Primary Repair Of Coarctation Research Articles

Ambulatory Blood Pressure Monitoring in Assessment of Systemic Hypertension Following Successful Aortic Coarctation Repair

Abstract Background Hypertension following primary coarctation repair affects up to a third of subjects. A number of studies suggest that future hypertension risk is reduced if primary repair is performed at a younger age. This study aims to assess prevalence of systemic hypertension after early coarctation repair (within the first two years of life) compared with late coarctation repair (after the first two years of life), including both catheter-based and surgical intervention using twenty-four hour ambulatory blood pressure monitoring. the study included 30 patients who underwent successful repair of aortic coarctation. All patients underwent complete history taking and clinical examination.All patients underwent full transthoracic echocardiographic study and ambulatory blood pressure monitoring. Results HTN had higher incidence in patients who underwent late coarctation repair than patients underwent early coarctation repair but difference was statistically insignificant. Conclusions Early intervention of aortic coarctation during infancy decreases the risk of late systemic hypertension. However, further studies are needed to evaluate increased risk of recoarctation after early intervention of aortic coarctation.

Interventions in Adults With Repaired Coarctation of the Aorta.

Background Coarctation of the aorta coexists with other cardiac anomalies and has long-term complications, including recoarctation, which may require intervention after the primary coarctation repair. This study aims to clarify the prevalence of and risk factors for interventions related to the coarctation complex as well as late mortality in a large contemporary patient population. Methods and Results The Swedish National Register of Congenital Heart Disease was used, which comprised 683 adults with repaired coarctation of the aorta. Analysis was performed on freedom from intervention thereafter at the coarctation site, aortic valve, left ventricular outflow tract, or ascending aorta. One hundred ninety-six (29%) patients had at least 1 of these interventions. Estimated freedom from either of these interventions was 60% after 50 years. The risk of undergoing such an intervention was higher among men (hazard ratio, 1.6 [95% CI, 1.2-2.2]). Estimated freedom from another intervention at the coarctation site was 75% after 50 years. In women, there was an increase in interventions at the coarctation site after 45 years. Patients who underwent one of the previously mentioned interventions after the primary coarctation repair had poorer left ventricular function. Eighteen patients (3%) died during follow-up in the register. The standardized mortality ratio was 2.9 (95% CI, 1.7-4.3). Conclusions Interventions are common after coarctation repair. The risk for and time of interventions are affected by sex. Our results have implications for planning follow-up and giving appropriate medical advice to the growing population of adults with repaired coarctation of the aorta.

Improving Prenatal Diagnosis of Coarctation of the Aorta

BackgroundThe purpose of the study was to evaluate the association between fetal echocardiographic measurements and the need for intervention (primary coarctation repair, staged coarctation repair, or catheter intervention) in prenatally diagnosed coarctation of the aorta. MethodsA single-centre retrospective cohort study (2005-2015) of 107 fetuses diagnosed with suspected coarctation of the aorta in the setting of an apex-forming left ventricle and antegrade flow across the mitral and aortic valves. ResultsMedian gestational age at diagnosis was 32 weeks (interquartile range, 23-35 weeks). Fifty-six (52%) did not require any neonatal intervention, 51 patients (48%) underwent a biventricular repair. In univariable analysis, an increase in ascending aorta (AAo) peak Doppler flow velocity (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.05-1.91] per 20 cm/s; P = 0.03) was associated with intervention. No intervention was associated with larger isthmus size (OR, 0.23; P < 0.001), transverse arch diameter (OR, 0.23; P < 0.001), and aortic (OR, 0.72; P = 0.02), mitral (OR, 0.58; P = 0.001), and AAo (OR, 0.53; P < 0.001) z-scores. In multivariable analysis, higher peak AAo Doppler (OR, 2.51 [95% CI, 1.54-4.58] per 20 cm/s; P = 0.001) and younger gestational age at diagnosis (OR, 0.81 [95% CI, 0.70-0.93] per week; P = 0.005) were associated with intervention, whereas a higher AAo z-score (OR, 0.65 [95% CI, 0.43-0.94] per z; P = 0.029) and transverse arch dimension (OR, 0.44 [95% CI, 0.18-0.97]; P = 0.05) decreased the risk of intervention. ConclusionsIn prenatally suspected coarctation, the variables associated with intervention comprised smaller AAo and transverse arch size, earlier gestational age at diagnosis, and the additional finding of a higher peak AAo Doppler.

Is the medical treatment for arterial hypertension after primary aortic coarctation repair related to age at surgery? A retrospective cohort study.

Hypertension following primary coarctation repair affects up to a third of subjects. A number of studies suggest that future hypertension risk is reduced if primary repair is performed at a younger age. The objective of this study was to evaluate the risk of future medical treatment for hypertension depending on age of primary coarctation repair. This study was carried out at a tertiary paediatric cardiology referral centre. Retrospective database evaluation of children aged 28 days and ⩽12 months), and children (>12 months). Main outcome measure is the need for long-term anti-hypertensive medication. The risk for re-coarctation was also evaluated. A total of 87 patients were analysed: 60 neonates, 17 infants, 10 children. Among them, 6.7% neonates, 29.4% infants, and 40% children required long-term anti-hypertensive medications. Group differences were statistically significant (p=0.004). After adjustment for type of repair, the risk of long-term anti-hypertensive therapy was 4.5 (95% confidence interval 1.2-16.9, p=0.025) and 10.5 times (95% confidence interval 2.6-42.3, p=0.001) higher if primary repair was carried out in infancy and childhood, respectively, compared with neonates. Among all, 13 patients developed re-coarctation: 21.7% in the neonatal group, 5.9% in the infant group, and 20% in the child group. We could not demonstrate a significant difference between these proportions or calculate a reliable risk for developing re-coarctation. Risk of medical treatment for hypertension was lowest when primary repair was carried out during the neonatal period, rising 10-fold if first operated on as a child. Knowing the likelihood of hypertension development depending on age of primary repair is useful for long-term surveillance and counselling.

P19 Is the requirement for long term antihypertensive therapy after primary coarctation repair related to age at surgery?

Introduction Systemic hypertension manifesting after surgical coarctation repair is a known long term sequela and affects about two thirds of subjects. Previous studies suggest the risk of developing hypertension is reduced if the coarctation repair is performed at a younger age with the optimal time for repair between the first year of life up to 9 years of age. Objective Using our experience of patients operated on since the opening of the new Evelina London Children’s Hospital in 2005, we sought to further clarify the optimal age at which coarctation repair is most effective in reducing the risk of systemic hypertension. Risk of developing re-coarctation related to the age of primary surgical repair was also examined. Methods Retrospective analysis of patients with coarctation undergoing primary surgical repair from October 2005 to October 2014, identified from the institutional database (Heartsuite, Systeria, Glasgow, UK). Included patients were all Results Eighty seven patients were included: 58 neonates ( 2 9.83, P = 0.0073). The relative risk of requiring long term anti-hypertension medication if repaired during the neonatal period versus during infancy was 0.26 (95% CI 0.078 to 0.88, P = 00.03), 0.65 (95% CI 0.23 to 1.92, P = 00.44) for repair during infancy versus over 1 year of age, and 0.17 (95% CI 0.051 to 0.58, P = 00.0045) for repair during the neonatal period versus being over 1 year of age. There was no significant difference in the proportion of those developing re-coarctation depending on the age they were first operated, though the prevalence was lowest in the infant age group, 5.3%, versus 22.4% in the neonatal group and 20% in those over 1 year of age. Conclusion We have demonstrated that the risk of being on long term anti-hypertensive medication if operated on during neonatal period was 74% less compared to being operated on during infancy and 83% less if operated in the neonatal period compared to surgery after the first year of life. Therefore primary surgical repair of coarctation of the aorta to reduce the future risk of hypertension is optimal in the neonatal period. We were unable to demonstrate a significant difference in the prevalence of re-coarctation depending on age of first coarctation repair.

0490: Long term follow-up of repaired aortic coarctation between 1978 and 2012. A single centre cohort

Repaired aortic coarctation (CoA) is associated with high long-term mortality and morbidity. Despite optimal early correction, patients with CoA remain at high risk of hypertension and death. We evaluated outcomes and follow-up of all patients who underwent CoA surgery, and alive at 30 days, between 1978 and 2012. Retrospective cohort study in a single university teaching hospital. All data were obtained from medical records. Vital status, medical history and results of imaging were analyzed A total of 85 patients (63 men) were included. Median age (range) at surgery was 69 (2-13356) days; 19 (2-54) years at examination. Mean follow up was 15.8 years (1343 person-years). No deaths were observed. Reintervention was common (31%) and most often due to ReCoA (13 patients, 16%). In case of ReCoA, 8 patients had thoracic surgery, and 5 percutaneous angioplasty with stenting. Half (53%) had a bicuspid aortic valve, associated with aortic valve regurgitation (21 cases). Aneurysm of the ascending aorta was diagnosed in 8 patients, without surgical indication. Prevalence of hypertension was high (18 pts, 21%); no related complications were noted; 17 patients were being treated. All patients had normal LV ejection fraction, but half (56%) had increased LV mass. In total, 28 MRI were performed. MRI showed 22 Romanesque aortic arches, 2 Crenel arches and 1 Gothic arch. Regarding follow-up, 66% were followed as recommended by ESC guidelines. Only 4 patients were lost to follow up. There were 15 pregnancies (8 patients); no complications were noted. Primary repair of CoA was performed with low rates of mortality and morbidity. However, prevalence of hypertension, aortic valve abnormalities and ascending aorta aneurysms remain high, confirming CoA as an overall vascular disease. Furthermore, many patients required further reoperation. These findings emphasize that patients with CoA need lifelong follow-up.

Do High-Risk Infants Have a Poorer Outcome From Primary Repair of Coarctation? Analysis of 192 Infants Over 20Years

Do High-Risk Infants Have a Poorer Outcome From Primary Repair of Coarctation? Analysis of 192 Infants Over 20Years

Do High-Risk Infants Have a Poorer Outcome From Primary Repair of Coarctation? Analysis of 192 Infants Over 20 Years

Balloon angioplasty for infant coarctation is associated with a high recurrence rate, making operative repair the gold standard for low-risk infants. Debate exists as to whether high-risk infants might be better served with primary angioplasty. We compared the outcome in high-risk versus low-risk infants over 20 years, in a center that always used surgical repair as the primary intervention. Of 192 infants from 1986 to 2005, 56 were considered "high-risk," defined as requiring prostaglandin infusion together with either epinephrine infusion for 24 hours preoperatively, or ventilation and milrinone infusion for 24 hours preoperatively. All high-risk patients had a period of ventricular dysfunction prior to surgery, ranging from mild to severe. Outcomes were compared using Bonferroni comparison of means or the Fischer exact test as appropriate. Although the high-risk patients were smaller (3.3 ± 0.1 vs 4.2 ± 0.2 kg, p < 0.01), younger (18 ± 4 vs 57 ± 7 days, p < 0.01), and more often required a concomitant pulmonary artery band (25% vs 15%, p = 0.05), their cross-clamp times were the same as the low-risk patients (18.9 ± 0.9 vs 18.0 ± 0.4 minutes, p = 0.27) and there was no difference in postoperative morbidity (7% vs 3%, p = 0.11). However, there was a trend toward higher perioperative mortality (7% vs 2%, p = 0.07). When compared with the published studies of primary angioplasty in comparable high-risk infants, the mortality rate in our surgically treated high-risk group is much lower. Additionally, only 11% of our high-risk group required reintervention, with two-thirds treated successfully with a single angioplasty at 3.8 ± 2.2 years later, far lower than recurrence rates with primary angioplasty. We propose that primary surgical repair of coarctation in infants who are high risk should be the primary treatment, with angioplasty reserved for recurrent coarctation.

Velocity-Encoded Magnetic Resonance Image Assessment of Regional Aortic Flow in Coarctation Patients

During primary coarctation repair, collateral blood vessels contribute significantly to distal perfusion. We sought to determine if velocity-encoded cine magnetic resonance imaging (VENC-MRI) could provide insight into anatomy and hemodynamics of collateral flow in patients with unrepaired coarctation. Sixteen patients (median age, 6.2 years; range, 1 to 18) with discrete coarctation (65% severe, 29% mild-moderate) and 10 controls (median age, 12.0 years; range, 9 to 15) without left-sided heart lesions were referred for cardiac MRI. Flow volumes were calculated from VENC-MRI images at the coarctation (proximal), diaphragm (distal), and midway between the two points (midpoint). A means model, repeated-measure analysis, was performed for volumes. In coarctation patients, flow volumes increased by 59% (p = 0.0002) from coarctation to diaphragm, primarily between the proximal and midpoint sites (by 77%, p < 0.0001). In controls, flow volumes decreased by 11% along the entire aortic study length. Coarctation volumes were lower than controls by 54% (p = 0.0003) at the proximal site but showed no statistical difference at the midpoint or diaphragm. Coarctation flow volumes maximally increase in the upper thoracic aorta, but approach normal flow volumes in the lower thoracic region. Arteries arising from mid and lower thoracic level, such as those supplying the anterior spinal cord, may have nearly normal flow if collaterals are present. Velocity-encoded MRI can evaluate flow in patients who have poor collateral circulation to improve surgical planning and decrease neurologic complications of coarctation repair.

Recurrent aortic coarctation: Is surgical repair still the gold standard?

Objective: We reviewed our experience with surgical repair compared with balloon aortoplasty of recurrent coarctations of the aorta. Methods: This is a retrospective review of 1 institution's 27-year experience with surgical repair of recurrent aortic coarctation. A thorough chart review was performed of all pediatric patients undergoing surgical repair for recurrent aortic coarctation ( n = 56) from January 1970 through July 1996. Results: The vast majority of recoarctations were repaired with a prosthetic patch technique, with a greater than 96% success rate. No deaths or major complications occurred in the 56 patients. Although a direct comparison with balloon aortoplasty cannot be done, we have reviewed the data available in the literature and found higher complication rates and lower success rates than we obtained in our series. Conclusions: Although the treatment of aortic coarctation has improved significantly during the past decades, persistent hypertension after repairs at an older age and recurrent coarctation after repairs in neonates occur in all institutions. Surgeons have not agreed on the optimal approach to primary coarctation repair, and invasive cardiologists have challenged operative intervention for both recurrent and primary coarctation. This study demonstrates that surgical repair of recurrent coarctation of the aorta can be performed safely and with excellent results. We believe it is still the gold standard in the management of recurrent coarctation of the aorta. (J Thorac Cardiovasc Surg 1998; 116:560-5)

Primary repair of coarctation of the thoracic aorta by patch graft aortoplasty. A three-decade experience and follow-up in 60 patients

The present report is a critical review on primary repair of aortic coarctation by patch aortoplasty on the basis of over 30 years surgical experience. Since 1962, 60 patients (mean age 9.4 +/- 4.8 years, range 2-25 years), affected by aortic coarctation, underwent patch aortoplasty repair. During the operation protective guidelines were adopted: additional external Dacron was placed around the repaired site in cases of friable host tissue, the aortic ridge was not excised to leave the posterior aortic wall intact, and the patent ductus arteriosus or ligamentum arteriosum was transected and sutured. Prophylactic measures of neurologic sequelae were: dual pressure monitoring, sequential aortic clamping, surgical shunt or left heart bypass associated with moderate hypothermia when the distal aortic pressure was less than 50 mmHg. No early deaths occurred. The overall survival rate was 92.77 +/- 4.04% at 31 years from surgery. Three late deaths occurred. Pressure gradients across the patch ranged between 9 and 20 mmHg. Late aneurysm occurred in one patient (1.3%), 2 years after bacterial endocarditis had developed on a biscuspid aortic valve. Patch aortoplasty is an effective and safe surgical procedure for primary repair of isthmic aortic coarctation when other surgical techniques cannot be performed.

Aortic aneurysm after patch angioplasty for aortic isthmic coarctation in childhood

Repair of aortic coarctation, pioneered by Craaford and Nylin 1 and Gross and Hufnagel 2 in 1944, is an accepted procedure with relatively low morbidity and mortality rates. Repair was initially accomplished by excision of the aortic coarctation with end-to-end anastomosis of healthy aortic tissue. Newer techniques, such as patch angioplasty 3–5 and subclavian flap angioplasty, 6 were introduced to avoid the complications of stricture at anastomotic site and allow for further growth of the aorta. Reports of aneurysm formation in the region of the patch angioplasty 7–9 have raised concern as to long-term safety of this procedure. Development of a large true aneurysm of the aorta in 2 asymptomatic patients (Fig. 1) who underwent primary repair of coarctation by the technique of patch angioplasty (the subject of a previous report 10) prompted recall of all patients who underwent repair of coarctation of the aorta at the University of Virginia Hospital since 1971. This study assesses the incidence of aortic aneurysm in the pericoarctation region after surgical repair of coarctation of the aorta in childhood, and attempts to determine if the presence of aneurysmal dilatation was related to the type of operative procedure, age at operation or presence of residual gradient.