Transumbilical balloon coarctation angioplasty in neonates with critical aortic coarctation

Abstract

Balloon angioplasty of previously unoperated, “native,” aortic coarctation has been successfully used in neonates and infants younger than 1 year of age.l-14 Symptomatic improvement and pressure gradient reduction after balloon angioplasty14 has been well documented. The high incidence of recoarctation and the potential for development of aneurysms and arterial complieations15-*7 are of concern. We report the feasibility of balloon angioplasty for native coarctation via an umbilical artery approach, which spares the femoral arteries. An 11-day-old infant who weighed 3.9 kg was first seen in the local physician’s office with a 3-day history of upper respiratory tract infection. He was found to be grunting, cyanotic, and poorly perfused. He was immediately ventilated manually and rushed to a local emergency room. There he was intubated, given volume expansion, and started on vasopressor agents; only a transient improvement in color and perfusion was observed. The initial pH was 7.1 with a base deficit of 12.8. Chest x-ray films showed cardiomegaly and evidence of pulmonary venous congestion. Pediatric cardiology consultation along with a Doppler echocardiographic study was obtained immediately. An echocardiogram showed evidence of severe aortic coarctation, mild aortic stenosis, no ventricular septal defect, and poor left ventricular shortening fraction. Because severe aortic coarctation was diagnosed, intravenous prostaglandin Ei infusion was started, and significant improvement occurred over the next 30 minutes of observation. The infant was transferred to the University of Wisconsin Children’s Hospital. After further stabilization in the pediatric intensive care unit, the infant was taken to the cardiac catheterization laboratory. Percutaneous right heart catheterization and antegrade left ventricular angiography, which was performed via the right femoral vein, revealed severe aortic coarctation with a large gradient (Table I) across the aortic coarctation. The coarcted aortic segment measured 2 mm, and the descending aorta at the level of the diaphragm measured 6 mm. Because the need for relief of aortic coarctation was indicated, the previously placed 3.5F umbilical arterial catheter was exchanged for