Emergency balloon dilation or stenting of critical coarctation of aorta in newborns and infants: An effective interim palliation
ABSTRACT 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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ABSTRACT: Repaired aortic coarctation(CoA) is associated with high long-term cardiovascular mortality and morbidity. Persisting hypertension and left ventricular dysfunction are possibly associated with residual or recurrent aortic arch obstruction (ReCoA) and abnormal activation of vasoactive hormones. Furthermore, knowledge regarding these patients' functional health status late after repair is missing. A total of 133 adults who underwent surgical repair of CoA in childhood and youth (84 men) were examined in this observational cohort study. Median age (range) at surgery was 10 (0.1-40) years and 44 (26-74) years at examination. Thirty-six age and gender-matched healthy subjects served as controls. Prevalence of previous cardiovascular reintervention, current cardiac and valvular function, exercise capacity, blood pressure levels, as well as the presence of residual or recurrent aortic arch obstruction (ReCoA) and aortic aneurysms. Echocardiography (including tissue Doppler), bicycle exercise testing, 24-h ambulatory blood pressure monitoring, MRI/ CT scan of the thoracic aorta were performed. Analysis of renal function and vasoactive hormones was performed by blood and urine tests at rest and after maximal physical effort. Functional health status was assessed by means of the SF-36 health survey. The prevalence of hypertension was high (44% of the cohort had blood pressure levels above the recommended levels, half of those despite medication). Reinterventions were common (26%) and most often performed due to aortic valve dysfunction and ReCoA. Above half of the cohort had a bicuspid aortic valve, which was strongly associated with ascending aorta aneurysms and aortic valve regurgitation. A total of 48% of the patients had a mild to moderate ReCoA, which was only weakly associated with the presence of hypertension as well as to exercise capacity and echocardiographic measurements of cardiac function. Both normotensive and hypertensive patients had increased left ventricular mass, normal ejection fraction, reduced long-axis systolic function, and impaired diastolic function compared with controls, with differences being more pronounced in hypertensive patients. Natriuretic hormone levels were slightly increased among normotensives, whereas renin-angiotensin-aldosterone and renal function parameters were normal at rest and during exercise. Mild to moderate ReCoA had no significant influence on the measured parameters. SF-36 scores among patients were only slightly lower compared with those from controls. However, patients with reduced exercise performance and those taking daily cardiovascular medication scored significantly lower in several mental and physical categories compared with patients with unmedicated patient and with those with preserved exercise capacity. Surgical correction of CoA only repairs the anatomical narrowing, but not the associated vasculo- and valvulopathy. Increased left ventricular mass, systolic and diastolic dysfunction, aortic valve dysfunction, aortopathy, and hypertension are common. Morbidity is only weakly associated with mild and moderate degrees of ReCoA, and not associated with changes in vasoactive hormone levels and renal function. Despite late morbidity, functional health status is overall only slightly impaired in patients after surgical correction of CoA compared with healthy subjects. Nevertheless, the subgroup with reduced exercise capacity and need for cardiovascular medications have a considerable impairment of both physical and mental aspects of functional health.Danish Medical Journal 04/2012; 59(4):B4436. · 0.61 Impact Factor
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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 · 1.20 Impact Factor
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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