Recurrent Coarctation Of Aorta Research Articles

Determinants and prognostic implications of left atrial reverse remodelling after coarctation of aorta repair in adults.

Left atrial (LA) dysfunction and atrial fibrillation are also relatively common in adults with coarctation of aorta (COA), and the severity of LA dysfunction is associated with a higher risk of atrial fibrillation in this population. The purpose of this study was to determine whether LA function improved after COA repair (LA reverse remodelling), and the relationship between LA reverse remodelling and atrial fibrillation. Retrospective cohort study of adults undergoing COA repair (2003-20). LA reservoir strain was assessed pre intervention and 12-24 months post intervention, using speckle tracking echocardiography. Incident atrial fibrillation was assessed from COA repair to last follow-up. Of 261 adults who underwent COA repair [age 37 ± 13 years; males 148 (57%)], 124 (47%) and 137 (53%) presented with native vs. recurrent COA, respectively. Of 261 patients, 231 (82%) and 48 (18%) underwent surgical and transcatheter COA repair, respectively. The LA reservoir strain increased from 32 ± 8% (pre intervention) to 39 ± 7% (post intervention), yielding a relative increase of 21 ± 5%. Older age [β ± standard error (SE) -0.16 ± 0.09 per 5 years, P = 0.02], higher systolic blood pressure (β ± SE -0.12 ± 0.04 per 5 mmHg, P = 0.005), and higher residual COA mean gradient (β ± SE -0.17 ± 0.06 per 5 mmHg, P = 0.002) post intervention were associated with less LA reverse remodelling, after adjustment for sex, hypertension diagnosis, and left ventricular indices. LA reverse remodelling (hazard ratio 0.97, 95% confidence interval 0.96-0.98 per 1% increase from pre-intervention LA function, P = 0.006) was associated with a lower risk of atrial fibrillation after adjustment for age, sex, pre-intervention LA reservoir strain, and history of atrial fibrillation. COA repair resulted in improved LA function and decreased risk for atrial fibrillation, especially in patients without residual hypertension or significant residual COA gradient.

Incidence and risk factors for late complications after the arterial switch operation.

The purpose of this study was to evaluate our institution's 16-year arterial switch operation (ASO)experience and to determine early and late mortality and late morbidity, as well as the need for reoperation and catheter intervention, and finally, to explore risk factors for late complications and reintervention. The clinical data of 185 transposition of the great arteries (TGA)patients who received ASO treatment in our center from January 2006 to January 2022 were continuously included for retrospective study. There were 13 early deaths (7.03%), 5 late deaths (3.01%), and 6 lost to follow-up. The median follow-up time for the 166 hospitalized survivors was 88.5 (2190) months. Moderate or above new aortic valve regurgitation (NAR;in this article, NAR represents moderate or greater reflux unless otherwise specified) occurred in 19 cases (11.45%), and aortic root dilation (ARD) occurred in 28 cases (16.87%). Late right ventricular outflow tract obstruction (RVOTO) occurred in 33 cases (19.88%). There were 18 patients (10.84%) who underwent late re-intervention, and the most common indication for intervention was RVOTO, followed by recurrent aortic coarctation in patients undergoing concurrent arch repair and NAR or ARD. Receiver operating characteristicsanalysis found that NAR had the strongest predictive power for ARD, followed by RVOTO, followed by bicuspid native pulmonary valve (BPV), and aorto-pulmonary diameter mismatch (APDMM) was the weakest. Multivariate analysis showed that APDMM, previous pulmonary artery banding (PAB), and mild NAR at discharge were independent risk factors for late NAR and ARD. Low surgical weight was an independent risk factor specific to NAR, and BPV was an independent risk factor specific to ARD. Older surgical age and ARD were independent risk factors for late RVOTO. Older surgical age, operation before 2014, late RVOTO, and late ARD were independent risk factors for late intervention. No reintervention events for coronary dysfunction were found in the late stage, but one patient occurred myocardial infarction due to coronary embolism after reoperation. Early and late survival rates after ASO in TGA patients have been remarkably improved in recent decades. Increased rates of NAR, ARD, recurrent coarctation of the aorta, and RVOTO as children age are major future outcomes of concern and may imply more late reinterventions. Careful follow-up of neo-aortic valve and root function is imperative, especially in patients with APDMM, previous PAB, mild NAR at discharge, low surgical weight, and BPV structures.

The Role of Computed Tomography in The Diagnosis of Rare Congenital Heart Disease: Interrupted Aortic Arch

Interrupted aortic arch (IAA) is a rare congenital anomaly of the aortic arch and an anatomical interruption of the lumen between the ascending and descending aorta. Computed tomography (CT) has become a reliable noninvasive diagnostic method for congenital IAA. The purpose of this study was to investigate the imaging features of IAA and improve the understanding and diagnosis of the disease. The imaging features and postoperative pathological data of 25 patients with IAA confirmed by dual-source computed tomography (DSCT) angiography were analyzed in this retrospective study. Among the 25 patients with IAA, 15 were type A, seven were type B, 0 were types C and D, and two were type E. The diameter of the pulmonary artery trunk in type A was larger than that in type B (P < 0.05). However, there were no significant differences between types A and B along the ascending aorta diameter, descending aorta, ascending aorta/descending aorta ratio, left pulmonary artery main trunk diameter, right pulmonary artery main trunk diameter, left pulmonary artery trunk/pulmonary artery trunk ratio, right pulmonary artery trunk/pulmonary artery trunk ratio, and left pulmonary artery trunk/right pulmonary artery trunk ratio. The imaging findings of IAA have typical and specific signs, and the types of IAA are not comprehensive. One type of patient identification can be added: Patients who are dissected between the left common carotid artery and left subclavian artery opening, and the descending aorta is circulated by the chest collaterals. Patients with a wide pulmonary artery in the IAA are usually type A patients. Patients with IAA after surgical repair require lifetime follow up, mainly to monitor left ventricular outflow tract obstruction and recurrent aortic coarctation. This study was approved by the Ethics Committee of Kunming Yan'an Hospital (Kunming City, Yunnan Province, China), and consent was waived because of the retrospective data collection.

Endovascular repair of recurrent aortic coarctation with a custom made hourglass shaped stent graft

A 76-year-old male patient with previous open repair resection and end-to-end anastomosis in young adulthood of a congenital coarctation of the descending thoracic aorta was referred to our center for a symptomatic recurrence (A). The patient reported dyspnea and lower extremity fatigue, whereas clinical examination showed weak femoral pulses and a 50 mm Hg gradient between brachial and ankle systolic blood pressure measurements. Medical history was otherwise unremarkable and renal function was normal.

Early and midterm outcomes of bare metal stenting in small children with recurrent aortic coarctation.

The aim of this study was to report our experience with the Cook Formula stent in the treatment of (recurrent) coarctation of the aorta in children below 12 kg. In vitro study of the Cook Formula 418 (8 mm) and 535 (8 and 10 mm) stents demonstrated successful down-crimping on smaller balloons and predictable fracturing patterns. Between November 2012 and January 2019, one patient with native, one patient with post-interventional and thirteen patients with post-surgical coarctation of the aorta underwent implantation of a Cook Formula stent. Patient and procedural characteristics were obtained as well as procedural success, complications, and follow-up. Median age was 4.3 months and median weight 5.5 kg. Arterial sheath size ranged from 5 to 7 Fr. In-stent diameters of 3.7 to 8.8 mm were obtained with a median residual gradient of 0 mmHg. Major complications consisted of periprocedural haemodynamic instability (n=1), dissection of the iliac artery (n=1) and non-deployment with surgical removal (n=1). Re-dilations were performed after a median interval of 24.3 months. Median follow-up was 31.7 months. The bare metal Cook Formula stent provides a durable and effective alternative to reoperation and balloon dilatation for native as well as post-surgical aortic coarctation in children below 12 kg.

The immediate and late results for balloon angioplasty of native coarctation of aorta in pediatrics age group

Background: percutaneous balloon dilation of corotation of aorta is a less invasive and alternative to surgical repair for patients with discrete coaction of aorta and although the used of balloon angioplasty in patients with recurrent postoperative coarctation gained a wide consensus, the use this technique for native coarctation is still controversial in children less one years. &#x0D; Objective: to evaluate the immediate and late result of balloon dilation of native coarctation of aorta in infant and children.&#x0D; Type of the study: A prospective study. &#x0D; Subjects &amp; Methods: The study was done on forty-five patients who were referred for cardiac catheterization and balloon angioplasty of native coarctation of the aorta at Ibn-AL-Bitar center for cardiac surgery between January 2015 to May 2016.Left heart catheterization was performed with evaluation of the morphology and pressure gradient across the stenotic segment of aorta. Follow up evaluations were done between 1 week and 18 months after discharge (mean 6 months) with transthoracic echocardiography. &#x0D; Results: The age of patients range from 1month to 4 years (median age at time of procedure was12.3month). Associated lesions in 11 patients (24.4%). Immediate results were reduction in gradient from 42.5± 17.3 to 10.3± 8.2 mm Hg in forty-two patients (93.3%). Late result during follow up period, 29 patients (69%) had maintain gradient less than 20mmHg. Complications were reported in 6 patients (13.3%). there was one procedure related death (2.2%). &#x0D; Conclusions: Balloon angioplasty for treatment of native coarctation of the aorta is effective with sustained benefit on long-term follow-up in infants and children &gt;6 months. Transverse arch hypoplasia and children &lt;6 months old has major effect on late outcome of recurrent coarctation of aorta.

Early and late outcome of covered and non-covered stents in the treatment of coarctation of aorta- A single centre experience

ObjectiveStenting of coarctation of aorta with covered or uncovered stents is the accepted modality of treatment in older children and adults. The indications which mandate the use of covered stents are still unclear. We attempted to study the early and late outcomes after stenting of native and recurrent coarctation of aorta with uncovered and covered stents. MethodThis is a retrospective study of patients who underwent stenting for coarctation of aorta with covered or non-covered stents at our institute. Early and late outcome for both the groups were studied. ResultsTwenty patients underwent implantation of covered stent and twenty five patients had uncovered stent implantation. Patients in the covered stent group were older and had greater basal pressure gradient. More patients in the covered stent group had residual gradient >10 mm Hg after the procedure. There was no mortality or aortic wall injury in either group. Four patients in the covered stent group underwent planned re-intervention and two had unplanned re-intervention. None of the patients in the uncovered stent group had re-intervention. Higher incidence of late lumen loss was noted in the covered stent group. ConclusionUncovered stents can be safely implanted with minimal risk of aortic wall injury in patients with low risk anatomic features. Covered stent implantation is associated with higher incidence of planned and unplanned re-intervention.

Surgical treatment of congenital aortic arch disease

To report treatment outcomes in patients with congenital aortic arch disease. There were 65 patients (45 boys and 20 girls) for the period from 2005 to 2019. Mean age of patients was 53±12 days (range 1-98), weight - 3,3±1,3 kg (range 2.2-4.6). All patients were divided into 2 groups depending on the method of surgical repair. The 1st group included 33 patients who underwent patch repair, the 2nd group (n=32) - anastomosis in end-to-side fashion. In group I, recurrent aortic arch coarctation was observed in 16.8% of cases, in group II - only in 4% of cases (p=0.02). Analysis of systolic pressure in both groups revealed that arterial hypertension was detected in 39% of cases in group I and only in 9,1% of cases in group II (p=0,0025). Surgical treatment of aortic arch disease using anastomosis in end-to-side fashion is associated with reduced risk of recurrent aortic arch coarctation and residual arterial hypertension in long-term postoperative period.

The Challenges of Redo Aortic Coarctation Repair in Adults.

Aortic coarctation is a common congenital abnormality causing significant morbidity and mortality if not corrected. Re-coarctation or restenosis of the aorta following treatment is a relatively common long-term problem and the optimal therapy has not been elucidated. In this review, we identify the challenges associated with and the optimal management for recurrent aortic coarctation and the most appropriate therapy for different patient cohorts. Open surgery provides a durable long-term aortic repair, however, given the complex nature of the procedure, has a somewhat higher rate of serious complications. Endovascular repair, although less invasive and relatively safe, has limitations in treated complex anatomy and is more likely to require repeat intervention. Open surgical repair is more appropriate for infants that have not been intervened on and endovascular therapy should be reserved for older children and adults and those that require repeat intervention.

Procedural risk factors, incidence and timing of reintervention after treatment for native coarctation of the aorta in children: a population-based study†.

The aim of the present study was to evaluate procedural risk factors, incidence and timing of reintervention because of recurrent aortic coarctation in children. The study cohort consisted of 304 patients with isolated coarctation: 251 underwent surgery and 53 were treated percutaneously (40 balloon angioplasty, 13 stent) at the Helsinki Children's Hospital in 2000-2012. Characteristics, intervention and reintervention data were retrospectively collected from clinical records until 2014 (median follow-up 7.9 years). Age- and sex-matched comparisons between the treatment groups were performed in 86 patients (surgery n = 43, percutaneous n = 43). Forty of the 251 (16%) patients after surgery, 9/40 (23%) patients after balloon angioplasty and 4/13 (31%) patients after stent placement underwent a reintervention after a median time of 3.4, 11.7 and 19.5 months (P < 0.05), respectively. In the surgery group, all reinterventions occurred in children operated on ≤12 months of age and were related to lower body weight and smaller dimensions of the aorta. In the balloon angioplasty group, a higher post-procedure systolic arm-leg blood pressure gradient was associated with reintervention. After stent placement, three-fourths of the reinterventions were performed in a planned postinterventional catheterization. In the age- and sex-matched comparisons (median 5,7 years, range 0,5-17,6), post-procedure blood pressure gradients were higher (mean 10 vs 4 mmHg, P = 0.03), and reinterventions were more common (28%, 95% confidence interval 17-43 vs 2%, 95% confidence interval 0-12) in the percutaneous group compared to the surgery group. Reinterventions after surgery in neonates were relatively common. In older children, percutaneous treatment carried a higher risk of reinterventions, which were mainly related to residual coarctation after primary treatment.

Immediate and midterm results of balloon angioplasty for recurrent aortic coarctation in children aged < 1 year

Several publications have considered results of percutaneous angioplasty for aortic recoarctation, but none focused on procedures performed in children aged<1 year. To describe the immediate and midterm results of balloon angioplasty for recoarctation before the age of 1 year, and to define the factors that might influence outcome. We retrospectively reviewed data from 20 consecutive children undergoing percutaneous dilatation for aortic recoarctation before the age of 1 year in the University Hospitals of Tours and Nantes. In all patients except one, dilatation improved the median recoarctation diameter Z-score from -5.5 (range -10.6 to -2.5) to -2.8 (range -4.3 to 0.7) (P<0.001), and reduced the median peak systolic gradient from 33mmHg (range 20 to 60mmHg) to 21mmHg (range 6 to 50mmHg) (P<0.001). There was no procedure-induced mortality and no acute intimal flap or long-term aneurysm. Three patients experienced a transient femoral artery thrombosis, one of whom had a transient ischemic stroke. Eight children (40%) needed reintervention for further recoarctation (new surgery [n=4] or new dilatation [n=4]). A smaller balloon size was significantly associated with the risk of reintervention: balloon to recoarctation diameter ratio 2.0 (range 1.3 to 3.3) vs. 2.7 (range 2.1 to 4.5) (P=0.05); balloon to descending aorta ratio 0.8 (range 0.7 to 1.2) vs. 1.0 (range 0.9 to 1.3) (P<0.05). In this study, percutaneous balloon angioplasty for recoarctation in young infants aged<1 year improved aortic isthmus diameter with a low incidence of adverse event. However, the rate of further intervention is high, and is associated with a smaller balloon size.

Midterm to long-term safety and efficacy of self-expandable nitinol stent implantation for coarctation of aorta in adults.

Endovascular treatment of coarctation of aorta (CoA) by self-expandable Nitinol stents is one of the recognized treatment methods and may be an alternative to surgery or balloon-expandable stent implantation for CoA but there is little information about midterm to long term results of self-expandable stents. Sixty-two patients with CoA (40 men), with a mean age of 30.7 ± 11 years, (range 17-63 years) underwent stent implantation with Optimed self-expandable Nitinol stents between 2005 and 2014. Successful outcome was defined as peak systolic pressure gradient ≤20 mmHg after stent implantation. The patients were followed-up clinically and by echocardiography and in patients, in whom there was suspicion of recoarctation, CT angiography or recatheterization was performed. 65 stents were successfully implanted in all 62 patients. Peak systolic pressure gradient decreased from mean 62.4 ± 18 mmHg (range 35-100 mmHg) to mean 2.8 ± 5 mmHg (range 0-15 mmHg; P < 0.001). Stent displacement occurred in 3 patients during the procedure. These were managed successfully by an overlapping second stent. None of the patients had major complications such as aortic dissection, rupture, or vascular access problems. In follow up, only three patients had recoarctation, and two of these were managed successfully by balloon redilation or further stenting 16 and 18 months after the first procedure and one patient refused reintervention. There were two deaths, unrelated to the procedure, 12 and 78 months after the initial intervention. Follow-up of a mean of 45.5 ± 17 months (range 12-105 months) demonstrated no evidence of aneurysm formation or stent fracture. Self-expandable nitinol stents for the treatment of native and recurrent CoA is safe and has good efficacy with acceptable midterm to long-term outcome.

Extra-anatomical bypass in complex and recurrent aortic coarctation and hypoplastic arch.

Our goal was to report the selection schemes, technical variations and long-term outcome of extra-anatomical bypass to correct complex, recurrent aortic coarctation and hypoplastic aortic arch. Between 1989 and 2012, 53 patients (mean age 13.2 ± 4.3, median 11.6, range 9-23 years) with complex aortic coarctation (n = 33; long-segment hypoplastic aortic arch in 15), recurrent coarctation (n = 20; anastomosic pseudoaneurysm in 10), underwent correction using extra-anatomical bypass, either with (n = 18: femoral bypass = 13, left heart bypass = 5) or without (n = 35) extracorporeal circulation via a left lateral thoracotomy (n= 48) and combined median sternotomy and median laparotomy (n = 5). The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, the length of the hypoplasia and a history of previous repair. Preoperatively, mean systolic blood pressure was 130 ± 30 mmHg at rest and 180 ± 40 mmHg during exercise, with a mean pressure gradient of 80 ± 11.6 (range 40-120) mmHg. Various extra-anatomical bypass strategies included left subclavian artery to descending aorta (n = 38), ascending aorta to left subclavian artery (n = 3), ascending aorta to descending aorta (n = 4), aortic arch to descending aorta (n = 3) and ascending aorta to abdominal aorta (n = 5). Graft size (median 18, range 10-26, mm) was chosen according to the diameter of the vessel proximal and distal to the planned graft. No operative deaths, paraplegia or abdominal malperfusion occurred. The mean reduction in systolic blood pressure was 60 ± 25 mmHg without pressure gradients. During a mean follow-up of 18.3 ± 3.7 years, there were no reoperations, graft complications or pseudoaneurysm formation on anastomotic sites. Seven (11.6%) patients are on antihypertensive medications. No patient presented with claudication nor did anyone experience orthostatic problems from the steal phenomenon. Extra-anatomical bypass is safe, an effective technique, and achieves satisfactory long-term results.

Effectiveness of Balloon Angioplasty in Children With Recurrent Aortic Coarctation Depends on the Type of Aortic Arch Pathology.

The aim of this study was to evaluate the effectiveness of balloon angioplasty (BAP) for recurrent aortic coarctation (ReCoA) in infants comparing simple and complex type of aortic arch pathology (Norwood I procedure). ReCoA is a known complication after cardiovascular surgery for coarctation of the aortic arch. In a single center case study, we analyzed 20 infants undergoing BAP for ReCoA comparing simple (n = 10) and complex type of aortic arch pathology (n = 10). At catherization diameter of ReCoA stenosis was 3.2 ± 0.7 mm (mean ± SD) with short localized (11/20) or long hypoplastic stenosis (9/20) before and 4.8 ± 1.2 mm after BAP (P < 0.001). Invasive systolic pressure gradient was reduced from 27.5 ± 16.2 mmHg before to 5.1 ± 6.6 mmHg after BAP (P < 0.001), comparable in simple and complex type of ReCoA. At day 1 after catherization noninvasive systolic arterial blood pressure gradient was reduced from 20.2 ± 23.1 to 6.7 ± 9.9 mmHg (P < 0.001), respectively, calculated continuous wave Doppler echo gradient from 36.3 ± 22 to 16.8 ± 9.6 mmHg (P < 0.01). Complications were aortic arch dissection (1/20), discrete aortic arch aneurysm formation (1/20), pericardial effusion (1/20), and peripheral arterial thrombosis (4/20). At a mid-term follow up of 9.5 months (1-40) after BAP, 3 infants needed early surgical reintervention due to secondary ReCoA, all with long hypoplastic aortic arch segments, but simple type of aortic arch pathology. At mid-term follow up, BAP remains an effective catheter intervention for ReCoA for infants with localized ReCoA, but not with long hypoplastic aortic arch segments, even in simple type of aortic arch pathology.

P17 Effect of interventional stent treatment of native and recurrent coarctation of aorta on blood pressure

Aim/Background The aim of this study was to describe the clinical impact of management of coarctation of the aorta by transcatheter stent placement in the context of longer term management of systemic hypertension. In the long term, poor outlook associated with untreated coarctation of the aorta is likely to relate to uncontrolled systemic hypertension. Transcatheter stent placement to treat native and recurrent coarctation of the aorta is an established therapy in adolescents and adults. There remains confusion about longer term outcomes, particularly the relation between procedural success and improvement in blood pressure (BP) control. Improvement in lifelong systemic BP control after transcatheter stent placement remains unproved. Results 89 patients underwent transcatheter stent placement over a 14-year period (2001 to 2015) at the Yorkshire Heart Centre. The average age at the time of procedure was 29.3 years (range 6 to 59). Figure 1 shows the ages of the patients undergoing treatment divided into 3 age groups. Figure 2 demonstrates that native coarctations formed the majority of the cases seen, followed by recurrent coarctations, and it shows that only a minority were as part of complex congenital heart disease. We found there was a reduction in peak systolic gradient across the narrowed segment from mean of 27.7 to Conclusion Transcatheter stent placement for the management of aortic coarctation is associated with a reduction in systolic BP that is maintained over the medium term. A significant minority of patients remain significantly hypertensive, and the best management strategy for this group of patients remains unclear.

A rare cardiovascular finding in two cases with Williams syndrome: recurrent coarctation of aorta

A rare cardiovascular finding in two cases with Williams syndrome: recurrent coarctation of aorta

Selection Strategy and Technical Variations of Extra-Anatomic Bypass in Surgical Management of Complex and Recurrent Aortic Coarctation and Hypoplastic Arch

Selection Strategy and Technical Variations of Extra-Anatomic Bypass in Surgical Management of Complex and Recurrent Aortic Coarctation and Hypoplastic Arch

Selection strategy and technical variations of extraanatomic bypass in surgical management of complex and recurrent aortic coarctation and hypoplastic aortic arch

Method In 1989-2012, 60 patients (mean age 29 ± 6.7years) with complex aortic coarctation (n = 33), recurrent coarctation (n = 27; anastomosis pseudoaneurysm in 10), underwent correction using extraanatomic bypass, either or without extracorporeal circulation. The decision to use extracorporeal circulation was based on the anatomical location of the coarctation, length of hypoplasia and history of previous repair. Various extraanatomic bypass strategies included left subclavian artery (LSCA) to descending aorta (DA) (n = 38), right subclavian artery (RSCA) to left carotid artery (LCA) (n = 2), LCA to LSCA (n = 3), LCA to DA (n = 2), ascending aorta (AA) to LSCA (n = 3), AA to DA (n = 4), aortic arch to DA (n = 3) and AA to abdominal aorta (n = 5). We choose the size of the graft according to the diameter of the ascending aorta.. Preoperatively, mean systolic blood pressure was 130 ±30mm Hg at rest and 180±40 mmHg during exercise, with mean pressure gradient of 80±11.6 (range 40-120) mmHg.

Aggressive catheter and surgical intervention for recoarctation after Norwood operation results in excellent long-term outcome

Background: Recurrent coarctation of aorta (reCoA) after Norwood operation might result in impaired cardiac function and the following poor prognosis in HLHS and its variants. The purpose of this study was to evaluate the initial arch repair technique as well as the outcome of aggressive treatment for re-CoA. Patients and methods: Twenty-four (24) reCoA patients after 80 Norwood operations between 1993 and 2012 were evaluated (30.8%, classical HLHS: 20, variants: 4). Initial procedure was primary Norwood in 11 (BT: 4, RV-PA: 7) and bilateral PAB in 13 (modified Norwood: 8, Norwood+BDG: 5). Arch repair technique at Norwood operation was direct anastomosis in 14, patch augmentation in 10. Results: Interval from Norwood to reCoA was 7 - 538 day (median: 102 day), and age at operation was not related with reCoA. Balloon aortoplasty (PTA) was performed in 22 patients, totally 31 times, and initial PTA resulted in the significant decrease in pressure gradient (PG) between AAo and DAo from 14.7±13.5 mmHg to 6.6±10.9 mmHg (P=0.04). PTA non-effective cases underwent stent implantation (2) or surgical intervention (10; patch plasty in 9, SCF in 2). Timing of surgery was pre BDG in 1, at BDG in 5, after BDG in 4, and the material of patch plasty was Xenopatch in 2, Hemashield graft in 1 and ePTFE in 6. There was significant decrease in pressure gradient from 28.0±14.7 mmHg to 5.1±4.3 mmHg (P<0.01). Two patients underwent surgery without PTA and other 2 patients underwent additional PTA after surgical repair. At present, 16 patients reached TCPC and 4 are awaiting TCPC. There were 4 late deaths after BDG with CHF (3) or pneumonia (1), but reCoA was not related with late death (PG: 0-4 (2) mmHg). The surviving 20 patients revealed RVEDV of 145.7±50.7%ofN, RVEF of 55.8±10.3%, PG of 0-12 (1) mmHg and BNP of 5.8-144.8 (16.8) pg/ml. Regarding the initial arch repair technique, patch enlargement at lesser curvature and swing-back technique are related with less reCoA (P<0.05). Conclusions: Re-CoA after Norwood operation was often recognized. Patch enlargement at lesser curvature or swing-back technique might be useful for arch reconstruction. Aggressive intervention for re-CoA in combination of balloon plasty and surgical repair could result in good cardiac function and the following excellent long-term outcome.

Extra-Anatomical Bypass: A Surgical Option for Recurrent Aortic Coarctation

Background. Balloon aortoplasty with or without stenting is a less invasive alternative to open surgery for the management of recurrent isthmic coarctation. However, in patients with previous small size tube graft, an open surgical correction is mandatory and, in most cases, an anatomical aortic reconstruction is carried out. Methods. We present the case of a 48-year-old woman with recurrent aortic coarctation and systemic hypertension with systolic value around 190–200 mmHg and preoperative systolic pressure gradient 70 mmHg, submitted to an extra-anatomical bypass. Through a median sternotomy, an extra-anatomical bypass from ascending to descending aorta was performed. Results. No intra- or postoperative complications were observed. The postoperative pressure gradient was 10 mmHg and the systolic pressure ranged from 130 to 140 mmHg. Conclusion. The extra-anatomical bypass can be considered an effective and safe alternative to the anatomical aortic reconstruction in the cases with recurrent aortic coarctation unfit for endovascular treatment.