Emergency balloon dilation or stenting of critical coarctation of aorta in newborns and infants: An effective interim palliation

Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Kochi, India.
Annals of Pediatric Cardiology 07/2009; 2(2):111-5. DOI: 10.4103/0974-2069.58311
Source: PubMed


Management of native uncomplicated coarctation in neonates remains controversial with current evidence favoring surgery. The logistics of organizing surgical repair at short notice in sick infants with critical coarctation can be challenging.
We reviewed data of 10 infants (mean age of 2.9 +/-1.6 weeks) who underwent catheter intervention for severe coarctation and left ventricular (LV) dysfunction between July 2003 and August 2007. Additional cardiac lesions were present in 7. Mean systolic gradient declined from 51+/-12 mm Hg to 8.7+/-6.7 mm Hg after dilation. The coarctation segment was stented in five patients. Procedural success was achieved in all patients with no mortality. Complications included brief cardiopulmonary arrest (n =1), sepsis (n = 1) and temporary pulse loss (n = 2). LV dysfunction improved in all patients. Average ICU stay was 5+/-3.4 days and hospital stay was 6.5+/-3.4 days. On follow-up (14.1+/-10.5 months), all developed restenosis after median period of 12 weeks (range four to 28 weeks). Three (two with stents) underwent elective coarctation repair, two underwent ventricular septal defect (VSD) closure and coarctation repair and one underwent pulmonary artery (PA) banding. Two patients who developed restenosis on follow-up were advised surgery, but did not report. Two (one with stent) underwent redilatation and are being followed with no significant residual gradients.
Balloon dilation +/- stenting is an effective interim palliation for infants and newborns with critical coarctation and LV dysfunction. Restenosis is inevitable and requires to be addressed.

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    • "Francis et al. reported on the use of stents in the setting of critically ill infants with left ventricular dysfunction.[6] It would appear that these patients presented relatively late, after the arterial duct had closed, to explain their critical state and the presence of a large pressure gradient across the coarctation. "
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    ABSTRACT: In selected neonates and infants, primary palliative stent implantation may be indicated for coarctation of the aorta. We describe our experience with this approach in five consecutive patients. Five neonates and infants (age range 6 to 68 days, gestation 33 to 38 weeks, weight range at procedure of between 1650 to 4000 g) underwent palliative stent implantation as primary therapy for coarctation of the aorta. Indications for primary stent implantation were varied. All procedures were performed by elective surgical cut down of the axillary artery. Standard coronary stents (diameter 4.5 to 5 mm, length 12 to 16 mm) were delivered via a 4F sheath. The axillary artery was repaired after removal of the sheath. All procedures were acutely successful, and without procedural complications. All patients survived to hospital discharge. Four patients have subsequently undergone elective stent removal and surgical repair of the arch, at between 38 and 83 days following stent implantation. Complete stent removal was achieved in three patients. Over a follow-up ranging between 8 weeks and 36 months, none of the patients has had any further complications. This palliative approach is warranted in carefully selected patients. Long-term follow-up is required.
    Annals of Pediatric Cardiology 07/2012; 5(2):145-50. DOI:10.4103/0974-2069.99616
  • Annals of Pediatric Cardiology 07/2009; 2(2):116-9. DOI:10.4103/0974-2069.58312
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    ABSTRACT: The objective of this study was to assess late morbidity after repair of aortic coarctation and its association with residual aortic arch obstruction. This is an observational cohort study of 133 patients who underwent surgical repair during 1965-1985. Echocardiography, bicycle exercise testing, 24-hour ambulatory blood pressure monitoring, and magnetic resonance imaging/computerized tomography scan of the thoracic aorta were performed. The setting of this study was a tertiary referral center. Among 156 survivors, 133 (84 men) accepted study participation. Median age (range) was 10 (0.1-40) years at repair and 44 (26-74) years at follow-up. Outcome measures used are prevalence of previous cardiovascular reinterventions, current cardiac and valvular function, exercise capacity, blood pressure levels at rest and during exercise, and presence of recurrent or residual aortic arch obstruction and/or aortic aneurysms. Thirty-five had undergone cardiovascular reinterventions. Sixteen had an aortic and three had a mitral valve prosthesis; 117 had a native aortic valve that was bicuspid in 63 and dysfunctional in 45. Ejection fraction was below 50% in 16. On exercise, performance was reduced in 37 and hypertension was induced in 47. Fifty-eight had elevated blood pressures and further 17 received antihypertensives. The ascending aorta was aneurysmal in 28 and the distal arch in five. The presence of a bicuspid aortic valve was significantly associated with valve regurgitation and ascending aortic ectasia. Fifty-eight of 121 patients had minimal aortic arch diameters between 46% and 79% of the diaphragmatic aortic diameter, indicating moderate/mild recoarctation. This was associated with elevated blood pressures and use of antihypertensive medication, but not with hypertension in unmedicated patients or with echocardiographic or exercise parameters. Only five patients had normal study findings, were normotensive, and without reinterventions after coarctation repair. Cure by repair of aortic coarctation is rare; heart diseases, aortopathy, and hypertension are common. Morbidity is only weakly associated with mild/moderate recoarctation.
    Congenital Heart Disease 10/2011; 6(6):573-82. DOI:10.1111/j.1747-0803.2011.00575.x · 1.08 Impact Factor
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