Coarctation of the aorta in older patients.

Abstract

Coarctation of the aorta has received increasing clinical attention since its surgical treatment has become possible (Crafoord and Nylin, 1945; Gross and Hufnagel, 1945). The diagnosis generally offers no difficulty, but the question as to whether and when a patient with this condition should be submitted to operation is not always readily answered. In this connexion it is important to know the expectation of life in a case of coarctation of the aorta not submitted to an operation; the mortality of surgical treatment in these cases; and the results obtained by resection of the stenosis. As early as 1928, investigations made by Hamilton and Abbott showed that the average age of untreated patients was 33.5 years, and Reifenstein, Levine, and Gross (1947) found an average of 35 years in 104 post-mortem cases. Since the mortality of the operation in uncomplicated cases in the favourable age group has become low, the general opinion is that patients in whom coarctation has been diagnosed should be considered for surgical treatment. Some maintain, however, that no operation must be resorted to in patients over 25 years of age who are asymptomatic. In 1948, Newman reported on the results of his investigations in 23 older patients with coarctation of the aorta. Three had been soldiers during the first world war. Of these three, one died at the age of 68. This led the author to the conclusion that the prognosis of coarctation of the aorta in older subjects is not so unfavourable if the condition does not give rise to symptoms before the age of 25, but it should be pointed out that Newman's series is too small to sustain his conclusion. Bramwell (1947) also believed that the expectation of life in patients with coarctation of the aorta was good if the condition caused no symptoms before the thirtieth year of life. Gross (1953) maintained that the operation should preferably not be performed in patients over 25 years of age because, in these patients, the aorta often already shows such changes as increase the risk entailed by a vascular suture. Groves and Effler (1960) reported on three surgical patients more than 45 years of age. Two of these died, one as a result of mycotic aneurysm and the other because of encephalomalacia of the right cerebral hemisphere. The authors believed that the cause should be found in the inadequate oxygen supply to the markedly arteriosclerotic cerebrum as a result of the decrease in blood pressure in the upper half of the body after the operation. They believed that no rules should be set up regarding an age limit; each case should be individually evaluated. We, too, were reserved in determining surgical indications in older patients with asymptomatic coarctation of the aorta. The case histories of the following patients show, however, that coarctation of the aorta can cause vitally dangerous complications even if it causes no symptoms or does so only at a more advanced age.