Current management of coarctation of the aorta

Aortic Coarctation Stenting in Adolescents and Adults: A Single-Center Experience

PURPOSE/BACKGROUND

The aim of this study was to evaluate the short and midterm results of aortic coarctation (AoCo) stenting in an adolescent and adult population.

METHODS

All patients with a AoCo older than 14 years treated by stent placement between December 2000 and November 2016 were included in this study. Twenty-eight patients with an invasive peak systolic pressure gradient >20 mmHg were identified. Number of redilations, non-invasive systolic blood pressure, peak systolic pressure gradient, antihypertensive medication intake, claudication status and complications were evaluated.

RESULTS

Twenty-two covered and 6 uncovered stents were successfully placed. Peak systolic pressure gradient decreased immediately after stenting from a mean of 32 mmHg to 0 mmHg (± 7 mmHg). Mean AoCo diameter increased from 8 tot 16 mm (± 4 mm). Peripheral arterial injury was seen in 2 patients (7.1%). The mean follow-up time was 60 ± 49 months. Redilation of the stent was required in 4 patients, 2 to accommodate for growth and 2 for restenosis. Six (35%) patients could stop all antihypertensive medication. All claudicants (6/28) became and remained asymptomatic after surgery and during their follow-up. No aneurysms, stent fractures or dissections were noticed. There were 2 stent migrations during the first procedure with only 1 needing additional stent placement.

CONCLUSION

Aortic coarctation stenting is a safe and effective treatment that significantly reduces the peak systolic pressure gradient. Antihypertensive medication can be reduced, and increase of walking distance in claudicants can be obtained. Younger patients may need more frequent reinterventions to accommodate for growth.

Coarctation of the Aorta: Modern Paradigms Across the Lifespan

While coarctation of the aorta varies greatly in both severity and age at presentation, all patients are at increased risk of hypertension both before and after repair. Despite advances in knowledge about genetic etiologies, pathophysiologic mechanisms, and optimal repair strategies, patients with repaired coarctation of the aorta remain at increased risk of acquired cardiovascular disease. The aims of this review are to describe the management of coarctation of the aorta at all ages before and after repair, highlight pathophysiologic mechanisms of hypertension, and review long-term follow-up considerations.

Percutaneous Treatment of Ascending Aortic Obstruction in a Young Child After Orthotopic Heart Transplantation

We report a case of a 14-month-old child with ascending aortic obstruction (AAO) post cardiac transplantation, who underwent successful percutaneous ascending aortic stent angioplasty. Congenital or acquired AAO is typically treated with surgical augmentation. The experience with percutaneous techniques is limited and often avoided due to challenges with equipment stability and proximity to coronary arteries and aortic valve leaflets. This case highlights that a percutaneous approach to relief of AAO is a feasible alternative even in small children utilizing a newer pre-mounted stent.

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.

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.

Aortic coarctation in an asymptomatic patient with arterial hypertension initially evaluated by Doppler ultrasound in the emergency room: A case report

Aortic coarctation is a severe pathology that can be underdiagnosed in pediatric patients. We present 1 case of a patient diagnosed with aortic coarctation in the emergency department, referred by his treating physician when detecting high blood pressure figures. This study focuses on the diagnostic approach and Doppler ultrasound findings.

Impact of extra-anatomical bypass on coarctation fluid dynamics using patient-specific lumped parameter and Lattice Boltzmann modeling

Accurate hemodynamic analysis is not only crucial for successful diagnosis of coarctation of the aorta (COA), but intervention decisions also rely on the hemodynamics assessment in both pre and post intervention states to minimize patient risks. Despite ongoing advances in surgical techniques for COA treatments, the impacts of extra-anatomic bypass grafting, a surgical technique to treat COA, on the aorta are not always benign. Our objective was to investigate the impact of bypass grafting on aortic hemodynamics. We investigated the impact of bypass grafting on aortic hemodynamics using a patient-specific computational-mechanics framework in three patients with COA who underwent bypass grafting. Our results describe that bypass grafting improved some hemodynamic metrics while worsened the others: (1) Doppler pressure gradient improved (decreased) in all patients; (2) Bypass graft did not reduce the flow rate substantially through the COA; (3) Systemic arterial compliance increased in patients #1 and 3 and didn't change (improve) in patient 3; (4) Hypertension got worse in all patients; (5) The flow velocity magnitude improved (reduced) in patient 2 and 3 but did not improve significantly in patient 1; (6) There were elevated velocity magnitude, persistence of vortical flow structure, elevated turbulence characteristics, and elevated wall shear stress at the bypass graft junctions in all patients. We concluded that bypass graft may lead to pseudoaneurysm formation and potential aortic rupture as well as intimal hyperplasia due to the persistent abnormal and irregular aortic hemodynamics in some patients. Moreover, post-intervention, exposures of endothelial cells to high shear stress may lead to arterial remodeling, aneurysm, and rupture.

Endovascular treatment of aortic coarctation with a novel BeGraft aortic stent in children and young adults: a single-centre experience with short-term follow-up results

OBJECTIVES

We present our experience and outcomes with the BeGraft in the treatment of aortic coarctation in a predominantly paediatric population.

METHODS

This study includes a retrospective analysis of patients who had Begraft aortic stent implantation between 2018 and 2020 from a single centre.

RESULTS

The BeGraft aortic stent was used in 11 patients (7 males, 4 females) with a median age of 14 (13-21) years and a median weight of 65 (46-103) kg. Coarctation was native in five patients and recurrent in six patients. Median stent diameter and length were 16 mm and 38 mm, respectively. The median peak-to-peak pressure was 30 (12-55) mmHg before the procedure and 5 (0-17) mmHg after the procedure. The stenting procedure was successful in 10 of the 11 patients. Stent migration to the abdominal aorta occurred on post-procedure day 1 in the 21-year-old patient, who had previously undergone surgical closure of the ventricular septal defect and balloon angioplasty for coarctation. After repositioning failed, the stent was safely fixed in the abdominal aorta. Strut distortion also occurred during balloon retrieval in one patient, but no aneurysm or in-stent restenosis was observed at 1-year follow-up. The patients were followed for a median of 14 (4-25) months and none required redilation.

CONCLUSIONS

Our initial results demonstrated that the BeGraft aortic stent effectively reduced the pressure gradient in selected native and recurrent cases. Despite advantages such as a smaller sheath and low profile, more experience and medium- to long-term results are needed.

Necessity of life-long follow-up after surgery for coarctation of the aorta: a case series of very late false aneurysm formation

BACKGROUND

Coarctation of the aorta accounts for 5-7% of congenital defects of the heart and great vessels. It requires treatment in the form of open surgical or percutaneous repair. Common long-term complications include re-stenosis and aneurysm formation. The formation of a false aneurysm is a complication with a significant morbidity and mortality.

CASE SUMMARY

We reviewed six cases of late false aneurysm after repair of a coarctation of the aorta. Our six cases developed a false aneurysm after an open surgical repair of a coarctation more than 30 years after initial surgical repair. All aneurysms were located at the aortic repair site.

DISCUSSION

The symptoms or risk factors in the described cases are not uniform and are difficult to include in a general follow-up protocol. Guidelines recommend frequent evaluation, but do not specify duration or intervals of imaging follow-up. Our cases support the necessity of life-long follow-up in patients with open aortic repairs irrespective of symptomatology.

Adult congenital heart disease: a review of the simple lesions

There has been a dramatic improvement in mortality rates among children with congenital heart disease with advances in neonatal screening and surgical techniques, resulting in a significant increase in the prevalence of adults living with congenital heart disease. The most common simple lesions of congenital heart disease include atrial and ventricular septal defects, patent ductus arteriosus and coarctation of the aorta, which are typically detected and treated in childhood. However, they may also present in adulthood with non-specific symptoms or incidental findings, such as refractory hypertension. As the adult population of those living with congenital heart disease grows, it is imperative that all clinicians remain abreast of these common cardiac conditions, irrespective of their specialty, as patients may present with sequelae of their congenital heart disease or other non-cardiac conditions.

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.

The clinical presentation and outcome of aortic coarctation associated with left ventricular inflow and outflow tract lesion in adult patients: Shone syndrome and beyond

BACKGROUND

Aortic coarctation (AoCoa) is a congenital stenosis of aorta, which often co-exists with other congenital heart defects. Many studies have shown the importance of regular follow-up in these patients however there is scarcity of knowledge relating to the impact of left ventricle inflow lesions (LVIT) and left ventricle outflow track lesions (LVOT). The aim of this study is to evaluate the impact of isolated AoCoa with LVIT and/or LVOT on haemodynamic, morbidity and mortality.

METHODS

We have retrospectively analysed clinical data of all adult AoCoa patients who underwent echocardiography between 2010-2018 in our centre. Outcome measures included death, number of hospitalisations for cardiac causes, development of cardiac arrhythmia, new prescription of HF medication.

RESULTS

A total of 406 AoCoa patients were included and were followed for a median 4.2 years. At baseline, 38% patients had AoCoa alone, 54% patients had LVOT, 3% patients had LVIT, and 5% patients had mixed LVIT and LVOT, including patients with Shone syndrome. Patients with mixed LVIT and LVOT had the highest mortality of the four groups and the highest heart failure-related morbidity. Moreover, they were the most prone to have a higher indexed LA volume compared to patients with no LVOT (p=0.0001). During follow-up, 13 patients died, of which 21% patients were from the mixed LVIT and LVOT group.

CONCLUSIONS

AoCoa patients with a combination of LVIT and LVOT including Shone complex are associated with a significantly higher morbidity and mortality compared to AoCoa alone.

The effect of coarctation degrees on wall shear stress indices

Coarctation of the aorta (CoA) is a congenital tightening of the proximal descending aorta. Flow quantification can be immensely valuable for an early and accurate diagnosis. However, there is a lack of appropriate diagnostic approaches for a variety of cardiovascular diseases, such as CoA. An accurate understanding of the disease depends on measurements of the global haemodynamics (criteria for heart function) and also the local haemodynamics (detailed data on the dynamics of blood flow). Playing a significant role in clinical processes, wall shear stress (WSS) cannot be measured clinically; thus, computation tools are needed to give an insight into this crucial haemodynamic parameter. In the present study, in order to enable the progress of non-invasive approaches that quantify global and local haemodynamics for different CoA severities, innovative computational blueprint simulations that include fluid-solid interaction models are developed. Since there is no clear approach for managing the CoA regarding its severity, this study proposes the use of WSS indices and pressure gradient to better establish a framework for treatment procedures in CoA patients with different severities. This provides a platform for improving CoA therapy on a patient-specific level, in which physicians can perform treatment methods based on WSS indices on top of using a mere experience. Results show how severe CoA affects the aorta in comparison to the milder cases, which can give the medical community valuable information before and after any intervention.

Can a self-expanding pediatric stent expand with an artery? Relationship of stent design to vascular biology

OBJECTIVES

A large-diameter, intravascular, self-expanding stent system capable of continued expansion during somatic and vascular growth was modeled with finite element analysis (FEA), manufactured and tested in an animal model.

BACKGROUND

Children can quickly outgrow intravascular stents. If a stent could expand after implantation in arteries this would be ideal for use in pediatric patients.

METHODS

Computer-aided design and FEA were used to design and manufacture large-diameter, self-expanding nitinol stents with both high and low chronic outward force (COF). Four distinct stents with similar designs but with variable lengths and strut thicknesses were manufactured. Fourteen of these stents were implanted in the abdominal aortas or iliac arteries of four juvenile swine.

RESULTS

All animals survived without complication to their designated time points of harvest (90 or 180-days), and all stents expanded to greater diameters than the adjacent non-stented artery. Luminal diameter growth was 34-49% and 20-23% for stented and non-stented segments, respectively. Histologic examination revealed variable degrees of the internal elastic lamina and/or medial disruption with a mean injury score ranging from 0.70 ± 0.56 to 1.23 ± 0.21 and low COF stents implanted in smaller arteries having a larger injury score. Inflammatory responses and stenosis formation were minimal and ranged from 0.50 ± 0.71 to 3.00 ± 0.00 and 5.52 ± 1.05% to 14.68 ± 9.12%, respectively. The stent's COF did not correlate with vessel expansion or vascular injury.

CONCLUSIONS

Self-expanding stents can mirror and even exceed somatic growth. Although longer-term testing is needed, it may be possible to custom tailor self-expanding stents to expand after arterial implantation in pediatric patients.

Delayed Therapy of Descending Aortic Coarctation Results in Anterior Cerebral Rupture: A Case Report

Background: Coarctation of the aorta (CoA) is the congenital constriction or narrowing of the aortic lumen. These constrictions are primarily located in the descending aorta causing significant discrepancies in systolic blood pressures of the upper and lower extremities. Thus, a delay in diagnosis and treatment may lead to severe and adverse consequences. Case presentation: Herein, we present a 13-year-old boy with anterior cerebral rupture following a delayed diagnosis for descending CoA. Percutaneous transluminal balloon dilatation and endovascular stent implantation were urgently and successfully performed alongside cerebral clipping of the vascular aneurysm. Conclusion: An early diagnosis is crucial for CoA's successful treatment and management to prevent complications, including anterior cerebral rupture.

A Rare Case of Haemoptysis Revealing Aortic Coarctation in an Adult

Haemoptysis is a frequently occurring but sometimes life-threatening condition. Congenital cardiovascular abnormalities are rare causes of haemoptysis. We report a case of a 33-year-old man without any past medical history complaining of haemoptysis with no other associated clinical manifestations. A contrast-enhanced chest computed tomography scan revealed aortic coarctation with dilation of the internal mammary, intercostal and bronchial arteries. He underwent stent placement after balloon angioplasty with favourable outcomes.

LEARNING POINTS

Adult patients with congenital cardiovascular abnormalities such as aortic coarctation may rarely, due to the high pressure and dilation in the bronchial arteries, present with recurrent haemoptysis as the sole clinical sign.A multidetector computed tomography scan contributes significantly to the aetiological diagnosis of haemoptysis in cases of congenital cardiovascular abnormalities.Interventional procedures such as stenting are currently the preferred approach for the treatment of aortic coarctation in adults, with good outcomes.

The efficacy and safety of percutaneous balloon angioplasty for aortic coarctation in children. Acute and mid-term results in a single center experience

OBJECTIVES

To assess the efficacy and safety of balloon angioplasty (BAP) procedure for treatment of coarctation of the aorta (CoA) in children. Methods: A retrospective study included 27 consecutive children, underwent BAP for either native-CoA (Na-CoA) or recoarctation (Re-CoA). Medical records, echocardiographic findings, angiographic and hemodynamic data were collected from the hospital database. Follow‑up was scheduled at 1, 3, 6, 12 months after the procedure. The study took place over a period of 4.5 years, from April 2014 to January 2019, in Madinah Cardiac Center, Madinah, Northwest region, Saudi Arabia.

RESULTS

The mean age of patients was 11.86±8.96 months. Seven children had Na-CoA and 20 children had Re-CoA. The success rate of the procedure was achieved in 23 children (85%), as BAP reduced the mean systolic pressure gradient across the CoA (Na-CoA: from 45.28± 18.3 to 9.8± 6.57 mm Hg, p=0.0009), and in Re-CoA groups (from 42.48±16.7 to 10.9±8.5 mm Hg, p less than 0.0001). In mid-term follow-up, the need for re-intervention occurred in 8 children of the cohort (3 children [42.8%] from the Na-CoA group, and 5 children [25%] from the Re-CoA group).  Conclusions: Balloon angioplasty is considered a safe procedure for the management of CoA, but its efficacy remains questionable especially for young infants with Na-CoA type. However, it is a reliable option for managing Re-CoA children, with a lower rate of future re-intervention.

Automatic Shape Optimization of Patient-Specific Tissue Engineered Vascular Grafts for Aortic Coarctation

This paper proposes a computational framework for automatically optimizing the shapes of patient-specific tissue engineered vascular grafts. We demonstrate a proof-of-concept design optimization for aortic coarctation repair. The computational framework consists of three main components including 1) a free-form deformation technique exploring graft geometries, 2) high-fidelity computational fluid dynamics simulations for collecting data on the effects of design parameters on objective function values like energy loss, and 3) employing machine learning methods (Gaussian Processes) to develop a surrogate model for predicting results of high-fidelity simulations. The globally optimal design parameters are then computed by multistart conjugate gradient optimization on the surrogate model. In the experiment, we investigate the correlation among the design parameters and the objective function values. Our results achieve a 30% reduction in blood flow energy loss compared to the original coarctation by optimizing the aortic geometry.

Perioperative Anaesthetic Management for Laparoscopic Gastrectomy in a Patient with Coarctation of Aorta

Coarctation of the aorta (CoA) is a congenital condition, usually diagnosed and corrected early in life. Long-term survival with untreated coarctation is uncommon and is associated with high mortality rates in the fifth decade. A patient with CoA may present with problems while undergoing cardiac or non-cardiac surgical procedures which could pose considerable challenges in their anaesthetic management. Hence, the choice of anaesthetic technique plays an important role in determining the perioperative course and postoperative outcome in patients with CoA. This report discusses a case of middle-age man, recently diagnosed with CoA while undergoing a preanaesthetic assessment prior to the surgery for gastric adenocarcinoma involving proximal gastro-oesophageal junction. It highlights the successful anaesthetic management of CoA scheduled for laparoscopic-assisted gastrectomy for gastric adenocarcinoma. Perioperative management goals of the patient included general anaesthesia, epidural analgesia to avoid pain-associated adverse effects and efficient control of blood pressure distal to coarctation to limit the risk of intraoperative morbidity. It also demonstrates a major impact on anaesthesiologists who serve the most important role in managing such patients undergoing surgery with ‘red flag’ features.

Subject-specific simulation for non-invasive assessment of aortic coarctation: Towards a translational approach

We present a multi-scale CFD-based study conducted in a cohort of 11 patients with coarctation of the aorta (CoA). The study explores the potential for implementation of a workflow using non-invasive routinely collected medical imaging data and clinical measurements to provide a more detailed insight into local aortic haemodynamics in order to support clinical decision making. Our approach is multi-scale, using a reduced-order model (1D/0D) and an optimization process for the personalization of patient-specific boundary conditions and aortic vessel wall parameters from non-invasive measurements, to inform a more complex model (3D/0D) representing 3D aortic patient-specific anatomy. The reliability of the modelling approach is investigated by comparing 3D/0D model pressure drop estimation with measured peak gradients recorded during diagnostic cardiac catheterization and 2D PC-MRI flow rate measurements in the descending aorta. The current study demonstrated that the proposed approach requires low levels of user interaction, making it suitable for the clinical setting. The agreement between computed blood pressure drop and catheter measurements is 10  ±  8 mmHg at the coarctation site. The comparison between CFD derived and catheter measured pressure gradients indicated that the model has to be improved, suggesting the use of time varying pressure waveforms to further optimize the tuning process and modelling assumptions.

Cardiovascular computed tomography versus transoesophageal echocardiography after cryptogenic ischaemic stroke – a pilot study of 12 patients

Objective

Transoesophageal echocardiography (TEE) is the gold standard for the detection of cardiac emboli sources in ischaemic stroke patients, but new computed tomography (CT) scanners are able to visualize the heart. This pilot study aimed to compare findings on TEE with combined cardiovascular scan and cerebral CT angiography in cryptogenic ischaemic stroke patients.

Methods

This pilot study enrolled patients with cryptogenic ischaemic stroke who underwent a combined cardiovascular and cerebral CT angiography scan and a TEE examination, which were interpreted in a blinded manner.

Results

Twelve patients with cryptogenic ischaemic stroke were included (mean age 56 years). Of these, 10 patients underwent both a combined cardiovascular and cerebral CT angiography and a TEE examination. All cardiovascular CT scans were readable at sinus rhythm. None of the simultaneous cerebral angiograms were compromised. Thrombi were not detected in any patients. Patent foramen ovale was visualized in five patients by TEE, while cardiovascular CT only identified three. Cardiovascular CT revealed in addition an X-ray negative pulmonary metastasis in one patient, aortic coarctation in another and significant coronary stenosis in four patients.

Conclusion

The sensitivity for detecting patent foramen ovale was considerably lower for cardiovascular CT than for TEE, however the cardiovascular CT revealed several other very important clinical findings.

Hypertensive Crisis in Pediatric Patients: An Overview

Hypertensive crisis can be a source of morbidity and mortality in the pediatric population. While the epidemiology has been difficult to pinpoint, it is well-known that secondary causes of pediatric hypertension contribute to a greater incidence of hypertensive crisis in pediatrics. Hypertensive crisis may manifest with non-specific symptoms as well as distinct and acute symptoms in the presence of end-organ damage. Hypertensive emergency, the form of hypertensive crisis with end-organ damage, may present with more severe symptoms and lead to permanent organ damage. Thus, it is crucial to evaluate any pediatric patient suspected of hypertensive emergency with a thorough workup while acutely treating the elevated blood pressure in a gradual manner. Management of hypertensive crisis is chosen based on the presence of end-organ damage and can range from fast-acting intravenous medication to oral medication for less severe cases. Treatment of such demands a careful balance between decreasing blood pressure in a gradual manner while preventing damage end-organ damage. In special situations, protocols have been established for treatment of hypertensive crisis, such as in the presence of endocrinologic neoplasms, monogenic causes of hypertension, renal diseases, and cardiac disease. With the advent of telehealth, clinicians are further able to extend their reach of care to emergency settings and aid emergency medical service (EMS) providers in real time. In addition, further updates on the evolving topic of hypertension in the pediatric population and novel drug development continues to improve outcomes and efficiency in diagnosis and management of hypertension and consequent hypertensive crisis.

320-slice Computed Tomography Angiography Imaging Findings and Follow-up in A Patient with Aortic Coarctation Misdiagnosed as Hypertension: A Case Report and Literature Review

In this case, we report a simple coarctation of the aortic isthmus (CoA) in a patient without intracardiac abnormalities or patent ductus arteriosus, who was misdiagnosed as essential hypertension for over 20 years. The patient underwent X-rays, echocardiography, and 320-slice CT angiography (CTA). Among them, CTA comprehensively showed the diameter of the aortic coarctation, the anatomy and morphology of the heart and aortic arch, and the collateral circulation before surgery. It also accurately evaluated the postoperative status of the bypass vessel. This article highlights the excellent performance of 320-slice CTA in the diagnosis, surgical planning, and follow-up in CoA. Moreover, when adolescents suffer from refractory hypertension, the possibility of organic cardiovascular disease should be considered.

Aortic coarctation repair through left thoracotomy: results in the modern era

OBJECTIVES

Surgical repair of coarctation of the aorta (CoA) is often possible through left thoracotomy and without the use of cardiopulmonary bypass. Recent studies reporting the outcome after CoA repair through left thoracotomy are limited. Therefore, the aim of this study is to evaluate the results of CoA repair through left thoracotomy in children who were operated on in our centre over the past 21 years.

METHODS

From January 1995 to December 2016, 292 patients younger than 18 years underwent primary CoA repair through left thoracotomy at our 2 institutions. Peri- and postoperative data and follow-up data collected from our hospital and the referring hospitals were retrospectively reviewed.

RESULTS

Median age at operation was 64 days (range 2 days-17 years). Most patients underwent the resection of the CoA followed by an (extended) end-to-end anastomosis (93%). Six patients died perioperatively and 2 more patients died during the follow-up, of which 7 patients had other major comorbidities. Actuarial survival was 97% at 5 years, 96% at 10 years and 96% at 15 years. Second arch interventions due to recoarctation were performed in 9.9% (n = 29) of patients, consisting of balloon dilatation in all but 2 patients. Recoarctation occurred significantly more often after initial repair in the neonatal period (21%) and could occur as late as 14 years after initial surgery. There were 7 re-recoarctations, and 14% of patients were on hypertensive medication during the follow-up.

CONCLUSIONS

Repair of CoA through left thoracotomy is a safe procedure with low rates of mortality. The long-term follow-up is necessary due to the significant risk of recoarctation requiring reintervention.

The importance of the early diagnosis of aorta coarctation

INTRODUCTION

Coarctation of the aorta is a congenital heart disease characterized by a narrowing that occurs in the aortic artery. This constriction can occur anywhere along its entire length; however, it is more common between the origin of the left subclavian artery and the ductus arteriosus. Its incidence corresponds to 3 cases per 10,000 births. Thus, it is a common cardiopathy, but with high mortality and morbidity rates, which are related to a failure in the early diagnosis.

METHOD

In the research, articles of the national and international literature in Pubmed, Scielo and Lilacs databases were selected using the following descriptors: coarctation, aorta, diagnosis, heart diseases, congenital abnormalities.

RESULTS

The pathophysiology of CoA and its systemic implications in the life of newborn and adults are well elucidated. However, due to the lack of habit to palpate pulses and to check the blood pressure in both upper and lower limbs during the physical examination, it is still a pathology little diagnosed in childhood. There are several techniques used in the repair of coarctation, each with their specifics, although, when not treated, aneurysms, heart failure, coronary diseases, and stroke are the main complications arising from the evolution of this pathology, which explains the low survival rate of these patients.

CONCLUSION

Coarctation of the aorta is, therefore, a cardiac malformation of significant importance due to its incidence and its significant mortality risk. In this sense, the early diagnosis stands out as an essential piece for better prognosis of the patient.

Coarctation of the Aorta with Aortic Arch Hypoplasia: Midterm Outcomes of Aortic Arch Reconstruction with Autologous Pulmonary Artery Patch

Background:

Coarctation of the aorta (CoA) with aortic arch hypoplasia (AAH) is a relatively common congenital heart disease in clinical practice. Nonetheless, the corrective surgical technique for infants and children is a clinical problem that remains controversial. In this study, we sought to evaluate the surgical effects of aortic arch (AA) reconstruction with coarctation resection and aortoplasty with autologous pulmonary artery patch for infants and young children with CoA and AAH.

Methods:

Between January 2009 and December 2015, a total of 22 infants and young children with CoA and AAH who underwent coarctation resection and aortoplasty with autologous pulmonary artery patch were enrolled in this study. The median age of patients was 4.5 (Q1, Q3: 2.0, 14.0) months and the median body weight was 5.75 (Q1, Q3: 4.10, 9.38) kg. All patients were diagnosed with CoA and AAH, and concomitant cardiac anomalies were corrected in one stage. Perioperative and postoperative data were collected and analyzed using the paired sample t-test.

Results:

No perioperative deaths occurred. No residual obstruction was detected by echocardiography. The postoperative pressure difference across the repaired segment of CoA was 14.05 ± 4.26 mmHg (1 mmHg = 0.133 kPa), which was smaller than the preoperative pressure difference (48.30 ± 15.73 mmHg; t = −10.119, P < 0.001). The median follow-up time was 29.0 (Q1, Q3: 15.5, 57.3) months. There was no death during the follow-up period, and all patients experienced obvious clinical improvement. Only one child underwent subsequent aortic balloon angioplasty due to restenosis. Computed tomography angiography showed that the AA morphology was smooth, with no aortic aneurysm or angulation deformity.

Conclusion:

AA reconstruction with coarctation resection and aortoplasty with autologous pulmonary artery patch could effectively correct CoA with AAH, and the rate of reintervention for restenosis is low.

Clinical validation and assessment of aortic hemodynamics using computational fluid dynamics simulations from computed tomography angiography

Background

Hemodynamic information including peak systolic pressure (PSP) and peak systolic velocity (PSV) carry an important role in evaluation and diagnosis of congenital heart disease (CHD). Since MDCTA cannot evaluate hemodynamic information directly, the aim of this study is to provide a noninvasive method based on a computational fluid dynamics (CFD) model, derived from multi-detector computed tomography angiography (MDCTA) raw data, to analyze the aortic hemodynamics in infants with CHD, and validate these results against echocardiography and cardiac catheter measurements.

Methods

This study included 25 patients (17 males, and 8 females; a median age of 2 years, range: 4 months–4 years) with CHD. All patients underwent both transthoracic echocardiography (TTE) and MDCTA within 2 weeks prior to cardiac catheterization. CFD models were created from MDCTA raw data. Boundary conditions were confirmed by lumped parameter model and transthoracic echocardiography (TTE). Peak systolic velocity derived from CFD models (PSV_CFD) was compared to TTE measurements (PSV_TTE), while the peak systolic pressure derived from CFD (PSP_CFD) was compared to catheterization (PSP_CC). Regions with low and high peak systolic wall shear stress (PSWSS) were also evaluated.

Results

PSV_CFD and PSP_CFD showed good agreements between PSV_TTE (r = 0.968, p < 0.001; mean bias = − 7.68 cm/s) and PSP_CC (r = 0.918, p < 0.001; mean bias = 1.405 mmHg). Regions with low and high PSWSS) can also be visualized. Skewing of velocity or helical blood flow was also observed at aortic arch in patients.

Conclusions

Our result demonstrated that CFD scheme based on MDCTA raw data is an accurate and convenient method in obtaining the velocity and pressure from aorta and displaying the distribution of PSWSS and flow pattern of aorta. The preliminary results from our study demonstrate the capability in combining clinical imaging data and novel CFD tools in infants with CHD and provide a noninvasive approach for diagnose of CHD such as coarctation of aorta in future.

A single-stage hybrid approach for the management of severely stenotic bicuspid aortic valve, ascending aortic aneurysm, and coarctation of the aorta with a literature review

The combination of aortic stenosis in the context of bicuspid aortic valve, aneurysmal dilatation of the ascending aorta, and coarctation is not uncommon. This condition has conventionally been addressed either by a complex open surgical approach or by staged hybrid approach combining open surgery of the ascending aorta with subsequent endovascular stenting of the coarctation. So far, the risk of a complex open approach for the aortic valve and ascending aorta and the cumulative risk of a staged second procedure for management of the coarctation are unknown; and similarly, the risk of a complex single-staged surgical procedure as an option instead of a single-staged hybrid approach is unknown. For the first time, we present a case of a patient with bicuspid aortopathy and concomitant coarctation who was simultaneously managed with both stenting of the coarctation and subsequent surgical replacement of the aortic valve and ascending aorta in one session. This new strategy has potential to become a future standard of care with various advantages. <Learning objective: Endovascular techniques are more frequently being used in the management of coarctation of the aorta, especially when associated with other cardiac pathologies. The definitive role of these techniques is still to be defined. A review of the risks and benefits of different management strategies may be beneficial with regard to making the right choice for each patient and a hybrid technique may be superior to purely surgical management, especially in a high-risk patient.>.

Midterm to long-term safety and efficacy of self-expandable nitinol stent implantation for coarctation of aorta in adults

PURPOSE

Endovascular treatment of coarctation of aorta (CoA) by self-expandable Nitinol stents is one of the recognized treatment methods and may be an alternative to surgery or balloon-expandable stent implantation for CoA but there is little information about midterm to long term results of self-expandable stents.

METHODS

Sixty-two patients with CoA (40 men), with a mean age of 30.7 ± 11 years, (range 17-63 years) underwent stent implantation with Optimed self-expandable Nitinol stents between 2005 and 2014. Successful outcome was defined as peak systolic pressure gradient ≤20 mmHg after stent implantation. The patients were followed-up clinically and by echocardiography and in patients, in whom there was suspicion of recoarctation, CT angiography or recatheterization was performed.

RESULTS

65 stents were successfully implanted in all 62 patients. Peak systolic pressure gradient decreased from mean 62.4 ± 18 mmHg (range 35-100 mmHg) to mean 2.8 ± 5 mmHg (range 0-15 mmHg; P < 0.001). Stent displacement occurred in 3 patients during the procedure. These were managed successfully by an overlapping second stent. None of the patients had major complications such as aortic dissection, rupture, or vascular access problems. In follow up, only three patients had recoarctation, and two of these were managed successfully by balloon redilation or further stenting 16 and 18 months after the first procedure and one patient refused reintervention. There were two deaths, unrelated to the procedure, 12 and 78 months after the initial intervention. Follow-up of a mean of 45.5 ± 17 months (range 12-105 months) demonstrated no evidence of aneurysm formation or stent fracture.

CONCLUSIONS

Self-expandable nitinol stents for the treatment of native and recurrent CoA is safe and has good efficacy with acceptable midterm to long-term outcome.

Effectiveness of Balloon Angioplasty in Children With Recurrent Aortic Coarctation Depends on the Type of Aortic Arch Pathology

OBJECTIVES

The aim of this study was to evaluate the effectiveness of balloon angioplasty (BAP) for recurrent aortic coarctation (ReCoA) in infants comparing simple and complex type of aortic arch pathology (Norwood I procedure).

BACKGROUND

ReCoA is a known complication after cardiovascular surgery for coarctation of the aortic arch.

METHODS AND RESULTS

In a single center case study, we analyzed 20 infants undergoing BAP for ReCoA comparing simple (n = 10) and complex type of aortic arch pathology (n = 10). At catherization diameter of ReCoA stenosis was 3.2 ± 0.7 mm (mean ± SD) with short localized (11/20) or long hypoplastic stenosis (9/20) before and 4.8 ± 1.2 mm after BAP (P < 0.001). Invasive systolic pressure gradient was reduced from 27.5 ± 16.2 mmHg before to 5.1 ± 6.6 mmHg after BAP (P < 0.001), comparable in simple and complex type of ReCoA. At day 1 after catherization noninvasive systolic arterial blood pressure gradient was reduced from 20.2 ± 23.1 to 6.7 ± 9.9 mmHg (P < 0.001), respectively, calculated continuous wave Doppler echo gradient from 36.3 ± 22 to 16.8 ± 9.6 mmHg (P < 0.01). Complications were aortic arch dissection (1/20), discrete aortic arch aneurysm formation (1/20), pericardial effusion (1/20), and peripheral arterial thrombosis (4/20). At a mid-term follow up of 9.5 months (1-40) after BAP, 3 infants needed early surgical reintervention due to secondary ReCoA, all with long hypoplastic aortic arch segments, but simple type of aortic arch pathology.

CONCLUSIONS

At mid-term follow up, BAP remains an effective catheter intervention for ReCoA for infants with localized ReCoA, but not with long hypoplastic aortic arch segments, even in simple type of aortic arch pathology.