Coarctation Of The Aorta Repair Research Articles

Selection of a Surgical Treatment Approach for Aortic Coarctation in Adolescents and Adults.

Coarctation of the aorta (CoA) in adolescents and adults is relatively rare. Several operative techniques for CoA in adolescents and adults have been reported, but there is still no consensus. This study aims to highlight the use of individual patient characteristics to select optimal treatment strategies for CoA in adolescents and adults. Surgical repair of CoA was performed in five patients (mean age: 34 ± 14 years, range: 13-58 years). All patients had primary CoA, and one had aneurysm above the CoA. One patient had undergone previous aortic valve replacement (AVR) and graft replacement of the ascending aorta. One patient underwent resection of the coarctation without cardiopulmonary bypass (CPB) followed by direct end-to-end anastomosis. Three patients underwent CoA resection with an interposition graft through a lateral thoracotomy with partial CPB. One patient underwent AVR with extra-anatomical bypass (ascending-descending aorta). No in-hospital deaths occurred, and there were no complications. During the follow-up period, there has been no recurrence of CoA. CoA in adolescents and adults is associated with different issues from those encountered in infant patients, and comprehensive surgery should be performed in all cases.

Hypertension in Coarctation of the Aorta: Challenges in Diagnosis in Children.

Evidence indicates that patients with coarctation of the aorta (COA) suffer from increased cardiovascular morbidity and mortality in later life despite successful repair of COA in childhood. Systolic arterial hypertension is common, presenting in up to one-third of patients, and is regarded as the main driver of premature cardiovascular events in this group of patients. In this review, we discuss the prevalence and pathophysiology of hypertension in children following successful COA repair with no residual arch obstruction. The challenges in accurate blood pressure assessment at this early phase are considered and non-invasive measures of central blood pressure are discussed. Although the pathways for investigations in adults are well defined, we highlight the need to address the issues of cardiovascular surveillance in children and describe techniques which can provide complementary information for cardiovascular assessment in this group of patients such that timely treatment can occur.

Coarctation Index Predicts Recurrent Aortic Arch Obstruction Following Surgical Repair of Coarctation of the Aorta in Infants

Recurrent aortic arch obstruction (RAAO) remains a major cause of morbidity following surgical neonatal repair of coarctation of the aorta (CoA). Elucidating predictors of RAAO can identify high-risk patients and guide postoperative management. The Coarctation index (CoA-I), defined as the ratio of the diameter of the narrowest aortic arch segment to the diameter of the descending aorta, has been used to help diagnose RAAO in neonates following the Norwood Procedure. We sought to assess the predictive value of the CoA-I on RAAO after CoA repair in infants with biventricular circulation. Clinical, surgical, and echocardiographic data of infants with biventricular circulation following neonatal CoA repair between 2010 and 2014 were evaluated. RAAO was defined using a composite quantitative outcome variable: a blood pressure gradient >20, a peak aortic arch velocity >3.5m/s by echocardiogram, or a catheter-measured peak-to-peak gradient >20 within 2years of surgery. Univariate and multivariate logistic regression analyses were used. Of the 68 subjects included in the analysis, 15 (22%) met criteria for RAAO. In the multivariate model, only CoA-I (OR 35.89, 95% CI 6.08-211.7, p<0.0001) and use of patch material (OR 9.26, 95% CI 1.57-54.66, p=0.014) were associated with increased risk of RAAO. The odds of developing RAAO was higher in patients with a CoA-I less than 0.7 (OR 33.8, 95% CI 5.7-199.5, p<0.001). Postoperative CoA-I may be used to predict RAAO in patients with biventricular circulation after repair of CoA. Patients with a CoA-I less than 0.7 or patch aortoplasty warrant close follow-up.

Abnormal Wave Reflections and Left Ventricular Hypertrophy Late After Coarctation of the Aorta Repair.

Patients with repaired coarctation of the aorta are thought to have increased afterload due to abnormalities in vessel structure and function. We have developed a novel cardiovascular magnetic resonance protocol that allows assessment of central hemodynamics, including central aortic systolic blood pressure, resistance, total arterial compliance, pulse wave velocity, and wave reflections. The main study aims were to (1) characterize group differences in central aortic systolic blood pressure and peripheral systolic blood pressure, (2) comprehensively evaluate afterload (including wave reflections) in the 2 groups, and (3) identify possible biomarkers among covariates associated with elevated left ventricular mass (LVM). Fifty adult patients with repaired coarctation and 25 age- and sex-matched controls were recruited. Ascending aorta area and flow waveforms were obtained using a high temporal-resolution spiral phase-contrast cardiovascular magnetic resonance flow sequence. These data were used to derive central hemodynamics and to perform wave intensity analysis noninvasively. Covariates associated with LVM were assessed using multivariable linear regression analysis. There were no significant group differences (P≥0.1) in brachial systolic, mean, or diastolic BP. However central aortic systolic blood pressure was significantly higher in patients compared with controls (113 versus 107 mm Hg, P=0.002). Patients had reduced total arterial compliance, increased pulse wave velocity, and larger backward compression waves compared with controls. LVM index was significantly higher in patients than controls (72 versus 59 g/m2, P<0.0005). The magnitude of the backward compression waves was independently associated with variation in LVM (P=0.01). Using a novel, noninvasive hemodynamic assessment, we have shown abnormal conduit vessel function after coarctation of the aorta repair, including abnormal wave reflections that are associated with elevated LVM.

Surgeries for Adults with Bicuspid Aortic Valve (BAV) in Adults with a Past History of Coarctation Repair–Differences from Isolated BAV Patients

Background: While the co-existence of bicuspid aortic valves (BAV) and coarctation of the aorta (CoA) is well documented, the impact of previous CoA repair on surgical intervention for BAV has not been explored. Methods: We reviewed our tertiary referral centre databases for Adult Congenital Heart Disease and for Aortic Surgery. Survival data were obtained from the National Death Index. Patients were followed for 8.3 ± 10.2 years post-operatively. Results: Of 472 patients who had surgery for BAV, 24 (5%) had had prior successful CoA repair. Age at surgery for those with CoA was 39 ± 16 years compared to 59 ± 15 years for those with isolated BAV (p < 0.0001). 17 patients with CoA (71%) received mechanical aortic valve replacements (AVR) compared to163/448(36%) with isolated BAV (p < 0.0001). 4 received tissue AVR and 3 had a Ross procedure. 12 with CoA (50%) required aortic root replacement, compared to 164/448(37%)(p = 0.19). In 17 patients with CoA and 368 patients overall, the primary indication for surgery was assessable. Only 7 patients with CoA (29%) presented with aortic stenosis (±root dilatation), compared with 230/351 without CoA (p < 0.0001). Postoperative survival for the CoA patients was 100% at 1 month; 95% at 1 and 3 years; and 88% at 5 years after BAV surgery, similar to those operated for isolated BAV. Conclusions: Patients with a history of CoA who are operated on for BAV are younger and more likely to come to surgery for reasons other than progressive aortic stenosis. Medium term postoperative outcomes are excellent, in this group.

Surgical management of aortic coarctation in adolescents and adults.

Coarctation of the aorta (CoA) in adolescents and adults is often complicated by other cardiac or aortic problems and may carry additional surgical difficulties. Limited studies have reported the surgical outcomes of CoA repair in this particular patient population. We reviewed our contemporary experience of open surgical management of CoA in adolescents and adults. From 2008 to 2016, a total of 60 adolescents and adults (mean age, 32years) underwent CoA repair at our centre. Of this cohort, 43 patients only underwent CoA repair (isolated group), while the remaining 17 underwent other concomitant cardiac procedures (concomitant group). Ascending-to-descending aortic bypass was the preferred repair technique in the concomitant group. Aortic valve replacement and a Bentall/David procedure were the two most frequently combined procedures. There were no in-hospital deaths in the isolated group compared with three in the concomitant group (0% vs 17.6%, P = 0.029). The median intensive care unit stay (1 vs 2days, P <0.01) and postoperative hospital stay (6 vs 9days, P <0.01) were significantly longer in the concomitant group. Postoperative respiratory failure occurred more frequently in the concomitant group (0% vs 17.6%, P = 0.029). The isolated group had better overall survival during follow-up ( P = 0.037). The 5-year overall survival rate was 98% in the isolated group and 82% in the concomitant group. Surgical management of coarctation in adolescents and adults can achieve similar satisfactory outcomes as their neonatal counterparts, but the complexity of the concomitant procedures is a risk factor for this particular patient population.

Persistent reduced myocardial deformation in neonates after CoA repair

IntroductionSurgical repair of coarctation of the aorta (CoA) is a safe procedure in children, however the condition is known for its potential recurrence and other related complications. The available evidence shows abnormal intrinsic properties of the aorta in CoA, thus suggesting additional effect, even after CoA repair, on left ventricular (LV) function. Accordingly, we sought to obtain a better understanding of LV myocardial mechanics in very early-corrected CoA using two-dimensional STE. Methods and resultsWe retrospectively studied 21 patients with corrected CoA at a median age of 9 (2–53) days at three time points: 1) just before intervention, 2) at short-term follow-up and 3) at medium-term follow-up after intervention and compared them with normal values. Speckle tracking analysis was conducted via vendor independent software, Tomtec. After intervention, LV function significantly improved (from −12.8±3.9 to −16.7±1.7; p<0.001), however normal values were not reached even at medium term follow-up (−18.3±1.7 vs. −20±1.6; p=0.002). Medium term longitudinal strain correlated with pre intervention EF (r=0.58, p=0.006). Moreover, medium term subnormal values were more frequently associated with bicuspid aortic valve (33.3% vs. 66.6%; p<0.05). ConclusionLV myocardial function in neonates with CoA can be feasibly evaluated and followed up by speckle tracking echocardiography. LV subendocardial dysfunction however, remains in early infancy coarctation long after repair. Long-term follow-up through adulthood using myocardial deformation measurements should shed light on the natural history and consequences of this anomaly.

Left ventricular hypertrophy in adults with previous repair of coarctation of the aorta; association with systolic blood pressure in the high normal range

BackgroundArterial hypertension is common in adults with repaired coarctation of the aorta (CoA). The associations between the diagnosis of hypertension, actual blood pressure, other factors affecting left ventricular overload, and left ventricular hypertrophy (LVH) are not yet fully explored in this population. Material and resultsFrom the national register for congenital heart disease, 506 adult patients (≥18years old) with previous repair of CoA were identified (37.0% female, mean age 35.7±13.8years, with an average of 26.8±12.4years post repair). Echocardiographic data were available for all patients, and showed LVH in 114 (22.5%) of these. Systolic blood pressure (SBP) (mmHg) (OR 1.02, CI 1.01–1.04), aortic valve disease, (OR 2.17, CI 1.33–3.53), age (years) (OR 1.03, CI 1.01–1.05), diagnosis of arterial hypertension (OR 3.02, CI 1.81–5.02), and sex (female) (OR 0.41, CI 0.24–0.72) were independently associated with LVH. There was an association with LVH at SBP within the upper reference limits [130, 140] mmHg (OR 2.23, CI 1.05–4.73) that further increased for SBP>140mmHg (OR 8.02, CI 3.76–17.12). ConclusionsLVH is common post repair of CoA and is associated with SBP even below the currently recommended target level. Lower target levels may therefore become justified in this population.

Most Coarctations, Recoarctations, and Coarctation-Related Aneurysms Should Be Treated Endovascularly.

For patients with coarctation of the aorta (CoA), surgical intervention results in an overall survival rate nearly twice that of medical management. Therefore, surgical correction of CoA has traditionally been warranted in the majority of patients, even though open repair entails its own complications. With the advent of endovascular technology, many interventionalists hoped that this approach would decrease the complications associated with open surgical repair of CoA. Nevertheless, there is still an ongoing debate about the merits of traditional open surgery versus endovascular therapy. In this review, we discuss the role of these two approaches for the management of CoA, recoarctation, and coarctation-related aneurysms.

Contemporary Results of Aortic Coarctation Repair Through Left Thoracotomy

Although surgical results for repair of coarctation of the aorta (CoA) have steadily improved, management of this condition remains controversial. The purposes of this study were to analyze the long-term outcomes of patients undergoing CoA repair through left thoracotomy and to define risk factors for reintervention. All patients who were less than 18 years old and who underwent initial repair of CoA through left thoracotomy from 1995 to 2013 at Texas Children's Hospital (Houston, TX) were included. Patients were classified into 3 groups: 143 (42%) neonates (0 to 30 days old), 122 (36%) infants (31 days to 1 year old), and 78 (23%) older children (1 to 18 years old). Univariate and multivariate analyses were performed. A total of 343 patients (129 [38%] girls) with median age of 53 days (interquartile range [IQR],12 days to 9 months) and weight of 4.1 kg (IQR, 3.1 to 8.0) underwent repair with extended end-to-end anastomosis (291 patients [85%]), end-to-end anastomosis (44 patients [13%]), interposition graft (2 patients [0.6%]), or subclavian flap (6 patients [2%]). Concomitant diagnoses included genetic abnormalities (48 patients [14%]), isolated ventricular septal defects (58 patients [17%]), small left-sided structures (53 patients,16%), or other complex congenital heart disease (18 patients [5%]). Perioperative mortality was 1% (n = 4, all neonates). At a median follow-up of 6 years (7 days to 19 years), only 14 (4%) patients required reintervention (10 catheter-based procedures, 6 surgical repairs). A postoperative peak velocity of 2.5 m/s or greater was an independent risk factor for reintervention (odds ratio [OR], 4.0; 95% confidence interval [CI], 1.4 to 11.6). Within the cohort, 95 (33%) patients were hypertensive or remained on cardiac medications a median of 12 years (6 months to 19 years) after the surgical procedure. Development of perioperative hypertension was associated with higher risk of chronic hypertension or cardiac medication dependency (OR, 1.9; 95% CI, 1.1 to 3.3). CoA repair through left thoracotomy is associated with low rates of morbidity, mortality, and reintervention. Aortic arch obstruction should be completely relieved at the time of surgical intervention to minimize the risk of long-term recoarctation.

Mortality and Operative Management for Patients Undergoing Repair of Coarctation of the Aorta: A Retrospective Review of the Pediatric Cardiac Care Consortium.

The surgical mortality associated with repair of coarctation of the aorta (CoA) over a 25-year period was examined. Risk factors for discharge mortality were evaluated as well as the surgical techniques and its evolution over the period studied. Utilizing the pediatric cardiac care consortium, we conducted a retrospective review of patients less than 18 years of age submitted between 1982 and 2007. Variables reviewed included weight at birth, age and weight at the operation, type of coarctation repair, associated cardiac anomalies, year of repair, center-specific volume, postoperative length of stay, and in-hospital mortality. There were 7,860 patients submitted with the procedural code for repair of CoA. Forty-five percent underwent repair within 30 days of life (n = 3,549), including 1,444 patients who were operated upon within the first 7 days of life (18% of all patients). Seventy percent (n = 5,528) of patients had an isolated CoA (iCoA). The overall mortality for the entire group was 4.2% (n = 331), decreasing to 2.0% (n = 114) for iCoA (P < .0001). A hypoplastic aortic arch occurred in 4.6%, with a mortality of 10.6%. Coarctectomy with an end-to-end reconstruction was the most common procedure performed. Multivariable modeling for discharge mortality was significant for diagnosis of ventricular septal defect, operative weight, operative year, and diagnosis of aortic arch hypoplasia. Operative repair of CoA is accomplished with a low mortality, although certain subgroups have persistently inferior outcomes. The techniques utilized for aortic reconstruction have evolved, with coarctectomy and an end-to-end anastomosis becoming the dominant surgical procedures.

Late outcomes in adults with coarctation of the aorta

AimsPrevious cohort studies of patients with coarctation of the aorta (CoA) demonstrate reduced long-term survival. Improved surgical outcomes in children and evolution of adult congenital heart disease (ACHD) services have...

Arterial-left ventricular-left atrial coupling late after repair of aortic coarctation and interruption.

This study aimed to explore the arterial-left ventricular (LV)-left atrial (LA) interaction in adolescents and young adults late after intervention for coarctation of the aorta (CoA) and interrupted aortic arch (IAA). Thirty-one (16 males) patients aged 23.4 ± 6.3, at 20.6 ± 5.2 years after intervention, and 31 controls were studied. Carotid arterial stiffness and intima-media thickness (IMT) and brachial-ankle pulse wave velocity were determined by radiofrequency-based echocardiography and oscillometry, respectively. Tissue Doppler and speckle tracking echocardiography (STE) were performed to assess, respectively, LV myocardial tissue velocities and linear and torsional deformation. Left atrial positive, negative, and total strain and strain rate at ventricular systole (aSRs), early diastole (aSRed), and atrial contraction (aSRac) were also determined using STE. Patients had significantly greater arterial stiffness and IMT than controls (all P < 0.05). Mitral annular systolic and diastolic velocities, LV longitudinal and radial strain and early diastolic strain rates, peak torsion and untwisting velocity, and LA peak positive and total strain, aSRs, aSRed, and aSRac were significantly lower in patients than in controls (all P < 0.05). Arterial stiffness correlated inversely with LV longitudinal strain and systolic and early diastolic strain rate (all P < 0.05), while LA total strain and aSRed were associated positively with LV diastolic annular velocity, longitudinal SRe, and peak untwisting velocity (all P < 0.05). Multiple linear regression further revealed arterial stiffness as an independent determinant of LA total strain (β = -1.3, P = 0.034). Our findings suggest impairment of arterial function and LV and LA mechanics in patients after CoA and IAA repair and implicate an abnormal arterial-LV-LA interaction.

Right ventricular myocardial motion and deformation in adolescents and young adults after repair of coarctation of the aorta.

Alteration of right ventricular (RV) function has been found in patients with pressure-loaded left ventricles due to systemic hypertension and aortic stenosis. We tested the hypothesis that RV mechanics are altered in adolescents and adults with repaired coarctation of the aorta (CoA). Twenty-eight (15 male) patients, aged 23.7 ± 6.5 years, and 28 (14 male) controls were studied. M-mode, tissue Doppler imaging, and speckle tracking echocardiography were performed to assess, respectively, LV mass and RV wall thickness, RV myocardial tissue velocities, and deformation. Systolic (P = 0.14) and diastolic (P = 0.32) blood pressures were similar between patients and controls. Compared with controls, patients had significantly greater LV mass (P = 0.016) and RV anterior wall thickness (P = 0.012). Tricuspid annular systolic (P < 0.001) and early diastolic (P < 0.001) velocities, isovolumic acceleration (P = 0.004), global RV systolic longitudinal strain (P = 0.03), systolic strain rate (P = 0.012), and early (P = 0.021) and late (P = 0.012) diastolic strain rates were significantly lower in patients than controls. Patients with an associated ventricular septal defect (n = 6) requiring closure compared to those without had even lower tricuspid annular systolic (P = 0.01) and early diastolic (P = 0.041) velocities. Left ventricular mass correlated negatively with RV systolic strain rate (r = -0.27, P = 0.045) and tricuspid annular early diastolic velocity (r = -0.40, P = 0.002), while RV anterior wall thickness correlated negatively with tricuspid annular systolic (r = -0.42, P = 0.002) and late diastolic (r = -0.40, P = 0.003) velocities, and positively with e/a ratio (r = 0.31, P = 0.024). RV systolic and diastolic mechanics are impaired in patients late after repair of CoA and related to increased LV mass and RV thickness.

Large Eddy Simulation of Pulsating Flow before and after CoA Repair: CFD for Intervention Planning

Large eddy simulation was applied to investigate hemodynamics in a model with coarctation of the aorta (CoA) and poststenotic dilatation. Special focus was put on the role of hemodynamics for success of CoA repair. Several parameters previously identified as related to cardiovascular disease were studied. Known risk factors were observed both with CoA and after repair, and the restoration of the anatomy seems to be crucial for a successful result.

Management of an Associated Ventricular Septal Defect at the Time of Coarctation Repair

Management of a ventricular septal defect (VSD) at time of coarctation of the aorta (CoA) repair remains controversial, with recent studies advocating concomitant repair of both defects. We evaluated the surgical management and mortality for patients undergoing CoA repair associated with a VSD. We retrospectively reviewed data submitted to the Pediatric Cardiac Care Consortium of patients undergoing repair of CoA from 1982 to 2007. The cohort was divided into three groups: CoA repair plus VSD closure (group 1); CoA repair plus pulmonary artery band (group 2); and CoA repair without repair of VSD (group 3). Variables reviewed included era, age, and weight at repair, and in-hospital mortality. There were 7,860 patients who underwent repair of CoA, of whom 2,022 had an associated VSD (25.7%). Mortality after CoA repair with and without an associated diagnosis of VSD was 8.3% versus 2.1% (p < 0.001). Mean age at repair for group 1 (n= 286) and group 2 (n= 472) was 87.4days and 21.6 days, respectively (p= 0.004), and median weight was 3.31 kg and 3.30 kg, respectively (p= 0.130). Discharge mortality for group 1 and group 2 was similar, at8.7% and 9.1%, respectively (p= 0.852). Patients with CoA/VSD who had neither VSD closure nor pulmonary artery banding (group 3) had a hospital mortality of 7.9%. The association of CoA and VSD is common. A strategy of concomitant VSD closure at CoA repair does not result in worse discharge mortality when compared with pulmonary banding with anticipated staged repair of the VSD. These outcomes support continued evaluation of a one-stage approach.

Aortic coarctation repair in neonates with intracardiac defects: the importance of preservation of the lesser curvature of the aortic arch.

The aim of this study was to evaluate the mid-term outcomes of a strategy for repair of coarctation of the aorta (CoA) and hypoplastic aortic arch (HAA) with a modified, extended end-to-end repair that preserves the lesser curvature of the aortic arch in neonates with intracardiac defects. We studied 21 neonates who underwent CoA repair and remote intracardiac repair (2000-2013). Fifteen patients had HAA, and six patients had no HAA. Follow-up ranged from 0.4 to 12.8 years (median, 7.5 years), and all patients underwent cardiac catheterization and blood pressure measurement in both the arms and legs. The overall median age at the time of CoA repair was seven days and the median age at the time of intracardiac defect repair was 18.6 months. There were no hospital deaths and one case had recoarctation (4.8%). The overall mean pressure gradient at the latest follow-up was 3.4 ± 5.7 mmHg. Critical deformation of arch geometry was not found. No patient had hypertension or an abnormal arm-leg gradient. There was no difference in the cardiac catheterization data or blood pressure between patients with and without HAA. A modified, extended end-to-end repair for CoA and HAA resulted in a low rate of recoarctation, no operative mortality, maintenance of a smooth rounded arch, and normal blood pressures in the arms and legs during mid-term follow-up. These results suggest that this technique may be acceptable for repair of CoA and HAA in neonates with intracardiac defects.

Abstract 167: Growth Induction to Reverse Congenital Aortic Developmental Hypoplasia

Objectives: Congenital heart disease may include hypoplastic heart valves, ventricles or great arteries. Infants with coarctation of the aorta (CoA) often have a hypoplastic transverse aortic arch (TAA) which can greatly complicate surgical repairs. Although these defects are often considered to be genetic in origin, our hypothesis was that they are problems of development which are potentially reversible. We tested the corollary hypothesis that hypoplastic TAAs retain normal developmental potential and the increased aortic flow after CoA repair provides the biomechanical signal for catch-up growth. Methods: Infants (N = 19) with TAA hypoplasia who underwent surgical CoA repair were studied for TAA growth by echocardiography done prior to and at intervals up to 13 years later. The TAA diameters were indexed using nomograms and calculated as standard deviations from expected size (SDE). Normal range is ± 2 SDE and &lt; −2 indicates hypoplasia. Results: 1) TAA growth was rapid and significant within 3 months. 2) The initial average TAA SDE = −3.7 (range: −7.6 to −2.1) (0/19 normal); 3 months = −1.5 (-4.1 to 0.9) (12/17); 1 year = −1.0 (-4.2 to 1.3) (15/19); 5 to 13 years = −0.6 (-2.1 to 0.9) (16/17 normal). Conclusions: 1) Hypoplastic aortic arches grew rapidly to normal size with increased flow following CoA repair. 2) The results suggest the cause of hypoplasia was underdevelopment from low flow and, when increased, flow provided the biomechanical signal to induce catch up growth. 3) Infants were a relevant model for demonstrating the aortic growth signal. 4) Growth induction by increased blood flow could be used to reverse aortic underdevelopment in other selected patients.

New-generation stent grafts for endovascular management of thoracic pseudoaneurysms after aortic coarctation repair

Late thoracic aneurysms develop in 5% to 12% of patients having undergone open repair for coarctation of the aorta (CoA). We report our early results for thoracic endovascular aortic repair for pseudoaneurysms after CoA repair. From 2008 to 2013, data regarding demographics, aneurysm morphology, procedure, and follow-up were collected prospectively on all patients treated for pseudoaneurysms after CoA repair. Retrospective analysis of identified patients was then performed. Thirteen patients (six men, seven women) were treated. Patients were a median age, 45 years (interquartile range (IQR), 39-56; range, 27-66 years, and the median time after CoA repair to aneurysm treatment was 34 years (IQR, 24-40 years). All patients had saccular pseudoaneurysms of the aortic arch, with a median aneurysm size of 4.1 cm (IQR, 3.4-5.1 cm). The left subclavian artery (LSCA) was involved in 10 patients and was occluded at presentation in three. Four patients had concurrent LSCA revascularization with carotid-subclavian bypass, one had aortic arch hybrid repair, and the LSCA was intentionally covered in two patients. Patients underwent thoracic endovascular aortic repair using the conformable TAG (6 of 13; W. L. Gore & Associates, Flagstaff, Ariz), Valiant device (4 of 13; Medtronic, Minneapolis, Minn), and a custom-made Relay endograft with LSCA scallop (4 of 13; Bolton Medical, Barcelona, Spain). Technical success was 100%, with satisfactory deployment of the stent grafts in all patients. There was no 30-day mortality, stroke, or paraplegia. Median follow-up was 15 months (IQR, 9-19 months; range, 1-67 months). Two type II endoleaks from an intercostal artery were managed conservatively, and one type Ib endoleak was treated successfully with distal stent extension. In this cohort, new-generation stent grafts have good early clinical and radiologic outcomes, avoiding the need for redo open surgery. Management of the LSCA can be tailored to individual patients with new stent graft technology. Long-term follow-up of these patients is crucial to understanding whether endovascular management of this cohort is acceptable.

Obesity and Elevated Blood Pressure following Repair of Coarctation of the Aorta

To determine whether patients with coarctation of the aorta (COA) were more likely to develop obesity compared with the general population or others with isolated forms of congenital heart disease. We conducted a cross-sectional study of 160 patients who underwent COA repair at our institution between 1974 and 2009. Body mass index (BMI) measurements were obtained from the most recent clinic visit and at 5, 10, 15, and 20 years of age from retrospective chart review. BMI values were compared against established normal data to obtain age-sex matched z-scores. We also compared the rates of developing obesity over time in adults with COA vs 96 adults with other isolated forms of congenital heart disease, including aortic valve stenosis, pulmonary valve stenosis, or atrial septal defect. After age 5 years, patients with COA had significantly greater BMI z-scores compared with age-sex matched normal data (P < .001). The proportion of obesity in patients with COA significantly increased over time (P < .001). Adults with repaired COA developed obesity at a greater rate than those with either aortic valve stenosis (P = .004) or with pulmonary valve stenosis or atrial septal defect (P < .001). There is a greater incidence of obesity that progressively increases with age in patients with repaired COA. Adults with repaired COA developed obesity at a greater rate than those with other isolated forms of congenital heart disease. Further prospective trials are needed to confirm our observations and to elucidate the potential mechanism relating COA to obesity.