagnostic method with the ability to also identify other associated cardiac or vascular malformations.

A Novel Diastolic Doppler Index Less Affected by Aortic Arch Anomalies Co-existing with Coarctation

Severity assessment for coarctation of the aorta (CoA) is challenging due to concomitant morphological anomalies (complex CoA) and inaccurate Doppler-based indices. Promising diagnostic performance has been reported for the continuous flow pressure gradient (CFPG), but it has not been studied in complex CoA. Our objective was to characterize the effect of complex CoA and associated hemodynamics on CFPG in a clinical cohort. Retrospective analysis identified discrete juxtaductal (n = 25) and complex CoA (n = 43; transverse arch and/or isthmus hypoplasia) patients with arm-leg systolic blood pressure gradients (BPG) within 24 h of echocardiography for comparison to BPG by conventional Doppler indices (simplified Bernoulli equation and modified forms correcting for proximal kinetic energy and/or recovered pressure). Results were interpreted using the current CoA guideline (BPG ≥ 20 mmHg) to compare diagnostic performance indicators including receiver operating characteristic curves, sensitivity, specificity, and diagnostic accuracy, among others. Echocardiography Z-scored aortic diameters were applied with computational simulations from a preclinical CoA model to understand aspects of the CFPG driving performance differences. Diagnostic performance was substantially reduced from discrete to complex CoA for conventional Doppler indices calculated from patient data, and by hypoplasia and/or long segment stenosis in simulations. In contrast, diagnostic indicators for the CFPG only modestly dropped for complex vs discrete CoA. Simulations revealed differences in performance due to inclusion of the Doppler velocity index and diastolic pressure half-time in the CFPG calculation. CFPG is less affected by aortic arch anomalies co-existing with CoA when compared to conventional Doppler indices.

The usefulness of staged extra-anatomic bypass for coarctation of the aorta with arch hypoplasia, from premature neonate to adult

Various surgical techniques have been developed for coarctation of the aorta. However, coarctation repair in neonates with arch hypoplasia remains challenging. We herein report a case in which a premature neonate under 1500 g with coarctation of the aorta and arch hypoplasia underwent an extra-anatomical bypass at 18 days old. A second extra-anatomical bypass was performed at 3 years of age, and a third extra-anatomic bypass for recurrent coarctation was performed in adulthood. By increasing the size of the graft as the patient grows, extra-anatomic bypass can be a useful surgical option for premature neonates with coarctation and arch hypoplasia.

Mini-access ascending aorto-bifemoral bypass surgery for the treatment of aortic steno-occlusive disease

Objectives

Mid-aortic syndrome is a rare condition characterized by severe aortic narrowing, leading to high upper body blood pressure and organ hypoperfusion, necessitating surgical intervention. Although central bypassing is considered ideal, it involves extensive incisions. To overcome these limitations, less-invasive approaches have been developed. This study aims to introduce a mini-access approach using video-endoscopy and to evaluate the feasibility and outcomes of mini-access ascending aorto-bifemoral bypass surgery.

Methods

From November 2020 to May 2022, we performed ascending aorta to bifemoral artery bypass operations on 7 patients to treat steno-occlusive diseases in the downstream aorta. A Y-graft was created, and procedures were conducted under general anesthesia using video-endoscopy with limited skin incisions.

Results

Intraoperatively, there were no major complications, and none of the patients required cardiopulmonary bypass support. Furthermore, there were no postoperative mortalities or major complications. Postoperatively, the mean ankle-brachial index significantly improved from 0.59/0.59 to 0.96/0.92 (P = .004), and the mean glomerular filtration rate increased from 61.1 to 85.3 mL/min/1.73 mm2 (P = .012). Additionally, symptoms of claudication resolved in all patients.

Conclusions

Videoscope-assisted mini-access aortic bypass surgery not only provides favorable early postoperative outcomes but also represents a technically feasible alternative to traditional surgical approaches for the treatment of steno-occlusive aortic diseases.

Team Approach: Diagnosis, Management, and Prevention of Sudden Cardiac Arrest in the Athlete

» Sudden cardiac events during sports competition are rare but tragic occurrences that require a timely, comprehensive response by well-prepared athletic trainers and medical providers. This sequence should prioritize prompt emergency medical system activation, immediate initiation of cardiopulmonary resuscitation (CPR), automated early defibrillation (AED), and comprehensive advanced life support efforts.» Exercise-induced cardiac remodeling, referred to as the "athlete's heart," refers to a host of adaptive changes that increase cardiac chamber size and wall thickness to allow for greater pressures and volumes during exercise. This remodeling phenotype may overlap with other inherited cardiomyopathies and cardiac abnormalities, which can complicate clinical care. The long-term implications of this electrical and structural remodeling on cardiac function are unknown.» Although the best screening strategies to optimize primary prevention of sudden cardiac arrest is an evolving topic, the effectiveness of CPR and early defibrillation use in treating out-of-hospital sudden cardiac arrest has been well-established, despite their reported underuse.

In-Depth Genomic Analysis: The New Challenge in Congenital Heart Disease

The use of next-generation sequencing has provided new insights into the causes and mechanisms of congenital heart disease (CHD). Examinations of the whole exome sequence have detected detrimental gene variations modifying single or contiguous nucleotides, which are characterised as pathogenic based on statistical assessments of families and correlations with congenital heart disease, elevated expression during heart development, and reductions in harmful protein-coding mutations in the general population. Patients with CHD and extracardiac abnormalities are enriched for gene classes meeting these criteria, supporting a common set of pathways in the organogenesis of CHDs. Single-cell transcriptomics data have revealed the expression of genes associated with CHD in specific cell types, and emerging evidence suggests that genetic mutations disrupt multicellular genes essential for cardiogenesis. Metrics and units are being tracked in whole-genome sequencing studies.

Consistency of the continuous flow pressure gradient despite aortic arch anomalies co-existing with coarctation

Aims

Severity assessment for coarctation of the aorta (CoA) is challenging due to concomitant morphological anomalies (complex CoA) and inaccurate Doppler-based indices. Promising diagnostic performance has been reported for the continuous flow pressure gradient (CFPG), but it has not been studied in complex CoA. Our objective was to characterize the effect of complex CoA and associated hemodynamics on CFPG in a clinical cohort.

Methods and Results

Retrospective analysis identified discrete juxtaductal (n=25) and complex CoA (n=43; transverse arch and/or isthmus hypoplasia) patients with arm-leg systolic blood pressure gradients (BPG) within 24 hours of echocardiography for comparison to BPG by conventional Doppler indices (simplified Bernoulli equation and modified forms correcting for proximal kinetic energy and/or recovered pressure). Results were interpreted using the current CoA guideline (BPG ≥20 mmHg) to compare diagnostic performance indicators including receiver operating characteristic curves, sensitivity, specificity, and diagnostic accuracy, among others. Echocardiography Z-scored aortic diameters were applied with computational stimulations from a preclinical CoA model to understand aspects of the CFPG driving performance differences.Diagnostic performance was substantially reduced from discrete to complex CoA for conventional Doppler indices calculated from patient data, and by hypoplasia and/or long segment stenosis in simulations. In contrast, diagnostic indicators for the CFPG only modestly dropped for complex vs discrete CoA. Simulations revealed differences in performance due to inclusion of the Doppler velocity index and diastolic pressure half-time in the CFPG calculation.

Conclusion

CFPG is less affected by aortic arch anomalies co-existing with CoA when compared to conventional Doppler indices.

Outcomes of Heart Failure Hospitalizations in Adult Patients With Coarctation of Aorta: Report From National Inpatient Sample

Coarctation of aorta (CoA) is a common congenital anomaly which portends patients to early diastolic and systolic heart failure. In this retrospective cohort study, we aimed to evaluate the impact of CoA on heart failure hospitalization. Using the national inpatient sample, the study compared the outcomes of heart failure hospitalization between patients with and without CoA. We noted increasing prevalence of CoA related heart failure admissions over the last decade. Heart failure patients with CoA were younger (mean age 57 vs 71.6 years, P < 0.001), had a longer length of stay (7.4 vs 5.4 days, P < 0.001), and a higher incidence of cardiogenic shock (6.5% vs 2.1%, P = 0.001). However, there was no statistically significant difference in in-hospital mortality (OR 1.45, 95% CI: 0.58, 3.62, P = 0.421) between both groups. These findings demonstrate that CoA increase healthcare resource utilization in patients admitted with heart failure without any significant increase in in-hospital mortality.

Arrhythmic and thromboembolic outcomes in adults with coarctation of the aorta

BACKGROUND

Adults with congenital heart disease (ACHD) experience a high prevalence of atrial arrhythmia (AA) and thromboembolic cerebrovascular complications. However, data on AA and associated long-term outcomes are limited in ACHD patients with coarctation of the aorta (CoA).

OBJECTIVES

This study aimed to characterize the prevalence and risk factors for AA and thromboembolic complications in adults with CoA.

METHODS

We conducted a retrospective cohort study in a tertiary ACHD care center and included consecutive CoA patients older than 18 years old with more than one year of follow-up.

RESULTS

Two hundred seventy patients with CoA were followed for 7.2 ± 3.95 years. The mean age was 35.3 ± 11.1 and 55.2% were male. Patients had a mean of 2.1 ± 1.8 cardiovascular surgical or transcatheter procedures. Thirty-five patients (13%) had AA. Ten subjects (3.8%) had a thromboembolic cerebrovascular event, of which four (1.4%) had AA. In univariate analysis, age (p = 0.005) and total intracardiac interventions (p = 0.007) were associated with the presence of AA. Age (p = 0.021), history of heart failure (p = 0.022), and dyslipidemia (p = 0.019) were associated with thromboembolism. In multivariate analysis, age (p < 0.001) and intracardiac interventions (p = 0.007) were associated with AA.

CONCLUSIONS

The rate of AA is higher in adults with CoA than in the general population but lower than in other ACHD. Increasing age and intracardiac interventions were associated with AA. The rate of thromboembolic events was low. Some traditional risk factors for stroke may apply. Larger studies are needed to validate predictors for stroke in this population.

Select Congenital Heart Disease: Important Echocardiographic Features and Changes during Pregnancy

Congenital heart disease (CHD), which affects 1% to 2% of all births, is the most common abnormality in women contemplating pregnancy in western countries. With diagnostic and interventional advances, most patients with CHD survive into adulthood and require lifelong cardiac follow-up with cardiac imaging, particularly echocardiography and cardiac computed tomography. Multiple hemodynamic and physiologic changes of pregnancy may predispose patients with CHD to clinical decompensation and an inability to tolerate pregnancy. This manuscript reviews common CHD lesions, their repair or palliative interventions, long-term sequelae, important features to assess on cardiac imaging, and the impact of pregnancy on these types of lesions. Moreover, the review bridges the fields of CHD, cardiac imaging, and maternal cardiology, which will aid clinicians in counseling patients and managing pregnancies.

How acute renal failure led to the diagnosis of aortic coarctation

The present case report focuses on a rare presentation of aortic coarctation. A 38-year-old man with well-controlled arterial hypertension, minimal change glomerulonephritis and colitis ulcerosa was suffering from recurrent acute renal failure episodes during viral gastroenteritis. No other symptoms at rest or during physical activity were present. The workup included renal duplex sonography, which unmasked tardus parvus profile in both kidneys without any acceleration of blood flow in the renal arteries. Further examination included CT angiography, which confirmed the diagnosis of aortic coarctation. The observed narrowing of the aorta measured 4 mm and was treated with percutaneous transluminal angioplasty and stent implantation (final diameter 12 mm). After the procedure, the patient had normal blood pressure values without the need of any medication; duplex sonography showed improved renal perfusion. The present case confirms the importance of evaluation for secondary hypertension and thorough workup of acute renal failure in young patients.

Diagnosis of covert coarctation of the aorta in adolescents

Objectives

By reviewing the diagnostic process for adolescents with coarctation of the aorta (CoA) in our institution, we analyzed the reasons for delayed diagnosis of CoA. We also proposed a diagnostic protocol to improve the detection rate of CoA.

Methods

In this retrospective study, we included 48 patients aged 12-18 years who were diagnosed with CoA in our hospital from January 2000 to November 2022. Clinical data from involved cases in local hospitals and our institution were collected.

Results

All patients had blood pressure (BP) measurements in upper and lower extremities in our institution. They all had hypertension, 29 (60.4%) of whom had known histories of the same. BP in the upper limbs of 47 (97.9%) patients was ≥20 mmHg higher than that in the lower limbs, and BP in the upper limb of 1 (2.1%) patient was greater than 0 and less than 20 mmHg than that in the lower limb. Echocardiography (ECHO) was performed in all patients, computed tomography (CT) or magnetic resonance imaging (MRI) was performed in 44 patients (91.7%). There were 38 (79.2%) patients who visited local hospitals. Among them, a total of 20 (52.6%) patients had their right upper extremity BP measured, 18 (47.4%) only had their left upper extremity BP measured, and 16 (42.1%) had their lower extremity BP measured. ECHO was performed in 27 (56.2%) patients and CT/MRI was performed in 18 (37.5%) patients. The detection rate for CT/MRI was 100%, and those of ECHO were 72.9% and 18.5% at our institution and a local hospital, respectively. Forty-eight (100%) and 23 (60.5%) patients were detected in our institution and local hospitals (P < 0.0001).

Conclusion

We recommend measuring BP in the bilateral upper extremities. Measurement of BP in the lower extremities is recommended if hypertension is diagnosed. MRI/CT is recommended when BP in the upper extremity is greater than that in the lower extremity.

A percutaneous treatment strategy of an adult patient with a bicuspid aortic valve, coarctation of the aorta, and an exceptionally large aneurysm of a collateral artery: Case report and literature overview

Coarctation of the aorta (CoA) is a congenital heart defect that is associated with a bicuspid aortic valve (BAV), ascending aorta dilatation, intracerebral aneurysms, and premature atherosclerotic disease. The first presentation during late adulthood is rare and is frequently driven by late sequelae. Hypertrophic collateral arteries can develop aneurysms which are at risk for spontaneous rupture, however, treatment recommendations for these aneurysms are scarce. Here, we describe the clinical course and percutaneous treatment strategy of a patient with a late diagnosis of a pin-point CoA, a BAV with moderate regurgitation, and an exceptionally large aneurysm of a collateral artery. A 59-year-old woman was diagnosed with Streptococcus bovis endocarditis of a BAV with moderate aortic valve regurgitation and small vegetation (<5 mm) on the non-coronary cusp. Work-up revealed hypertension and adenocarcinoma in situ of the ascending colon, considered the bacteremia porte d'entrée, for which a curative hemicolectomy was performed. Echocardiography showed a narrowing of the aorta distal from the origin of the left subclavian artery with the antegrade diastolic flow with a pathognomonic "sawtooth" pattern and an estimated pressure gradient of >70 mmHg. Computed tomography angiography (CTA) showed a network of well-developed collateral arteries and a levoatriocardinal vein. One of the collateral arteries arising from the left subclavian artery revealed an exceptionally large aneurysmatic dilation (29 × 24 × 24 mm). The invasive assessment confirmed a hemodynamically significant CoA. Treatment involved balloon dilatation and placement of a covered stent at the site of the pin-point CoA and a percutaneous coronary intervention (PCI) of the stenosis in the left anterior descending artery. No residual gradient over the CoA was observed. Antihypertensive drugs could be discontinued, and CTA performed 4 months later showed regression and thrombosis of the numerous collaterals and, importantly, thrombosis of the large aneurysm. This case illustrates the late diagnosis of CoA with associated congenital heart defects and late sequelae including hypertension, BAV endocarditis, coronary artery disease, and aneurysm formation of the extensive collateral network. The patient underwent pharmacological and percutaneous treatment, ultimately resulting in the alleviation of the CoA, normalization of the blood pressure, reduction of collateral flow, and thrombosis of the large aneurysm of the collateral artery.

Surgical treatment of Shone's syndrome and patent ductus arteriosus in an adult

BACKGROUND

Shone's syndrome is a rare complex congenital anomaly. The classical definition consists of four anomalies: supravalvular mitral membrane, parachute mitral valve (PMV), subaortic stenosis, and coarctation of the aorta (CoA). Few studies have been reported on Shone's syndrome in adults, particularly the primary surgical correction of the anomalies.

CASE PRESENTATION

A 22-year-old female patient presented with chest distress and tachypnea. Echocardiography and CT revealed supravalvular mitral membrane, PMV, Bicuspid aortic valve stenosis, CoA and patent ductus arteriosus. She underwent primary definitive surgical correction successfully and was discharged from hospital with symptoms free.

CONCLUSIONS

Our case report highlights the importance of echocardiographic evaluation in the diagnosis of Shone's syndrome. The surgical strategy should be tailored according to both the patient's profile and the surgeon's personal surgical experience. Extra-anatomical bypass procedure is an appropriate technique for adult patients with long-segment coarctation and concomitant cardiac lesions. The outcomes of the case study indicate that the primary definitive surgery is encouraging.

Difference and similarity between type A interrupted aortic arch and aortic coarctation in adults: Two case reports

BACKGROUND

Aortic coarctation (CoA) is usually confused with interrupted aortic arch (IAA), especially adult type A interrupted aortic arch, due to their similar anatomical location. Although the main difference between them is whether arterial lumen exhibits continuity or not, the clinical manifestations are similar and connection exists between them. Adult type A IAA is considered as an extreme form of CoA, which is complete discontinuity of aortic function and lumen caused by degenerative arterial coarctation. This paper reports two cases (interrupted aortic arch and severe aortic coarctation) to analyze the difference and similarity between them.

CASE SUMMARY

The two cases of patients presented with hypertension for many years. Computed tomography angiography showed that the aortic arch and descending aorta were discontinuous or significantly narrowed with extensive collateral flow. The IAA patient refused surgical treatment and blood pressure could be controlled with drugs. While the CoA patient underwent stent implantation because of uncontrollable hypertension, the blood flow recovered smoothly and the blood pressures at both ends of the stenosis returned to normal after surgery.

CONCLUSION

Adult type A IAA and CoA have difference and similarity, and type A IAA is associated with CoA to a certain extent. The treatment method should be chosen based on the patient's clinical symptoms rather than the severity of the lesion.

Aortic Arch Variants and Anomalies: Embryology, Imaging Findings, and Clinical Considerations

There is a wide spectrum of congenital anomalies or variations of the aortic arch, ranging from non-symptomatic variations that are mostly detected incidentally to clinically symptomatic variations that cause severe respiratory distress or esophageal compression. Some of these may be accompanied by other congenital heart diseases or chromosomal anomalies. The widespread use of multidetector computed tomography (CT) in clinical practice has resulted in incidental detection of several variations of the aortic arch in adults. Thus, radiologists and clinicians should be aware of the classification of aortic arch anomalies and carefully look for imaging features associated with a high risk of clinical symptoms. Understanding the embryological development of the aortic arch aids in the classification of various subtypes of aortic arch anomalies and variants. For accurate diagnosis and precise evaluation of aortic arch anomalies, cross-sectional imaging modalities, such as multidetector CT or magnetic resonance imaging, play an important role by providing three-dimensional reconstructed images. In this review, we describe the embryological development of the thoracic aorta and discuss variations and anomalies of the aortic arch along with their clinical implications.

Hybrid Procedure for Coexistence of Coarctation of the Aorta and Aberrant Right Subclavian Artery: A Case Report and Review of the Literature

Background: Coarctation of the aorta (CoA) can either present alone as an isolated condition or in association with other aortic arch or cardiac anomalies. One percent of patients with CoA have concomitant an aberrant right subclavian artery (ARSA). Purpose: We report the case of a 35-year-old woman with uncontrolled hypertension who was found to have CoA and ARSA. Results: The patient was treated successfully using a hybrid procedure comprising ARSA ligation and subclavian to carotid transposition, followed by thoracic endovascular aortic repair. Conclusions: Patients with CoA should be carefully studied, considering the possible coexistence of other congenital aortic arch defects, such as ARSA. Hybrid repair is a safe and effective approach for this condition.

Delayed presentation of massive haemoptysis from aortic aneurysm after aortic coarctation repair (a case report)

Introduction

Massive haemoptysis refers to coughing and losing a huge amount of blood in a 24-hour period. It's a life-threatening condition with high mortality rate.

Case presentation

We report a rare case of massive haemoptysis in a 60-year-old female patient who had aortic coarctation repair 30 years ago. Her Computed tomography (CT) angiography showed huge aneurysmal dilatation and dissection of the descending thoracic aorta at the site of the repair. Thoracic endovascular aortic repair (TEVAR) was done, but the patient had recurrent massive haemoptysis due to extension of the aneurysm to the aortic arch. The patient then underwent one stage surgical right to left carotid artery shunt followed by TEVAR to the aortic arch covering the left common carotid artery. The procedure was successful, and haemoptysis was controlled without any complications.

Discussion

In this case the high index of suspicion for thoracic aortic aneurysm in patients presenting with haemoptysis and prior history of coarctation repair were demonstrated.

Conclusion

massive haemoptysis in patients who had aortic coarctation repair is an alarming sign, and surgical intervention is required. TEVAR has become one of the best approaches for managing aortic aneurysm and has replaced open repair.

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Thoracic aortic aneurysms must be ruled out in those patients who present with massive hemoptysis.

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In case of aortic coarctation repair, thoracic aortic aneurysms should be considered.

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Thoracic endovascular aortic repair (TEVAR) has become one of the best approaches for managing thoracic aortic pathology.

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In patients who present with massive hemoptysis post TEVAR, aneurysms and endoleak must be ruled out.

Late Complications After Previous Surgical Repair for Coarctation With Extra-Anatomic Bypass Graft: Report on Two Cases

Surgical correction of aortic coarctation (CoA) has been the standard treatment in infants and adolescents to prevent late consequences related to obstruction and distal hypoperfusion. Several surgical techniques for CoA repair have traditionally been applied. However, late complications, including re-CoA and pseudoaneurysm formation, are not uncommon. The incidence of complications is highly related to the type of initial surgery. Here, we are reporting two cases of late complications related to an infrequently used surgical technique, the extra-anatomical aortic bypass graft (EABG). The first case presented with pseudoaneurysm at the distal anastomosis site with the descending aorta and treated by endovascular stent graft. The second case presented with stenosis at the proximal anastomosis site with the left subclavian artery (LSCA) and treated medically upon the request of the patient.