Repaired coarctation of the aorta does not affect four-dimensional flow metrics in bicuspid aortic valve disease

OBJECTIVES

The objective of this study was primarily to compare four-dimensional flow magnetic resonance imaging metrics in the ascending aorta (AA) of patients with right-left fusion type bicuspid aortic valve (RL-BAV) and repaired coarctation of the aorta (CoA) to RL-BAV without CoA. Metrics of patients with RL-BAV were also compared to the matched group of patients with common tricuspid aortic valve (TAV).

METHODS

Eleven patients with RL-BAV and CoA, 11 patients with RL-BAV without CoA and 22 controls with TAV were investigated. Peak velocity (cm/s), peak flow (ml/s) and flow displacement (%) were analysed at 5 pre-defined AA levels. In addition, regional wall shear stress (WSS, mN/m2), circumferential WSS (WSSc) and axial WSS (WSSa) at all levels were quantified in 6 sectors of the aortic circle. Averaged WSS values on each level (WSSavg, WSSc, avg and WSSa, avg) were calculated as well.

RESULTS

Peak velocity at the proximal tubular AA was significantly lower in BAV and CoA group (P = 0.047) compared to BAV without CoA. In addition, the WSSa, avg was found to be higher for the BAV and CoA group at proximal AA respectively (P = 0.040). No other significant differences were found between these groups. BAV group's peak velocity was higher at every level (P < 0.001-0.004) compared to TAV group. Flow displacement was significantly higher for the BAV group at every level (P < 0.001) besides at the most distal level. All averaged WSS values were significantly higher in BAV patients in distal AA (P < 0.001-0.018).

CONCLUSIONS

Repaired CoA does not relevantly alter four-dimensional flow metrics in the AA of patients with RL-BAV. However, RL-BAV majorly alters flow dynamics in the AA when compared to patients with TAV.

CLINICAL TRIAL REGISTRATION NUMBER

https://www.clinicaltrials.gov/study/NCT05065996, Unique Protocol ID 5063566.

Non-invasive Estimation of Pressure Drop Across Aortic Coarctations: Validation of 0D and 3D Computational Models with In Vivo Measurements

Blood pressure gradient ( Δ P ) across an aortic coarctation (CoA) is an important measurement to diagnose CoA severity and gauge treatment efficacy. Invasive cardiac catheterization is currently the gold-standard method for measuring blood pressure. The objective of this study was to evaluate the accuracy of Δ P estimates derived non-invasively using patient-specific 0D and 3D deformable wall simulations. Medical imaging and routine clinical measurements were used to create patient-specific models of patients with CoA (N = 17). 0D simulations were performed first and used to tune boundary conditions and initialize 3D simulations. Δ P across the CoA estimated using both 0D and 3D simulations were compared to invasive catheter-based pressure measurements for validation. The 0D simulations were extremely efficient ( ∼ 15 s computation time) compared to 3D simulations ( ∼ 30 h computation time on a cluster). However, the 0D Δ P estimates, unsurprisingly, had larger mean errors when compared to catheterization than 3D estimates (12.1 ± 9.9 mmHg vs 5.3 ± 5.4 mmHg). In particular, the 0D model performance degraded in cases where the CoA was adjacent to a bifurcation. The 0D model classified patients with severe CoA requiring intervention (defined as Δ P ≥ 20 mmHg) with 76% accuracy and 3D simulations improved this to 88%. Overall, a combined approach, using 0D models to efficiently tune and launch 3D models, offers the best combination of speed and accuracy for non-invasive classification of CoA severity.

Very long-term follow-up after aortic stenting for coarctation of the aorta

INTRODUCTION AND OBJECTIVES

Stent implantation is the preferred treatment in older children and adults with aortic coarctation (CoA). We aimed to determine the incidence of very late events after CoA stenting.

METHODS

We analyzed a cohort of CoA patients who underwent stent implantation at our center between 1993 and 2018. Patients were periodically followed up in outpatient clinics, including computed tomography (CT) and fluoroscopy assessment.

RESULTS

A total of 167 patients with CT and fluoroscopy data were included: 83 (49.7%) were aged ≤ 12 years and 46 (28%) were female. The mean clinical follow-up time was 17±8 (range 4-30) years and the mean time to CT/fluoroscopy was 11±7 years. Aortic aneurysm was present in 13% and was associated with the PALMAZ stent (OR, 3.09; 95%CI, 1.11-9.49; P=.036) and the stented length (OR, 0.94; 95%CI, 0.89-0.99; P=.039). Stent fracture was frequent (34%), but was not related to the presence of aneurysm. Stent fracture was associated with young age (OR, 3.57; 95%CI, 1.54-8.33; P=.003), male sex (OR, 4.00; 95%CI, 1.51-12.5, P=.008) and inversely with the PALMAZ stent (OR, 0.29; 95%CI, 0.12-0.67, P=.005). Reintervention was lower in adults (10%), mainly related to aneurysms. Those treated when aged ≤ 12 years had higher reintervention rates (43%) due to recoarctation somatic growth.

CONCLUSIONS

This long-term follow-up study of CoA patients treated with stenting revealed a significant incidence of late events. Reintervention rates were higher in patients treated at younger ages. Periodic imaging surveillance appears to be advisable.

15-Year Analysis of Surgical Approaches and Outcomes for Coarctation in 132 Neonates and Infants

A variety of surgical approaches exist to treat aortic coarctation in neonates and infants. Our institutional approach is designed to match the surgical approach to the individual anatomy of the patient. The objective of this study is to evaluate operative characteristics and outcomes of all neonates and infants who underwent surgical repair of coarctation of the aorta or hypoplastic aortic arch at University of Florida from 2006 to 2021, inclusive, either in isolation or with concomitant repair of atrial septal defect (ASD) and/or ventricular septal defect (VSD). A retrospective review was performed of 132 patients aged 0-1 year who underwent surgical repair of aortic coarctation or hypoplastic aortic arch between 2006 and 2021, inclusive, either in isolation or with concomitant repair of ASD and/or VSD. Patients were divided into two groups based on the surgical approach: Group 1 = Median Sternotomy and Group 2 = Left Lateral Thoracotomy. Continuous variables are presented as median (minimum-maximum); categorical variables are presented as N (%). The most common operative technique in Group 1 was end-to-side reconstruction with ligation of the aortic isthmus. The most common operative technique in Group 2 was extended end-to-end repair. Operative Mortality was one patient (1/132 = 0.76%). Transcatheter intervention for recurrent coarctation was performed in seven patients (7/132 = 5.3%). Surgical re-intervention for recurrent coarctation was performed in three patients (3/132 = 2.3%). From these data, one can conclude that a strategy of matching the surgical approach to the anatomy of neonates and infants who underwent surgical repair of aortic coarctation or hypoplastic aortic arch, either in isolation or with concomitant repair of ASD and/or VSD, is associated with less than 1% Operative Mortality and less than 3% recurrent coarctation requiring reoperation.

Echocardiographic score to predict neonatal surgery for aortic coarctation in newborns with prenatal suspicion and patent ductus arteriosus

INTRODUCTION

The evaluation of upcoming Aortic Coarctation (CoA) in new-borns with prenatal suspicion entails a close echocardiographic monitor until Arterial Duct (AD) closure, in a department with pediatric cardiological and surgical expertise. The significant number of false-positive prenatal diagnoses causes parental stress and healthcare costs.

AIM

The aim of this study was to elaborate an echocardiographic prediction model to be employed at birth when PDA is still present, in patients suspected of CoA during fetal life in order to foretell CoA requiring neonatal surgical intervention.

METHODS

This retrospective monocentric study included consecutive full-term and late preterm neonates with prenatal suspicion of CoA born from 01 January 2007 to 31 December 2020. Patients were divided into two groups according to the need for aortic surgery (CoA - NoCoA). All patients underwent a comprehensive transthoracic echocardiographic exam in presence of PDA. Multivariable logistic regression was used to create a coarctation probability model (CoMOD) including isthmal (D4), transverse arch (D3) diameters, the distance between a left common carotid artery (LCA) and left subclavian artery (LSA), presence/absence of ventricular septal defect (VSD) and bicuspid aortic valve (BAV).

RESULTS

We enrolled 87 neonates (49 male, 56%). 44 patients developed CoA in need of surgical repair. Our index CoMOD showed an AUC = 0.9382, high sensitivity (91%) and specificity (86%) in the prediction of CoA in neonates with prenatal suspicion. We classified neonates with CoMOD > 0 to be at high risk for surgical correction of CoA, with good PPV (86.9%) and NPV (90.9%).

CONCLUSIONS

CoMOD > 0 is highly suggestive of the need for CoA corrective surgery in newborns with prenatal suspicion.

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.

Echocardiography in Simple Congenital Heart Diseases: Guiding Adult Patient Management

This article provides comprehensive insights into the evaluation of simple congenital heart diseases (CHDs) in adults, emphasizing the pivotal role of echocardiography. By focusing on conditions such as congenital aortic stenosis, aortic coarctation, patent ductus arteriosus, atrial septal defects (ASDs), and ventricular septal defects (VSDs), the review underscores echocardiography's intricate contributions to precise clinical decision-making. Echocardiography serves as the primary imaging modality, offering high-resolution visualization of anatomical anomalies and quantification of hemodynamic parameters. It enables tailored therapeutic strategies through its capacity to discern the dimensions, spatial orientation, and dynamic shunt dynamics of defects such as ASDs and VSDs. Moreover, echocardiography's advanced techniques, such as tissue Doppler imaging and speckle tracking, provide detailed insights into atrial mechanics, diastolic function, and ventricular filling kinetics. Integration of echocardiographic findings into clinical practice empowers clinicians to create personalized interventions based on quantified ventricular function, which spans systolic and diastolic aspects. This approach facilitates risk stratification and therapeutic planning, particularly pertinent in heart failure management within the CHD patient population. In summary, echocardiography transcends its role as an imaging tool, emerging as a precision-guided instrument adept at navigating the complexities of simple CHD in adults. Its ability to expedite diagnosis, quantify hemodynamic impacts, and unravel multifaceted functional dynamics culminates in a comprehensive depiction of these conditions. The fusion of these insights with clinical expertise empowers clinicians to navigate the intricate pathways of CHD, crafting tailored therapeutic strategies characterized by precision and efficacy.

Isolated coarctation repair through a left thoracotomy in children

INTRODUCTION

Isolated aortic coarctation performed through a left thoracotomy resection and end-to-end anastomosis results in low mortality and morbidity rates. Recoarctation and late hypertension are among the most important complications after such repairs. In this study, we reviewed the results of children who underwent left-side thoracotomy to correct an isolated aortic coarctation.

METHOD

A consecutive sample of 90 patients who underwent resection and extended end-to-end anastomosis through a left-side thoracotomy in our centre between 2011 and 2021 was retrospectively analysed. The patients' preoperative characteristics, operative data, and post-operative early and long-term results were examined.

RESULTS

All patients underwent resection and extended end-to-end anastomosis. A pulmonary artery band was applied simultaneously to three (3.3%) patients, and an aberrant right subclavian artery division was applied to one (1.1%) patient. The mean cross-clamp time was 29.13 ± 6.97 minutes. Two (2.2%) patients required reoperation in the early period. Mortality was observed in one (1.1%) patient in the early period. Eight (8.8%) patients developed recoarctation, of whom four (4.4%) underwent reoperation and four (4.4%) underwent balloon angioplasty. Twenty-two (26.8%) patients received follow-up antihypertensive treatment. The mean follow-up period was 41.3 ± 22.8 months. No mortality was observed in the late period.

CONCLUSION

Isolated coarctation is successfully treated with left-side thoracotomy resection and an extended end-to-end anastomosis technique with low mortality, morbidity, and low long-term recoarctation rates. Long-term follow-up is required due to the risks of early and late post-operative recoarctation, which requires reintervention.

Incidental finding of undiagnosed aortic coarctation in an elderly patient with a rare association with thymic carcinoma: a case report with review of the literature

Aortic coarctation is a congenital malformation that is relatively prevalent, occurring in approximately 5 out of every 1000 births. The narrowing typically happens at the aortic isthmus between the left subclavian artery and the arterial ligament. It is frequently associated with a bicuspid aortic valve. Generally, coarctation of the aorta is identified and treated during childhood or early adulthood. If left untreated, this condition can lead to a reduced life expectancy in individuals who have not received treatment. We present a case of a 52-year-old man who complained of chest pain, sputum, and hemoptysis persisting for approximately 2 years. Contrast-enhanced computed tomography (CT) scans revealed the presence of an anterior mediastinal mass, which was later confirmed to be a thymic carcinoma (on histological study). Additionally, an incidental finding of a thoracic aortic coarctation with a well-developed collateral circulation was observed. The discovery of aortic coarctation in adult patients as an incidental finding is rare and particularly uncommon in association with mediastinal or thoracic tumor pathology. Adult and elderly patients with uncorrected coarctation generally have a low survival rate, and the management strategies for such cases are controversial, especially when it is associated to other pathologies. Due to the complexity of therapeutic management and the limited literature available on postsurgical outcomes in these cases, making therapeutic decisions requires a multidisciplinary approach and personalized consideration for each individual case. This approach is necessary to evaluate the risk-benefit ratio and determine the most suitable therapeutic solution.

Rapid reversal of left ventricular enlargement after percutaneous closure of pulmonary sequestration in a newborn with prune belly syndrome

In this article, we describe a newborn with Prune belly syndrome who presented with left ventricular dilation due to an extensive intralobar sequestration of the left lung. Pulmonary sequestration was combined with congenital cystic adenomatoid malformation and also had coarctation of the aorta. Percutaneous closure of the anomalous aberrant artery feeding the sequestrated lung and balloon angioplasty for coarctation resulted in prompt regression of the left ventricular enlargement in the catheterization lab.

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.

Surgical timing of endoluminal repair of Stanford type B aortic coarctation and relationship to prognosis: a single-center retrospective cohort study

Background

Stanford type B aortic dissection (TBAD) is a rare cardiovascular emergency with rapid onset and great harm. Currently, no relevant studies have analyzed the difference in clinical benefits of endovascular repair in patients with TBAD in acute and non-acute stages. To investigate the clinical characteristics and prognosis of endovascular repair in patients with TBAD at different surgical timing.

Methods

The medical records of 110 patients with TBAD from June 2014 to June 2022 were retrospectively selected as the study subjects. The patients were divided into an acute group (onset time ≤14 days) and a non-acute group (onset time >14 days) according to the time to surgery, and the two groups were compared in terms of surgery and hospitalization, aortic remodeling, and follow-up results. Univariate and multivariate logistic regression were used to analyze the factors affecting the prognosis of TBAD treated with endoluminal repair.

Results

The proportion of pleural effusion, heart rate, the rate of complete thrombosis of the false lumen and the difference in the maximum diameter of the false lumen in the acute group were higher than those in the non-acute group (P=0.015, <0.001, 0.029, <0.001). The length of hospital stay and the maximum postoperative diameter of the false lumen was lower than in the non-acute group (P=0.001, 0.004). There was no statistically significant difference between the two groups in the technical success rate, overlapping stent length, overlapping stent diameter, immediate postoperative contrast type I endoleak, incidence of renal failure, ischemic disease, endoleaks, aortic dilatation, retrograde type A aortic coarctation, and death (P=0.386, 0.551, 0.093, 0.176, 0.223, 0.739, 0.085, 0.098, 0.395, 0.386); coronary artery disease [odds ratio (OR) =6.630, P=0.012], pleural effusion (OR =5.026, P=0.009), non-acute surgery (OR =2.899, P=0.037), and involvement of the abdominal aorta (OR =11.362, P=0.001) were all independent risk factors affecting the prognosis of TBAD treated with endoluminal repair.

Conclusions

Acute phase endoluminal repair of TBAD may contribute to aortic remodeling, and the prognosis of TBAD patients can be assessed clinically in combination with coronary artery disease, pleural effusion, and involvement of the abdominal aorta for early intervention to reduce the associated mortality.

Stent Implantation and Balloon Angioplasty for Native and Recurrent Coarctation of the Aorta

Evidence on the effectiveness and comparative effectiveness of stent implantation and balloon angioplasty for native coarctation of the aorta (CoA) and recurrent CoA separately is lacking. The present meta-analysis was performed to assess the efficacy and safety of stent implantation and balloon angioplasty in native (NaCo) and recurrent (ReCo) CoA.A systematic computerized literature search was conducted to retrieve all relevant studies of stent implantation and balloon angioplasty for CoA. Both single-arm and comparative studies were included. Data on NaCo and ReCo were pooled separately.A post-procedure gradient of ≤ 20 mmHg was achieved in 97% and 92% of patients undergoing stent implantation and balloon angioplasty for NaCo, and in 98% and 90% for ReCo, respectively. A post-procedure gradient of ≤ 10 mmHg was achieved in 97% and 83% of patients undergoing stent implantation and balloon angioplasty for NaCo, and in 86% and 78% for ReCo, respectively. Comparative results confirmed that stent implantation provided a significantly higher success rate compared with balloon angioplasty (odds ratio [OR] = 2.09; 95% confidence interval [CI] = 1.13-3.86; P = 0.019) in treating NaCo. Incidences of all-cause complications, mortality, reintervention, and aneurysm formation were similar between the groups. Patients undergoing stent implantation had a significantly lower incidence of dissection (OR = 0.15; 95% CI = 0.02-0.92; P = 0.040).Current evidence indicates that stent implantation might have superior efficacy compared with balloon angioplasty for the treatment of NaCo with higher success rates and similar complication rates. However, whether this superior effect is also present in ReCo patients needs further evaluation.

Assessment of aortic and cerebral haemodynamics and vascular brain injury with 3 and 7 T magnetic resonance imaging in patients with aortic coarctation

Aims

Coarctation of the aorta (CoA) is characterized by a central arteriopathy resulting in increased arterial stiffness. The condition is associated with an increased risk of stroke. We aimed to assess the aortic and cerebral haemodynamics and the presence of vascular brain injury in patients with previous surgical CoA repair.

Methods and results

Twenty-seven patients with CoA (median age 22 years, range 12-72) and 25 age- and sex-matched controls (median age 24 years, range 12-64) underwent 3 T (heart, aorta, and brain) and 7 T (brain) magnetic resonance imaging scans. Haemodynamic parameters were measured using two-dimensional phase-contrast images of the ascending and descending aorta, internal carotid artery (ICA), basilar artery (BA), middle cerebral artery (MCA), and perforating arteries. Vascular brain injury was assessed by rating white matter hyperintensities, cortical microinfarcts, lacunes, and microbleeds. Pulse wave velocities in the aortic arch and descending aorta were increased and ascending aortic distensibility was decreased in patients with CoA vs. controls. Patients with CoA showed a higher mean flow velocity in the right ICA, left ICA, and BA and a reduced distensibility in the right ICA, BA, and left MCA. Haemodynamic parameters in the perforating arteries, total cerebral blood flow, intracranial volumes, and vascular brain injury were similar between the groups.

Conclusion

Patients with CoA show an increased flow velocity and reduced distensibility in the aorta and proximal cerebral arteries, which suggests the presence of a generalized arteriopathy that extends into the cerebral arterial tree. No substantial vascular brain injury was observed in this relatively young CoA population, although the study was inadequately powered regarding this endpoint.

Computed tomography jellyfish angiography in pediatric endovascular interventions

Contrast pooling (CP) reconstruction is widely used in computed tomography (CT) studies of congenital heart diseases. However, endovascular devices are usually obscured in CP. To improve visualization of the vascular lumen, we developed jellyfish angiography (JFA), a semitransparent blood pool inversion technique. Ten CT studies of patent ductus arteriosus (PDA) or coarctation of the aorta (CoA) were selected retrospectively for reconstruction using both CP and JFA. Four of the studies were conducted before the endovascular intervention, and six were conducted after the intervention. Radiology residents and pediatric cardiologists completed questionnaires regarding the reconstruction models. For radiology residents, JFA was superior to CP in postintervention PDA diagnosis, device evaluation, and overall satisfaction. For pediatric cardiologists, JFA outperformed CP in both PDA and CoA postintervention cases. Our findings show that JFA overcomes the disadvantages of CP and can improve the visualization of intraluminal devices which is essential for endovascular treatment evaluation.

Advanced echocardiographic assessment in adults with repaired aortic coarctation: myocardial work analysis provides novel insights on left ventricular mechanics

AIM

To analyze left ventricular (LV) mechanics through advanced echocardiography, including speckle tracking analysis and myocardial work (MW) in a cohort of adults with repaired aortic coarctation (CoA).

METHODS

Data on standard echocardiography, LV speckle-tracking and MW analysis were collected in CoA patients > 18 years with no significant recoartation or valvular disease and normal LV ejection fraction at the time of the exam. MW indices were calculated using the blood pressure measured in the right arm. A group of healthy subjects with comparable sex, age and body surface area was included for comparison.

RESULTS

Eighty-nine CoA patients and 70 healthy subjects were included. Patients had higher systolic blood pressure (p < 0.0001), LV mass index (p < 0.0001), left atrial volume index (p = 0.005) and E/E' ratio (p = 0.001). Despite similar LV ejection fraction, speckle tracking analysis revealed lower global longitudinal strain (GLS: - 18.3[17-19] vs - 20.7[19-22]%, p < 0.0001) and increased peak systolic dispersion (PSD: 45[40-54] vs 37.5[32-43] ms, p < 0.0001) in CoA patients. Global work index (GWI) and global constructive work were similar to healthy controls (p = 0.6 and 0.5, respectively), whereas CoA patients showed significant increased wasted work (GWW: 125[90-185] vs 89.5[64-127]mmHg%, p < 0.0001) and a mild but significant reduction in global work efficiency (GWE: 93%[92-95] vs 95%[94-97], p < 0.0001). Moreover, when stratifying for GLS values, MW analysis showed increased GWW and PSD with impaired GWE in 54(61%) patients with normal GLS compared to healthy individuals. Spearman's linear method illustrated an inverse relation between GWE and PSD (r: - 0.53, p < 0.0001), while GCW was associated with peak (r: 0.2, p = 0.01) and mean gradient across the descending aorta (r: 0.3, p = 0.004) and with systolic blood pressure (r: 0.48, p < 0.0001). PSD was the sole univariate predictor of GWE on linear regression analysis (β: - 0.1 [- 0.16 to - 0.07], p < 0.0001), whereas female sex, SBP and gradients across the descending aorta were independently associated with higher GCW values. When CoA patients were divided based on the history of redo CoA repair and arterial hypertension, no significant differences in MW indices were found.

CONCLUSIONS

MW is a novel echocardiographic tool, which provides additional information on LV performance in CoA patients over GLS allowing a more comprehensive understanding of LV dysfunction mechanisms in a setting of increased afterload.

Mid-aortic Syndrome in a Pediatric Cohort

Mid-aortic syndrome (MAS) is an uncommon condition characterized by severe narrowing of the abdominal aorta, usually involving visceral and renal arteries. Most patients are asymptomatic and typically present with incidental hypertension which might evolve into end-organ damage if untreated. Our aim was to review 8 new pediatric MAS cases. A retrospective observational study of all pediatric patients with MAS diagnosis (April 1992-November 2021) was conducted. Patients underwent systematic evaluation (medical and family history; 12-lead electrocardiogram; echocardiogram; angiography and/or computed tomography or magnetic resonance angiography). 8 pediatric patients with MAS were included. Median age at diagnosis was 2.6 [0.2-4.7] years; median follow-up time was 8.6 [6.6-10.0] years. 6/8 patients presented with incidental hypertension, 1/8 with heart murmur, and 1/8 with heart failure symptoms. All patients were on antihypertensive treatment. 1/8 patients underwent surgery and 7/8 an endovascular treatment. At the end of the study period, among the 6 patients that underwent a successful endovascular procedure, 2 achieved good blood pressure (BP) control, 2 acceptable BP control, 1 stage 1 hypertension and, another, stage 2 hypertension. There was 1 death during follow-up. BP monitoring in pediatric patients is crucial for early recognition of MAS. Treatment should be based on the individual clinical characteristics of patients with careful planning of surgical revascularisation, if possible, after adult growth is completed. Our study demonstrates that endovascular treatment might be a good alternative to surgery. Nevertheless, further trials with larger sample size and longer-term follow-up are required to determine the best treatment approach.

In-Stent Late Thrombus in a Patient with Aortic Coarctation

A 27-year-old man applied for routine control due to aortic coarctation stent. During routine control, a late in-stent thrombus was detected. The patient was asymptomatic. Thrombus resolution was achieved with anticoagulant therapy. Anticoagulant therapy is one of the options in the treatment of aortic stent graft-associated asymptomatic thrombus. Surgical intervention might be required in case of thromboembolism, haemodynamic deterioration, and intra-aortic gradient with high blood pressure in the upper extremity.

Severe coarctation of the aorta, developmental delay, and multiple dysmorphic features in a child with SMAD6 and SMARCA4 variants

Pathogenic variants in SMARCA4 cause Coffin-Siris syndrome (CSS) while those in SMAD6 lead to aortic valve disease and other dysmorphisms. We identified a 6-year-old Thai boy with features of CSS alongside unusual manifestations including, very severe coarctation of the aorta (CoA) requiring coarctectomy in the neonatal period and bilateral radioulnar synostoses. Trio exome sequencing revealed that the patient harbored two de novo variants, a missense c.2475G > T, p.(Trp825Cys) in SMARCA4 and a nonsense c.652C > T, p.(Gln218Ter) in SMAD6. Both of which have never been previously reported. The clinical presentations in our patient are a result of the combinational features of each genetic variant: the SMARCA4 p.(Trp825Cys) variant leads to facial features of Coffin Siris syndrome and Dandy-Walker malformation, while the SMAD6 p.(Gln218Ter) variant underlies radioulnar synostosis. Interestingly, the severity of CoA in the proband is beyond the phenotypic spectra of each genetic variant and may be a result of the synergistic effects of both variants. Here, we report a child with variants in SMARCA4 or SMAD6 with combined features of each plus a severe CoA, possibly due to an additive effect of each variant.

Late Outcomes of Transcatheter Coarctation Intervention in Infants with Biventricular Anatomy

Determine outcomes of catheter intervention for aortic coarctation in infants. Aortic coarctation in infants following surgical repair and in high surgical risk native cases remains a challenging problem. Catheter intervention is an alternative to surgical intervention. Single-center, chart review of infants with biventricular anatomy who underwent coarctation stent placement or balloon angioplasty between 04/2004 and 04/2020. Outcomes of interest included change in aortic lumen diameter, peak gradient, number of re-interventions, time to re-intervention, and adverse events. Thirty-four patients were included in analysis, of those 16 underwent stent placement. Patients' mean age was 4.0 ± 3.0 months and weight of 5.3 ± 1.9 kg. Follow-up interval was 5.4 ± 5.1 years (0.2-16.1 years). Twelve (35%) patients underwent procedure due to ventricular dysfunction; the rest were for high resting gradient. Coarctation diameter increased from 2.4 ± 1.0 to 4.5 ± 1.3 (p < 0.01) and gradient decreased from 32.0 ± 18.4 mmHg to 9.2 ± 8.8 mmHg (p < 0.01). Thirteen (81%) of the stented patients required at least one re-intervention, at an average of 1.7 ± 3.2 years from the index procedure. Five (28%) of those undergoing balloon angioplasty required repeat intervention. There was no mortality due to the procedure and one late mortality. One patient had a serious procedural adverse event. On follow-up, 12 (35%) were on anti-hypertensive medications. Catheter intervention, including stent placement, for aortic coarctation in infants is feasible with an acceptable adverse event profile. Repeat interventions are common.

4D flow MRI derived aortic hemodynamics multi-year follow-up in repaired coarctation with bicuspid aortic valve

PURPOSE

The purpose of this study was to investigate the relationships between hemodynamic parameters and longitudinal changes in aortic dimensions on four-dimensional (4D) flow magnetic resonance imaging (MRI) in patients with bicuspid aortic valve (BAV) and repaired coarctation.

MATERIALS AND METHODS

The study retrospectively included patients with BAV and childhood coarctation repair who had at least two cardiothoracic MRI examinations including 4D flow MRI at baseline and follow-up. Analysis included the calculation of aortic peak velocities, wall shear stress (WSS), pulse wave velocity (PWV), aortic dimensions and annual growth rates. Differences between examinations were assessed using paired t-test or Wilcoxon signed rank test. Relationships between growth rate and 4D flow metrics were assessed using Pearson or Spearman correlation tests.

RESULTS

The cohort included 15 patients (mean age 35 ± 8 [SD] years, 9 men) with a median follow-up time of 3.98 years (Q1: 2.10; Q3: 4.96). There were no significant differences in aortic mean WSS, peak velocities, and PWV between baseline and follow-up values. Greater baseline peak velocities at the site of the coarctation were strongly associated with aortic narrowing (follow-up vs. baseline diameter) at coarctation zone (r = -0.64; P = 0.010) and moderately in descending aorta (r = -0.53; P = 0.042). In addition, increased baseline WSS in the aortic arch was strongly related with narrowing of the coarctation zone at follow-up (r = -0.64, P = 0.011).

CONCLUSION

Measures of aortic hemodynamics and aortic WSS are stable over time in patients with BAV with coarctation repair. Increased peak velocity was associated with a progressive narrowing at the site of the coarctation repair.

Serum complement C1q level is associated with left ventricular hypertrophy induced by coarctation of the aorta: A retrospective observational study

BACKGROUND

The complement system plays an important role in the development of left ventricular hypertrophy. Complement C1q is an initial component of the classical complement pathway and is related to many inflammatory diseases. We aimed to determine whether there was an association between serum complement C1q and left ventricular hypertrophy induced by coarctation of the aorta (CoA).

METHODS

Based on whether CoA was combined with a large ventricular septal defect (VSD) or patent ductus arteriosus (PDA), the patients were divided into a simple CoA group (n = 15) and a complex CoA group (n = 13). Meanwhile, we selected simple large VSD (n = 14) patients and normal children (n = 28) as the control group. The serum complement C1q level was compared using immunity transmission turbidity among different groups.

RESULTS

The preoperative content of C1q in the simple CoA group was significantly lower than that in the complex CoA group and normal group (96.97 ± 20.66 vs. 130.73 ± 35.78, 96.97 ± 20.66 vs. 156.21 ± 29.14, P < 0.05). There was no significant difference in the preoperative content of C1q between the complex CoA group and the large VSD group (P > 0.05). There was a negative correlation between the preoperative complement C1q content and the interventricular septal thickness and left ventricular posterior wall thickness (r = - 0.035, r = - 0.288, P < 0.05). The percentage of postoperative decrease in C1q in children with simple CoA or complex CoA was positively correlated with the time of cardiopulmonary bypass and aortic cross clamp, respectively (r = 0.797, r = 0.622, r = 0.898, r = 0.920, P < 0.05). There was no significant difference in the content of preoperative triglycerides (TG), total cholesterol (TCHO), high-density lipoprotein cholesterol (HDL-C) or low-density lipoprotein cholesterol (LDL-C) among the different groups (P > 0.05). In the simple CoA group and complex CoA group, the preoperative complement C1q, TG, TCHO, HDL-C and LDL-C levels were significantly higher than those after the operation (P < 0.05). There was no significant correlation between preoperative complement C1q and TG, TCHO, HDL-C or LDL-C (P > 0.05).

CONCLUSIONS

Complement C1q has an inhibitory effect on the formation of left ventricular hypertrophy, which may not be mediated by regulating lipid metabolism. During cardiac surgery, complement C1q may have a protective effect against myocardial injury.

The association between cardiac magnetic resonance-derived aortic stiffness parameters and aortic dilation in young adults with bicuspid aortic valve: With and without coarctation of aorta

Background

Bicuspid aortic valve (BAV) is associated with progressive aortic dilation. Studies in aortopathies have shown a correlation between increased aortic stiffness and aortic dilation. We aimed to evaluate aortic stiffness measures as predictors of progressive aortic dilation by cardiac magnetic resonance (CMR) in BAV patients.

Methods

This is a retrospective study of 49 patients with BAV (median age 21.1 years at first CMR visit) with ≥2 CMR at the Wisconsin Adult Congenital Heart Disease Program (WAtCH). Circumferential aortic strain, distensibility, and β-stiffness index were obtained from CMR-derived aortic root cine imaging, and aortic dimensions were measured at aortic root and ascending aorta. A linear mixed-model and logistic regression were used to identify important predictors of progressive aortic dilation.

Results

Over a median of 3.8 years follow-up, the annual growth rates of aortic root and ascending aorta dimensions were 0.25 and 0.16 mm/year, respectively. Aortic strain and distensibility decreased while β-stiffness index increased with age. Aortic root strain and distensibility were associated with progressive dilation of the ascending aorta. Baseline aortic root diameter was an independent predictor of >1 mm/year growth rate of the aortic root (adjusted OR 1.34, 95 % CI 1.03-1.74, p = 0.028). Most patients (61 %) had coexisting coarctation of aorta. Despite the higher prevalence of hypertension in patients with aortic coarctation, hypertension or coarctation had no effect on baseline aorta dimensions, stiffness, or progressive aortic dilation.

Conclusion

Some CMR-derived aortic stiffness parameters correlated with progressive aortic dilation in BAV and should be further investigated in larger and older BAV cohorts.

Outcomes of one-staged procedures to treat aortic coarctation complicated by cardiac anomalies

OBJECTIVE

One-staged surgical treatment of aortic coarctation combined with cardiac anomalies is challenging. We aim to evaluate the feasibility of bilateral aortofemoral bypass technique in one-staged surgery treating coractation by comparing surgical outcomes with catheter intervention plus stent (hybrid).

METHODS

Between January 2012 and December 2017, 50 patients underwent one-staged surgical procedures to treat coarctation and repair concomitant cardiac anomalies, like aortic root dilatation, cardiac valvular disease and so on. Among them, 30 patients underwent bilateral aortofemoral bypass and 20 patients underwent hybrid procedure to treat coarctation. We retrospectively analyzed the data of these patients and compared the early and late results.

RESULTS

All the baseline clinical characteristics were comparable between groups except that the mean age of bypass group was 39.5 ± 14.0 years which was older than hybrid group (27.9 ± 8.5 years, P = 0.002). Technical success was achieved in all patients, with no hospital death or other severe complications. Immediately after surgery, in bypass and hybrid group, the mean upper-limb systolic blood pressure decreased from 159.4 to 119.7 mmHg and 148.4 to 111.6 mmHg, the median peak systolic gradient decreased from 68.0 to 10 mmHg and 46.5 to 10 mmHg respectively (P = 0.09). And the mean upper-lower limbs gradient decreased from 21.7 to 5.9 mmHg and 21.0 to 2.7 mmHg respectively (P = 0.104). The mean follow-up time was 76.92 ± 18.7 in bypass group and 85.4 ± 20.6 months in hybrid group. There were 4 late deaths in bypass group (one died of gastrointestinal bleeding, one died of pulmonary embolism and the other two died of heart failure caused by mechanical prosthetic valve dysfunction). The follow-up peak systolic gradient and other blood pressure parameters showed stable and no differences between two groups.

CONCLUSIONS

The bilateral aortofemoral bypass surgery is a safe and effective method which can be used in one-staged surgical strategy to treat coarctation complicated by cardiac anomalies and can be an alternative to the hybrid method.

Surgical and endovascular treatment of late post-coarctation repair aortic aneurysms: results from an international multicenter study

OBJECTIVE

Formation of post-aortic coarctation aneurysms (pCoAA) is well described in the literature and carries a significant risk of rupture and death. Treatment strategies include open surgical, hybrid, and endovascular repair dependent on clinical presentation, risk assessment, and anatomy. The aim of this study is to report early and mid-term results of open surgical and endovascular repair of pCoAA.

METHODS

This is an international multicenter retrospective study including patients who underwent open surgical or endovascular repair for pCoAA between 2000 and 2021 at 14 highly specialized academic cardiovascular centers. The pre-, intra-, and postoperative data were recorded and analyzed.

RESULTS

A total of 74 patients [46 male, median age 44 years-old (IQR, 35-53)] underwent pCoAA repair. All patients had previously undergone surgical repair of aortic coarctation (CoA) at a median age of 11 years-old for the index procedure (IQR, 7-17). The most common first surgical correction was synthetic patch aortoplasty in 48 patients, followed by graft interposition in 11. Median pCoAA diameter was 54 mm (IQR, 44-63). The median time from the CoA repair to the pCoAA diagnosis was 33 years (IQR, 25-40). A total of 33 patients had symptoms at presentation, including thoracic or back pain in eight. Open surgical repair was performed in 28 patients, including four frozen elephant trunk (FET) procedures and one Bentall. The remaining 46 patients underwent endovascular repair of the pCoAA. Two in-hospital deaths were observed (one FET and one endovascular). After a median follow-up of 50 months (IQR, 14-127), there was a total of seven reinterventions.

CONCLUSIONS

This international multicenter study demonstrates that patients with pCoAA can be safely treated with either open surgical or endovascular interventions. Since the median time between the coarctation repair and the aneurysm formation was over 30 years, life-long surveillance of these patients is warranted.

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.

Personalized Pre- and Post-Operative Hemodynamic Assessment of Aortic Coarctation from 3D Rotational Angiography

PURPOSE

Coarctation of Aorta (CoA) is a congenital disease consisting of a narrowing that obstructs the systemic blood flow. This proof-of-concept study aimed to develop a framework for automatically and robustly personalizing aortic hemodynamic computations for the assessment of pre- and post-intervention CoA patients from 3D rotational angiography (3DRA) data.

METHODS

We propose a framework that combines hemodynamic modelling and machine learning (ML) based techniques, and rely on 3DRA data for non-invasive pressure computation in CoA patients. The key features of our framework are a parameter estimation method for calibrating inlet and outlet boundary conditions, and regional mechanical wall properties, to ensure that the computational results match the patient-specific measurements, and an improved ML based pressure drop model capable of predicting the instantaneous pressure drop for a wide range of flow conditions and anatomical CoA variations.

RESULTS

We evaluated the framework by investigating 6 patient datasets, under pre- and post-operative setting, and, since all calibration procedures converged successfully, the proposed approach is deemed robust. We compared the peak-to-peak and the cycle-averaged pressure drop computed using the reduced-order hemodynamic model with the catheter based measurements, before and after virtual and actual stenting. The mean absolute error for the peak-to-peak pressure drop, which is the most relevant measure for clinical decision making, was 2.98 mmHg for the pre- and 2.11 mmHg for the post-operative setting. Moreover, the proposed method is computationally efficient: the average execution time was of only [Formula: see text] minutes on a standard hardware configuration.

CONCLUSION

The use of 3DRA for hemodynamic modelling could allow for a complete hemodynamic assessment, as well as virtual interventions or surgeries and predictive modeling. However, before such an approach can be used routinely, significant advancements are required for automating the workflow.

Angioplasty of Native Coarctation in a Very Low Birth Weight, Donor of Twin-Twin Transfusion Infant

We present a case of successful balloon angioplasty of native aortic coarctation in a preterm infant, a donor of twin-twin transfusion syndrome with low birth weight. Angioplasty was done at the age of 15 days and weight of 480 g, using umbilical artery approach. Follow-up at 4 months of age showed no recurrence of coarctation.

Left heart bypass for repair of aortic coarctation in children: Technical tips and pitfalls

Spinal cord injury secondary to coarctation repair in children is a serious, though relatively uncommon, complication. Several measures have been proposed to minimize this risk, which seems to affect more older children than neonates and those with inadequate collateral circulation. Left heart bypass has been proposed as a protective strategy.

Effectiveness of Repair of Aortic Coarctation in Neonates: A Long-Term experience

To evaluate early and long-term results of surgical treatment of aortic coarctation (CoAo) in neonates. This is a retrospective clinical review of neonates with CoAo, who underwent surgery between 1995 and 2019. Data were retrieved from our institutional database, to identify preoperative and postoperative characteristics. Statistical analysis was performed by means of relative risk ratio and Cox and logistic multivariate analysis. 218 consecutive neonates (M/F: 129/89, median age 11 days, IQR 7-17 days) were included; 202 (92.7%) had a left thoracotomy; 178 underwent extended end-to-end anastomosis (EEEA, 81.6%). Hypoplastic aortic arch (HAA) was present in 102 patients (46.8%); complex cardiac anomalies in 85 (39%). Significant postoperative complications occurred in 20 (9.2%). Thirty-day mortality was 2.3% (most in complex types). At a median follow-up of 10.4 years (IQR 5.6-15.0 years; FU completeness 95.9%), there were 8 late deaths (3.7%), all associated to complex CoAo. Among 196 survivors, 177 (93.2%) were in NYHA class I; re-interventions on aortic arch occurred in 9.2% (2.0% were surgical). Freedom from mortality and re-intervention on aorta at 10 years were 94.3% and 96.7%, respectively. Surgical repair of CoAo in newborns without CPB in our series was safe and low-risk, with excellent early and late outcomes.

Echocardiographic findings for improved prenatal diagnosis of aortic coarctation with ventricular septal defect

Accurate prenatal diagnosis of coarctation of the aorta (CoA) associated with ventricular septal defect (VSD) remains challenging. The objective of the study was to identify which Doppler and/or two-dimensional sonographic findings are most useful for predicting fetal CoA/VSD. A retrospective cohort study identified 35 fetuses with suspected CoA/VSD. Prenatal imaging characteristics included the right ventricular/left ventricular, pulmonary artery (PA)/aorta ratio, aortic isthmus (AOI) Z score, diastolic velocity-time integral (VTID), and systolic velocity-time integral (VTIS) at the AOI. The area under the receiver operating characteristic curve (AUC), integrated discrimination improvement (IDI), and net reclassification improvement (NRI) were calculated. Significant differences in the PA/AO, VTID, VTID/VTIS, VTID/VTIS, VTID/(VTID + VTIS), and AOI Z score between the true CoA group and false positives were found. When associated with VSD, the VTID/VTIS and VTID/(VTID + VTIS) had the highest AUC (0.97, 95% confidence interval: 0.84-1.00), with 88.46% sensitivity and 100.00% specificity for predicting the true CoA. The AOI Z score had the highest sensitivity (92.31%). Adding the VTID/VTIS to the AOI Z score significantly improved the performance (IDI, 50%; NRI, 82%; P < 0.05), with an improvement in specificity (77.78% vs. 55.56%; non-Event P = 0.008) without sacrificing sensitivity (96.15% vs. 92.31%; Event P = 0.564). In fetuses with suspected CoA associated with VSD, the quantitative spectral Doppler metric aided accurate detection of the fetal CoA, with reduced false positives. The conventional AOI Z score plus spectral Doppler metric may improve the overall diagnostic accuracy of CoA/VSD.

Effect of coarctation of aorta anatomy and balloon profile on the outcome of balloon angioplasty in infantile coarctation

OBJECTIVE

Coarctation of the Aorta (CoA) is a relatively common cardiovascular disorder. The present study aimed to evaluate the effect of COA anatomy and high versus low-pressure balloons on the outcome of balloon angioplasty among neonates and infants.

METHODS

In this retrospective study, the neonates and infants undergoing balloon angioplasty at Namazi hospital were enrolled. After balloon angioplasty, immediate data results were promptly recorded.Moreover, midterm echocardiographic information was collected via electronic cardiac records of pediatric wards and clinical and echocardiographic data at least 12 months after balloon angioplasty. Finally, data were analyzed using SPSS-20.

RESULTS

In this study, 42 infants were included. The median age at the time of balloon angioplasty was 1.55 (range 0.1-12) months and 66.7% of the patients were male. The mean pressure gradient of coarctation was 38.49 ± 24.97 mmHg, which decreased to 7.61 ± 8.00 mmHg (P < 0.001). A high-pressure balloon was used in 27, and a low-pressure balloon was used in 15 patients. COA's pressure gradient changed 30.89 ± 18.06 in the high-pressure group and 24.53 ± 20.79 in the low-pressure balloon group (P = 0.282). In the high-pressure balloon group, 14.81% and in the low-pressure group, 33.33% had recoarctation and need second balloon angioplasty (p < 0.021). The infant with discrete coarctation had a higher decrease in gradient and lower recoarctation.

CONCLUSION

Recoarctation rate was lower in the high-pressure balloon. The infant with discrete COA had a better response to the balloon with more decrease in gradient and lower recoarctation rate. Therefore, the stenotic segment anatomy needs to be considered in the selection of treatment methods.

Prenatal Diagnosis of Aortic Coarctation: Prediction Algorithm according to Gestational Age

OBJECTIVES

The aim of the study was first to quantify the diagnostic accuracy of predictive anatomical factors of aortic coarctation (CoA) and second to design a postnatal CoA probability algorithm according to gestational age (GA) in prenatal period.

METHODS

Global and according to GA diagnostic performance of cardiac anatomical variables using the ROC curve were evaluated in a retrospective cohort of fetuses with suspicion of CoA (2004-2020). A serial testing strategy to predict postnatal CoA by fetal echocardiography was designed.

RESULTS

114 fetuses were included. Isthmus-to-ductal (I/D) ratio provided the best discrimination between healthy fetuses and those with CoA (AUC 0.91, 95% CI: 0.86-0.96, I/D < 0.74 sensitivity 96.3%, I/D < 0.6, specificity 92.5%) with good classification capacity in both the second and third trimesters of gestation. Isthmus z-score and pulmonary/aortic valve ratio increased accuracy in fetuses >28 and tricuspid/mitral valve ratio (TV/MV) in fetuses ≤28 weeks. Study of I/D plus TV/MV ratio in fetuses ≤28 and I/D ratio plus isthmus z-scores in fetuses >28 weeks allowed to correctly classify 91.8% of fetuses as high or low probability of postnatal CoA.

CONCLUSIONS

Diagnostic discrimination of anatomic predictive factors for CoA varies according to GA. Specific algorithms according to GA increase accuracy in CoA's prenatal prediction.

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.

Equal cerebral perfusion during extended aortic coarctation repair

OBJECTIVES

Aortic coarctation with distal aortic arch hypoplasia can be effectively addressed by coarctation resection with extended end-to-end-anastomosis (REEEA). Particularly, when unilateral cerebral perfusion (UCP) is established by clamping of left-sided supra-aortic vessels, the extent of cerebral blood flow distribution during repair remains undetermined, so far. Transfontanellar contrast-enhanced ultrasound (T-CEUS) can be utilized for real-time visualization and quantitative evaluation of cerebral blood flow. This study quantitatively evaluates cerebral perfusion during REEEA by using intraoperative T-CEUS.

METHODS

In a prospective study, 9 infants with open fontanelle undergoing REEEA [median age: 13 days (range 1-34) and median weight 3.1 kg (range 2.2-4.4)] were intraoperatively examined with T-CEUS at 3 consecutive time-points: before skin incision, during UCP and after skin suture. A software-based analysis of 11 parameters was used for data evaluation. Absolute and relative blood flow in contralateral hemispheres was measured in side-by-side comparison, and referenced to baseline measurements.

RESULTS

No side-depend absolute or relative cerebral perfusion differences were found during REEEA, except for an increased relative 'wash-out-rate' (P = 0.0013) in favour of the right hemisphere after surgery. Compared to ipsilateral baseline levels, 'rise time' was transiently increased in right (P = 0.0277) and 'time-to-peak' in both hemispheres (right: P = 0.0403 and left: P = 0.0286), all during UCP.

CONCLUSIONS

The use of T-CEUS provided evidence for homogenous distribution of contrast agent in both hemispheres during UCP. T-CEUS can be utilized for the postprocedural evaluation of cerebral perfusion during congenital cardiac surgery.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov Unique, Identifier: NCT03215628.

Combined endovascular and open treatment to prevent increase in afterload in anastomotic pseudoaneurysm and aortobronchial fistula after surgery for aortic coarctation

We report the treatment of a patient who had presented with hemoptysis due to an aortobronchial fistula from an anastomotic pseudoaneurysm after extra-anatomic bypass for aortic coarctation. An aortobronchial fistula can often result from an aortic pseudoaneurysm and is associated with high mortality if not treated. We decided to use combined endovascular and open surgical treatment and obtained a satisfactory intraoperative result. The perioperative outcome and first follow-up visit were favorable. In recent years, endovascular repair of pathologic aortic conditions has increased; thus, we have placed the present case within the context of the relevant medical literature.

Carotid atherosclerosis, changes in tissue remodeling and repair in patients with aortic coarctation

BACKGROUND AND AIMS

After aortic coarctation (CoA) repair, patients still suffer from cardiovascular complications. The aim of this study was to measure cardiovascular markers, intima-media thickness (IMT) and plaques in controls and patients with CoA.

METHODS

Sixty-four patients with CoA (66% male, mean age 48 ± 15 years) and controls (54% men, mean age 47 ± 16 years) underwent ultrasound of their arteries. A multiplex platform to analyze circulating blood levels biomarkers reflecting inflammation, tissue remodeling and repair was used.

RESULTS

In men following CoA repair, a significantly increased carotid bulb IMT was observed in comparison to the control group (1.05 [0.72-1.24] vs. 0.67 [0.59-0.95] mm; p = 0.003). Median common carotid artery (CCA) IMT was increased in men compared to controls (0.82 [0.61-0.97] mm vs. 0.58 [0.53-0.76] mm, p < 0.003) and in women compared to controls (0.83 [0.70-0.92] vs. 0.60 [0.55-0.69], p < 0.004). CoA demonstrated an independent association with IMT in both men and women. Men with CoA were also more likely to have a plaque in their carotid arteries (p = 0.010). In women with CoA, we observed significantly lower levels of stem cell factor (SCF, p = 0.004) while in men with CoA we observed significantly lower levels of matrix metalloproteinase-3 (MMP-3, p = 0.048), tumor necrosis factor receptor 1 (TNF-R1, p = 0.032), tumor necrosis factor receptor superfamily member 10B (TRAIL-R2, p = 0.019) and monocyte chemotactic protein 1 (MCP-1, p = 0.015).

CONCLUSIONS

This is the first study to show that despite successful CoA repair, patients have more carotid atherosclerosis than can be explained by changes in tissue remodeling and repair.

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.

•

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

•

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

•

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

•

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

Giant descending aortic pseudo-aneurysm in an adult man with uncorrected aortic coarctation

Background

Aortic coarctation (CoAo) accounts for 6 to 8% of all congenital heart diseases and occurs two to five times more often in males. The uncorrected aortic coarctation is complicated by hypertension, ascending and descending aortic aneurysms, endarteritis, and heart failure. The aortic pseudo-aneurysm (APD) usually occurs in patients with endarteritis. We report an adult man with bicuspid aortic valve, perimembranous ventricular septal defect, and uncorrected aortic coarctation complicated by descending aortic pseudo-aneurysm without aortic endarteritis.

Case presentation

A 40-year-old man was referred to our division for hemoptysis and severe aortic coarctation. Echocardiography confirmed the aortic coarctation diagnosis and showed a large aortic pseudo-aneurysm at the coarctation site with intra-cavity mural thrombus. Subsequently, the patient underwent contrast-enhanced computed tomography angiography, and diagnosis of coarctation and APD was confirmed. Due to various malformations and considering that the patient had become unstable due to hemoptysis, it was discussed in the heart team, and it was decided that the patient would undergo staged surgery.

Conclusions

The aortic pseudo-aneurysm is a rare complication in patients with untreated coarctation that requires prompt surgery, and this complication should be considered in patients with untreated aortic coarctation who present with hemoptysis.

Effects of Uncertainty of Outlet Boundary Conditions in a Patient-Specific Case of Aortic Coarctation

Computational Fluid Dynamics (CFD) simulations of blood flow are widely used to compute a variety of hemodynamic indicators such as velocity, time-varying wall shear stress, pressure drop, and energy losses. One of the major advances of this approach is that it is non-invasive. The accuracy of the cardiovascular simulations depends directly on the level of certainty on input parameters due to the modelling assumptions or computational settings. Physiologically suitable boundary conditions at the inlet and outlet of the computational domain are needed to perform a patient-specific CFD analysis. These conditions are often affected by uncertainties, whose impact can be quantified through a stochastic approach. A methodology based on a full propagation of the uncertainty from clinical data to model results is proposed here. It was possible to estimate the confidence associated with model predictions, differently than by deterministic simulations. We evaluated the effect of using three-element Windkessel models as the outflow boundary conditions of a patient-specific aortic coarctation model. A parameter was introduced to calibrate the resistances of the Windkessel model at the outlets. The generalized Polynomial Chaos method was adopted to perform the stochastic analysis, starting from a few deterministic simulations. Our results show that the uncertainty of the input parameter gave a remarkable variability on the volume flow rate waveform at the systolic peak simulating the conditions before the treatment. The same uncertain parameter had a slighter effect on other quantities of interest, such as the pressure gradient. Furthermore, the results highlight that the fine-tuning of Windkessel resistances is not necessary to simulate the post-stenting scenario.

"Undiagnosed aortic coarctation with 2 simultaneous acute aortic syndromes: Intramural hematoma and mycotic aneurysm"

Acute aortic syndrome can be a fatal pathology if not diagnosed and managed early. Although acute aortic syndrome is more often a diagnosis of adulthood, it may occasionally afflict the pediatric patients. We herein present a case of a 5-year-old female that was discovered to have multiple acute and congenital aortic abnormalities after presenting to the emergency department with infectious symptoms and lower extremity pain. Acute aortic syndrome may not be a top differential consideration in children with acute chest pain; however, it is important to consider because delayed diagnosis and management can have fatal implications.

Heating of an Aortic Stent for Coarctation Treatment During Magnetic Particle Imaging and Magnetic Resonance Imaging-A Comparative In Vitro Study

PURPOSE

To evaluate heating of a redilatable stent for the treatment of aortic coarctation in neonates and small children in the new imaging modality magnetic particle imaging and established magnetic resonance imaging.

MATERIALS AND METHODS

The cobalt-chromium stent (BabyStent, OSYPKA AG, Rheinfelden, Germany) has a stent design which allows for redilatation and adjustment of the diameter from 6 to 16 mm for a use in aortic coarctation. The stent loses its radial integrity while opening at predetermined breaking points at a diameter of 14 mm or 16 mm, respectively. We measured the temperature increase in the stent at different diameters during 7-min magnetic particle imaging and magnetic resonance imaging scans with fiber optic thermometers under static conditions surrounded by air. In magnetic particle imaging, stents with diameters from 6 to 16 mm were tested while in magnetic resonance imaging only stents with diameters of 6 mm and 14 mm were investigated exemplarily.

RESULT

In magnetic particle imaging, the measured temperature differences increased up to 4.7 K with growing diameters, whereas the opened stents with discontinuous struts at 14 and 16 mm showed only minimal heating of max. 0.5 K. In contrast to magnetic particle imaging, our measurements showed no heating of the stents during magnetic resonance imaging under identical conditions.

CONCLUSION

The BabyStent did show only slight heating in magnetic particle imaging and no detectable temperature increase in magnetic resonance imaging.

David & debranching techniques with combined axillar and femoral perfusion: a case report

We present the case of a 38-year-old male with a diagnosis of Stanford A aortic dissection and associated coarctation of the thoracic aorta. Acute dissection associated with coarctation of the aorta is a rare problem and difficult to manage surgically. Establishing a cardiopulmonary bypass (CPB) with adequate flows is the main objective of the procedure; optimal cannulation ensures the protection of cerebral and visceral organs. We successfully performed aortic valve re-implantation surgery (T. David Surgery), replacement of the ascending aorta and aortic arch, as well as debranching of the supra-aortic trunks. The cannulation technique was axillary and femoral to guarantee flows through the coarctation area.

Use of VA ECMO and percutaneous palliation of ductal dependent coarctation in a neonate with trisomy 21 and COVID-19 pneumonia

We present a case of a neonate with trisomy 21, ductal-dependent aortic coarctation, and severe respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. The neonate was managed with venoarterial extracorporeal membrane oxygenation (VA ECMO), palliative stenting of the coarctation, and a vascular plug occlusion of a large patent ductus arteriosus. The patient was successfully weaned off extracorporeal membrane oxygenation (ECMO). The patient is currently awaiting a definitive surgical repair in the near future.

Comparison of stenosis models for usage in the estimation of pressure gradient across aortic coarctation

Non-invasive estimation of the pressure gradient in cardiovascular stenosis has much clinical importance in assisting the diagnosis and treatment of stenotic diseases. In this research, a systematic comparison is conducted to investigate the accuracy of a group of stenosis models against the MRI- and catheter-measured patient data under the aortic coarctation condition. Eight analytical stenosis models, including six from the literature and two proposed in this study, are investigated to examine their prediction accuracy against the clinical data. The two improved models proposed in this study consider comprehensively the Poiseuille loss, the Bernoulli loss in its exact form, and the entrance effect, of the blood flow. Comparison of the results shows that one of the proposed models demonstrates a cycle-averaged mean prediction error of -0.15 ± 3.03 mmHg, a peak-to-peak prediction error of -1.8 ± 6.89 mmHg, which is the best among the models studied.

Incidental aortic coarctation in traumatic subclavian artery injury

Subclavian artery injuries are complex and challenging due to anatomy and exposure during surgery. The surgical management depends on the mechanism of injury, the patient's haemodynamic stability and other injuries sustained. If control of bleeding is lost during surgery, it results in immediate exsanguination, with high mortality and morbidity rates. New techniques with endovascular surgery have changed the approach and outcome of these injuries. In this case report, an incidental finding of coarctation of the aorta in a 32-year-old man after sustaining a gunshot to the chest, with a subsequent subclavian artery injury is reported.

Evaluation of Ductal Tissue in Coarctation of the Aorta Using X-Ray Phase-Contrast Tomography

We assessed the histological accuracy of X-ray phase-contrast tomography (XPCT) and investigated three-dimensional (3D) ductal tissue distribution in coarctation of the aorta (CoA) specimens. We used nine CoA samples, including the aortic isthmus, ductus arteriosus (DA), and their confluences. 3D images were obtained using XPCT. After scanning, the samples were histologically evaluated using elastica van Gieson (EVG) staining and transcription factor AP-2 beta (TFAP2B) immunostaining. XPCT sectional images clearly depicted ductal tissue distribution as low-density areas. In comparison with EVG staining, the mass density of the aortic wall positively correlated with elastic fiber formation (R = 0.69, P < 0.001). TFAP2B expression was consistent with low-density area including intimal thickness on XPCT images. On 3D imaging, the distances from the DA insertion to the distal terminal of the ductal media and to the intima on the ductal side were 1.63 ± 0.22 mm and 2.70 ± 0.55 mm, respectively. In the short-axis view, the posterior extension of the ductal tissue into the aortic lumen was 79 ± 18% of the diameter of the descending aorta. In three specimens, the aortic wall was entirely occupied by ductal tissue. The ductal intima spread more distally and laterally than the ductal media. The contrast resolution of XPCT images was comparable to that of histological assessment. Based on the 3D images, we conclude that complete resection of intimal thickness, including the opposite side of the DA insertion, is required to eliminate residual ductal tissue and to prevent postoperative re-coarctation.

Subclavian flap aortoplasty for infant coarctation of the aorta

Aortic resection with an extended end-to-end anastomosis is the surgical gold standard treatment for infant aortic coarctation and has excellent early and long-term outcomes.  Subclavian flap aortoplasty is an alternative surgical technique that offers some advantages because there is no need to do extensive dissection and mobilization of the aortic arch and descending aorta as required in an extended end-to-end anastomosis.  This video tutorial illustrates the technical aspects of subclavian flap aortoplasty in an infant.