Recurrent Coarctation Research Articles

Arch Augmentation via Median Sternotomy for Coarctation of Aorta With Proximal Arch Hypoplasia

Coarctation of the aorta can be associated with hypoplasia of the proximal transverse aortic arch. One approach to manage this condition is via left thoracotomy and extended end-to-end anastomosis with the expectation that the proximal arch will grow over time. Our preferred approach is to augment the aorta via midline sternotomy. We hypothesized that this approach is safe, durable, and allows reliable growth of the aorta. We identified the records of patients with biventricular anatomy who had coarctation of the aorta, hypoplasia of the proximal transverse arch, and no other cardiac lesion that would mandate cardiopulmonary bypass use and midline sternotomy. The records of 62 such patients operated on between 2005 and 2016 were retrospectively reviewed. Patient demographics, clinical variables and outcome data were collected and analyzed using SAS 9.4. Data are presented as median (interquartile range [IQR]). Sixty-two patients (23 girls [37%]) underwent repair at 10 (IQR, 5 to 21) days of life. Forty-nine (79%) patients were on prostaglandin infusion to maintain ductal patency. Fifteen (24%) patients presented in shock with end organ dysfunction, 17 (27%) were on inotropes, and 26 (42%) were mechanically ventilated. The proximal transverse arch was 41% (IQR, 34% to 47%) of the size of ascending aorta as measured by echocardiography (z-score, -5 [IQR, -5.8 to -4.3]). Following median sternotomy, repair was carried out on cardiopulmonary bypass (41 [IQR, 37 to 47] minutes). The arch was reconstructed with (n= 26 [42%]) or without (n= 36 [58%]) coarctectomy usually using homograft patch aortoplasty (n= 58 [94%]). In all but 2 patients, repair was undertaken with circulatory arrest (27 [IQR, 22 to 31] minutes). Patients were extubated 4 (IQR, 3 to 5) days later and discharged home in 12 (IQR, 8 to 18) days. There was no mortality, and 8 morbidity events (3 recurrent nerve injury, 2 chylothorax, 1 phrenic nerve injury, 1seizure, and 1 superficial wound infection) in 7 (11%) patients. All patients are alive at 41 (IQR, 11 to 64) months of follow-up. Reintervention was required in 6 (10%) patients (5 catheter based and 3 surgical) for recurrent distal coarctation. Reintervention-free survival at 1, 3, and 5 years was 87%. Only 1 child was currently on antihypertensive therapy, and all were in New York Heart Association functional class I symptoms. At last echocardiogram, the proximal transverse arch was 97% (IQR, 84% to 103%) of the diameter of the ascending aorta (z-score, 0.8 (IQR, 0.3 to 1.3]), ejection fraction was 70% (IQR, 60% to 76%), and only 2 patients had significant left ventricular hypertrophy. Arch augmentation via median sternotomy is a safe and effective procedure that can be accomplished with low morbidity and mortality. The reconstructed arch retains excellent growth potential resulting in a very favorable physiologic outcome.

Comparison Between Balloon Angioplasty and Surgical treatment for Native Coarctation of the Aorta in Infants

Coarctation of the aorta (CoA) is a discrete stenosis of the proximal thoracic aorta. The common clinical pattern is congestive heart failure in infancy. Treatment methods include balloon angioplasty (BA) and surgical repair in this age group. Percutaneous balloon angioplasty is a less invasive method for the repair of discrete coarctation but remains controversial as a primary treatment strategy for a native coarctation.
 This study aimed to compare the effectiveness and outcome of balloon angioplasty and surgical repair in infants with coarctation of the aorta younger than one year old.
 Methods. Between January 2011 and December 2017, 59 patients with native aortic coarctation were treated in National Amosov Institute of Cardiovascular Surgery. This retrospective study evaluated the results of the two methods in patients younger than one year old with the diagnosis of coarctation of the aorta. Group 1 included 18 patients who accepted balloon dilatation for discrete coarctation. Group 2 included 41 patients who underwent surgical resection with end-to-end anastomosis. Patients with complex cardiac anomalies were not included in this study.
 Results. Immediate results revealed no significant difference in the effectiveness of the two methods (p value =0.06). While the rate of recurrent coarctation was significantly lower in the surgery group [1 (2,4%) vs. 13 (72,2%), p value =0.0017]. The mean hospital stay was 6.4±3.6 days in the balloon angioplasty group and 21.5±8.7 days in the surgery group, which constitutes a significant statistical difference (p value <0.05). Aneurysm formation was not encountered.
 Conclusion. Both surgical repair and balloon angioplasty for native coarctation of the aorta in infants were effective and beneficial. These data suggest that balloon angioplasty can be acceptable alternative to surgical treatment but due to the high level of recoarctation this method may be considered in critically ill infants with congestive heart failure as a primary palliative procedure. The limitations of this study were its retrospective, nonrandomized nature, and smaller case numbers.

РЕЗУЛЬТАТЫ МОДИФИЦИРОВАННОЙ РЕВЕРСИВНОЙ ПЛАСТИКИ С ИСПОЛЬЗОВАНИЕМ ЛОСКУТА ЛЕВОЙ ПОДКЛЮЧИЧНОЙ АРТЕРИИ У ПАЦИЕНТОВ ПРИ КОАРКТАЦИИ АОРТЫ

Вступление. Коарктация аорты (КА) составляет от 5 до 8% всех врожденных пороков сердца, часто ассоциируется с другими врожденными аномалиями, в частности, гипоплазией дуги аорты (ДА). Непосредственные результаты лечения больных значительно улучшены, однако отдаленные результаты нельзя назвать удовлетворительными. Клинические проблемы после коррекции КА включают повторную КА, персистирующую артериальную гипертензию, аневризму аорты и цереброваскулярных сосудов, раннюю ишемическую болезнь сердца. Высокую частоту осложнений связывают с выбранной методикой коррекции КА и вариантом формирования анастомоза. В настоящее время нет проспективных рандомизированных исследований, однозначно доказывающих преимущества того или иного способа коррекции КА с гипоплазией дистальной части ДА.
 Целью проспективного исследования было сравнение двух методов: модифицированной реверсивной пластики (І група) и формирования «extended» анастомоза (ІІ група).
 Материалы и методы. Приведены результаты оценки хирургического лечения 64 пациентов раннего возраста по поводу КА в сочетании с гипоплазией дистальной части ДА в период с 2011 по 2015 г.
 Результаты. Анализ отдаленных результатов проведен у 62 (98,8%) пациентов в сроки до 48 мес.
 Совокупный показатель выживаемости в сроки до 4 лет составил 95,9% - в I группе, 95,6% - во ІІ группе. Диаметр перешейка аорты у пациентов ІІ группы в отдаленном периоде составлял (0,98 ± 0,4) мм, І группы – (1,2 ± 0,86) мм. В І группе повторной КА в отдаленном периоде не было у 98,2% пациентов, во ІІ группе – у 96,3%.
 Выводы. Метод модифицированной реверсивной пластики с использованием лоскута левой подключичной артерии воспроизводимый и безопасный, о чем свидетельствовало отсутствие фатальных осложнений как в раннем, так и отдаленном периоде после выполнения вмешательства.
 Ключевые слова: коарктация аорты; гипоплазия дуги аорты; хирургическая коррекция; повторная коарктация аорты.

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.

Outcomes of thoracic endovascular aortic repair in adult coarctation patients

BackgroundAortic coarctation (AC) is most commonly identified in pediatric patients; however, adults can present with late sequelae of untreated coarctation or complications of prior open repair. To date, there are limited data about the role of thoracic endovascular aortic repair (TEVAR) in this group of patients. The purpose of this analysis was to describe our experience with management of adult coarctation patients using TEVAR. MethodsAll TEVAR patients treated for primary coarctation or late sequelae of previous open repair (eg, pseudoaneurysm, recurrent coarctation or anastomotic stenosis related to index open coarctation repair) were reviewed. Demographics, comorbidities, procedure-related variables, postoperative outcomes, and reintervention were recorded. Computed tomography centerline assessments of endograft morphology were completed to delineate stent anatomy at the coarctation site. Survival and reintervention were estimated using life-table analysis. ResultsA total of 21 patients were identified (median age, 46 years [range, 33-71 years]; 67% male [n = 14]). Nine patients (43%) were treated for symptomatic primary (n = 6) or recurrent (n = 3) coarctation. Other indications included degenerative thoracic aneurysm (n = 6), pseudoaneurysm (n = 4), and dissection (n = 2). Technical success was 100% (95% confidence interval [CI], 84%-100%). No 30-day mortality or paraplegia events occurred; however, two patients (10%) experienced postoperative nondisabling stroke. In primary or recurrent coarctation patients with available computed tomography imaging (n = 8 of 9), nominal stent graft diameters were achieved proximal and distal to the coarctation (range, −0.4 to −1.2 mm of desired final stent diameter). Specific to the coarctation site, there was a significant increase in aortic diameter after TEVAR (before stenting, 11.5 [95% CI, 6.8-12.3] mm; after stenting, 15 [95% CI, 13.7-15.7] mm; P = .004). Concurrently, systolic arterial blood pressure at time of discharge was significantly lower (before stenting: 147 mm Hg; 95% CI, 137-157 mm Hg; after stenting: 124 mm Hg; 95% CI, 118-134 mm Hg; P = .02). For all patients, median clinical follow-up time was 8 months (interquartile range, 3-13 months; range, 1-106 months). Three endoleaks were detected, all of which were type II related to left (n = 2) or aberrant (n = 1) subclavian arteries. Four patients (19%) underwent reintervention (median time, 7 months; range, 2-12 months), with three of four being subclavian artery embolization; one was an aortic root replacement for ascending aneurysm with bicuspid aortic valve. One-year freedom from reintervention was 78% ± 9% (95% CI, 42%-92%). The 1- and 3-year survival was 95% ± 5% (95% CI, 71%-99%). One late death was related to complications from pre-existing congenital heart disease. ConclusionsAdult AC patients can be treated safely with TEVAR, and the annular constriction of an AC can be successfully dilated by the stent graft. Given these findings, a greater number of patients with longer term follow-up is warranted to further define the role of TEVAR in the management of adult AC patients.

Acute and mid-term outcomes of stent implantation for recurrent coarctation of the aorta between the Norwood operation and fontan completion: A multi-center Pediatric Interventional Cardiology Early Career Society Investigation.

We sought to evaluate outcomes of stent implantation (SI) for recurrent coarctation of the aorta (RC) following the Norwood operation. RC is common following the Norwood operation. Balloon angioplasty (BA) is standard treatment but may result in unsatisfactory relief of RC. SI may improve RC, but outcome data are limited. We performed a multi-center retrospective study of patients who underwent SI for RC between the Norwood operation and Fontan completion. Outcomes were examined, including procedural success, serious adverse events (SAE), and freedom from re-intervention. A core laboratory was utilized to review angiograms. Coarctation Index (CI) was calculated before and after SI. Paired t-test and Wilcoxon signed-rank test were used to compare pre- and post-SI variables. Thirty-three patients at 8 centers underwent SI for RC at a median age of 5 months (IQR 4.1, 13.3) and weight of 5.9 kg (5.2, 8.6). Aortic arch gradient improved from 20 (15, 24) to 0 (0, 2) mmHg following SI (P < 0.0001). The median CI improved from 0.54 (0.43, 0.62) to 0.97 (0.89, 1.06) following SI (P < 0.0001). There were no procedural deaths but SAEs occurred in 12 (36%) patients. During a median follow-up duration of 29.7 months (6.8, 48.0), freedom from death or heart transplant was 82%, and from re-intervention was 45%, with median time to re-intervention of 20.1 months (11.4, 40.3). SI for treatment of RC in patients after the Norwood operation provides excellent acute relief of obstruction. Intraprocedural hemodynamic instability is common and re-intervention is frequent at mid-term follow-up.

Stent Therapy for Aortic Coarctation in Children

To report our experience of coarctation stent therapy in small children weighing less than 30kg, with the low profile dilatable Valeo stent and review the literature on coarctation stent therapy in this patient population. Coarctation stent implantation was undertaken in 14 consecutive children using the Bard Valeo Stent. Demographic, angiographic, echocardiographic and clinical data were reviewed retrospectively. The median age at the time of procedure was 5.1 (2.6-7.5)years and median weight was 20.8 (14.7-27)kg. There was improvement in median coarctation diameter from 4 (1.3-5.2) to 9.5 (5.8-12.7)mm, p<0.001; and a reduction in the median peak pressure gradient across the coarctation from 35 (20-49) to 9 (0-15)mmHg, p<0.001. Median stent recoil was 7.9 (0-20)%. There was one case of access related complication that resolved without sequelae. Follow-up was a median of 15 (3.0-57.2)months. CT angiogram performed at a median time of 3.3 (2.6-10.2)months post procedure showed no aortic wall injury and preserved stent integrity in all cases. Two children underwent re-intervention for stent dilation and further stent implantation due to in-stent stenosis and somatic growth after 3years. Six of fourteen children remained on a single antihypertensive agent post-intervention at last follow-up. Implantation of the dilatable Valeo stent is a feasible treatment strategy in native or recurrent coarctation in small children, accepting that additional stent implantation may be necessary with somatic growth. Further study is required to determine longer-term stent efficacy and clinical outcome.

Exercise Capacity Before and After Stent Placement for Coarctation of the Aorta: A Single-Center Case Series.

Over the last 15years, stent placement has become a viable and safe alternative to surgical repair for native and recurrent coarctation of the aorta. Although patients with coarctation of the aorta often have lower exercise tolerance, there is no published data regarding the effect of coarctation stenting on exercise capacity. We aimed to determine the effect of coarctation stent placement on exercise capacity. We conducted a retrospective chart review of all patients who underwent stent placement for native or recurrent coarctation of the aorta at our institution from January 2000 to October 2012. We identified those patients who underwent exercise testing before and after stent placement. We compared measures of exercise capacity pre- and post-stent placement using paired t tests. Among 48 patients who underwent coarctation stenting, 7 (mean age=40, range 21-65years) were found to have isolated coarctation of the aorta and had the necessary pre- and post-stent exercise data. Only one patient had native coarctation of the aorta. The peak-to-peak systolic gradient improved by a mean of 26mmHg (p<0.02) after stent placement. Functional aerobic capacity (FAC) improved from a mean of 69-83% after stent placement (p<0.03). Metabolic equivalents (METs) also improved significantly from a mean of 8.7 to 10.2 (p<0.03). In our cohort, stent placement for relief of recurrent coarctation of the aorta resulted in a significant improvement in exercise capacity. This improvement may not be as significant in patients with milder coarctation of the aorta or those with complicating morbidities. Larger studies with more long-term follow-up are needed to better quantify this improvement and to define any lasting effect of this intervention on exercise tolerance.

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.

Results of a multimodal approach for the management of aortic coarctation and its complications in adults.

We aimed to assess the results of various tailored management strategies for adults with coarctation in our centre. We reviewed all adults patients treated for aortic caorctation between January 2000 and December 2015 in our institution. The primary end point was a composite of death, perioperative stroke, paraplegia, need for unplanned reoperation or occurrence of pseudoaneurysm during the follow-up. The mean follow-up was 82 ± 5 months. Sixty-three adults were treated for a native coarctation (n = 34), a recurrent coarctation (n = 14) or aneurysmal complication (n = 15). Mean age of the patients was 42 ± 1.7 years. All but 1 patient with native coarctation (33/34, 97%) and recurrent coarctation (13/14, 93%) underwent endovascular repair and 10 (67%) patients with aneurysmal complications were treated surgically. Freedom from the primary composite end point was 94, 84 and 81% at 1, 5 and 10 years, respectively, without difference between the 3 indication groups (P = 0.96). A tailored management strategy is necessary to provide good results for the treatment of adults with aortic coarctation. Thus, centres that are involved in the care of this complex pathology should be able to propose a multimodal approach, either endovascular or surgical depending on patient's characteristics and anatomic features.

Outcomes of Thoracic Endovascular Aortic Repair in Adult Aortic Coarctation Patients

Although aortic coarctation is most commonly seen in pediatric patients, adults can present with late sequelae of untreated coarctation or complications of the index repair. To date, there are limited data about the role of thoracic endovascular aortic repair (TEVAR) in this group of patients. The purpose of this analysis is to describe our experience with management of adult coarctation patients treated with TEVAR. A retrospective review was completed of a prospectively maintained endovascular aortic registry at a university hospital. All patients treated for primary coarctation or for late sequelae of previous open repair (eg, pseudoaneurysm, recurrent coarctation/anastomotic stenosis related to index open coarctation repair) were included. Patient demographics, comorbidities, procedure-related variables, postoperative outcomes, and reintervention were abstracted. Computed tomographic centerline assessments of endograft morphology were also completed to delineate stent anatomy at the site of coarctation. Survival was estimated using Kaplan-Meier life tables. A total of 21 patients were identified (median age = 46 years [range, 33-71]; 67% male [n = 14]). Nine patients (43%) were treated for symptomatic primary (n = 6) or recurrent coarctation (n = 3). Other indications included degenerative thoracic aneurysm (n = 6), pseudoaneurysm (n = 4), and dissection (n = 2). Zone 1 or 2 landings were employed in 15 patients (zone 2, n = 13; zone 1, n = 2). Additional procedure-related data is depicted in the Table. No 30-day mortality events occurred, and two patients (10%) experienced a postoperative complication (nondisabling stroke, n = 2). At a median clinical follow-up time of 8 months (range, 1-106), three endoleaks were detected, all of which were type 2 related to patent left subclavian (n = 2) or aberrant subclavian arteries (n = 1). Four patients (19%) underwent reintervention (median time, 7 months [range, 2-12]), and three out of four of these were subclavian artery embolizations, whereas one was for aortic root replacement because of pre-existing bicuspid aortic valve with concomitant ascending aortic aneurysm. In patients with available computed tomography imaging (n = 6 of 9 primary/recurrent coarctation subjects), nominal stent diameters at the site of coarctation were effectively achieved within these patients (range, -0.4 to -1.2 mm of desired final stent diameter). One- and 3-year survival is estimated to be 95 ± 5% (Fig). One late death occurred related to complications from pre-existing congenital heart disease. Adult patients with aortic coarctation can be treated safely with TEVAR. The annular constriction of an aortic coarctation can be successfully dilated by the self-expanding stent graft. Greater patient numbers and longer term follow-up are needed to further define the role of TEVAR in the management adult patients with complications of aortic coarctation.TableProcedure-related variables of adult aortic coarctation patients undergoing TEVAR (thoracic endovascular aortic repair)Feature, N = 21No. (%)Preoperative spinal drain8 (38%)Intraoperative adjuncta10 (47%) -Left carotid-subclavian bypass/transposition7 -Left subclavian artery embolization6 -Left carotid stent1 -Right carotid subclavian bypass/transposition2 -Right atrial inflow balloon occlusion1 -Right subclavian artery embolization1Device type Medtronic17 (81%)-Valiant11-Talent6 Cook TX23 (14%) Gore TAG1 (5%)Operative time, minutesb139 [70, 200]Fluoroscopy time, minutesb15 [12, 20]Contrast exposure, mLb95 [40, 130]Estimated blood loss, mLb150 [100, 200]aSome patients received multiple adjuncts.bMedian [interquartile range]. Open table in a new tab

Aortic Arch Advancement and Ascending Sliding Arch Aortoplasty for Repair of Complex Primary and Recurrent Aortic Arch Obstruction.

The optimal treatment of patients with complex coarctation of the aorta and hypoplastic aortic arch is controversial. Children undergoing repair of obstructive arch lesions are at lifelong risk of recurrence. Multiple techniques have been described to address complex primary and recurrent coarctation. Our approach at Texas Children's Hospital (Houston, TX) has been to address these lesions in an anatomic fashion via median sternotomy, under cardiopulmonary bypass using the techniques of aortic arch advancement and ascending sliding arch aortoplasty. Anatomic repair of complex primary or recurrent aortic obstruction is safe and produces a favorable repair with a low rate of recurrence. Both operations restore normal arch contour using native aortic tissue. The decision of which particular surgical strategy to use depends on the patient's age, anatomy, and the elasticity of the tissue.

Type II endoleak after endoluminal repair of thoracic aortic aneurysm associated with native coarctation.

Aneurysm formation and recurrent coarctation are common complications of coarctation repair, and various types of treatment have been described. Native aortic coarctation during adult life is rarer and can be responsible for severe complications. We report an original case of thoracic aortic aneurysm associated with native coarctation successfully treated by a hybrid approach, comprising retrograde implantation of a thoracic stent graft and carotid-axillary bypass graft. A large intercostal collateral was embolized with coils.

Adverse outcome of coarctation stenting in patients with Turner syndrome.

This study examines the outcome and procedural outcomes of percutaneous stent angioplasty for aortic coarctation in patients with Turner syndrome (TS). TS occurs in 1 in 2,500 live-born females and is associated with aortic coarctation. In this multicenter, retrospective cohort study, all patients with TS and a coarctation of the aorta, treated with percutaneous stent implantation were included. The procedural strategies were dictated by local protocols. Adverse events at short- and long-term follow-up and qualitative parameters concerning the stent implantation were assessed. In the largest study to date of TS patients receiving aortic stents, a total of 19 patients from 10 centers were included. Twelve patients were treated for native and 7 for recurrent coarctation. Age at intervention was 16.9 (7-60) years (median; min-max). The coarctation diameter increased significantly from 8.0 mm (2-12) pre-intervention to 15.0 mm (10-19) post-intervention (P < 0.001). Three (15.8%) adverse events occurred within 30 days of the procedure, including two dissections despite the use of covered stents, one resulting in death. At long-term follow-up (6.5 years, min-max: 1-16), two additional deaths occurred not known to be stent-related. Though percutaneous treatment of aortic coarctation in TS patients is effective, it is associated with serious morbidity and mortality. These risks suggest that alternative treatment options should be carefully weighed against percutaneous stenting strategies. © 2016 Wiley Periodicals, Inc.

Off-pump midline repair of coarctation of aorta when associated with intracardiac defects: an alternate approach for single-stage correction.

Strategies for the optimal surgical management of coarctation of aorta with associated intracardiac defects continue to be debated upon. We describe a previously unreported surgical technique for the management of this combination of defects and present our early results. Thirty-one patients (median age: 73 days and median weight: 3.9 kg) underwent repair of coarctation of aorta with associated cardiac defects, in a single-stage, through a midline sternotomy. Twenty-eight patients had associated distal arch hypoplasia and 1 had a type I interruption. The coarctation and when necessary, the distal arch, was repaired prior to the institution of cardiopulmonary bypass. Cardiopulmonary bypass was subsequently instituted for the repair of the associated intracardiac defects. All patients had successful repair of coarctation and distal arch hypoplasia without the need for rescue cardiopulmonary bypass. In addition, 29 patients had closure of one or more ventricular septal defects, 3 patients had an arterial switch procedure and 1 had repair of double outlet right ventricle. Repair of supramitral ring and subaortic membrane was performed in another 3 patients. One patient underwent concomitant mitral valve repair. There was one in-hospital mortality (3.22%) due to fulminant sepsis. The median follow-up was 29.5 months (range: 1-58 months). There was no late mortality. Two patients required balloon dilatation for recurrent coarctation. Overall event-free survival rate was 88.5% at both 2 and 3 years of follow-up after surgery. However, intervention-free survival at 2 and 3 years of follow-up was 91.7% among the survivors. Repair of coarctation and distal arch hypoplasia or type I arch interruption is feasible prior to the institution of cardiopulmonary bypass without the use of hypothermic circulatory arrest or regional cerebral perfusion, with acceptable and reproducible 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.

Repair of adult aortic coarctation by resection and interposition grafting.

Aortic coarctation presenting during adult life most frequently represents cases of re-coarctation, following previous transcatheter or surgical therapy, or missed cases of native coarctation. In the area of evolving endovascular therapy, we believe that there is still a place for durable open repair by means of resection and interposition grafting. We, therefore, evaluated our results in adult patients with primary aortic coarctation or complications of a previous coarctation repair. A total of 38 patients were operated between 1989 and 2014. Median age was 43 years (range 18-69 years), and 20 were male (52.6%). Seventeen patients (44.7%) had recurrent coarctation or dilatation after previous repair during childhood; the remaining 21 (55.3%) had primary coarctation diagnosed at adult age. Data were retrospectively reviewed and analysed for indications, type of repair, operative details and outcomes. Resection and interposition grafting was performed primarily with the use of left-left bypass (mean cross-clamping time 41 ± 13 min). There were no in-hospital deaths, stroke, spinal cord ischaemia, renal or respiratory failure. No patient had evidence of symptomatic aortic re-coarctation or pseudoaneurysm formation on follow-up. Long-term survival after 20 years was 94.7%. Open surgical repair of primary, recurrent or complicated adult aortic coarctation by interposition grafting is a safe and feasible therapeutic option, providing durable long-term results and excellent long-term survival.

Recurrent Coarctation After Neonatal Univentricular and Biventricular Norwood-Type Arch Reconstruction

Previous studies have evaluated recurrent coarctation after the Norwood procedure (NP) in patients with single-ventricle (SV) anatomy. Extended patch augmentation of the aorta, a Norwood-type arch reconstruction (NTAR), is also used in patients with 2 ventricles and a diffusely hypoplastic arch; however, outcomes after NTAR in these patients are not well described. A retrospective review was performed of neonates with SV and 2-ventricle (2V) anatomy who underwent an NP or NTAR at our institution from 2000 to 2010. The incidence of recurrent coarctation requiring intervention and associated risk factors were evaluated. Overall, 101 patients with 2V anatomy and 361 patients with SV anatomy were included. Eighteen patients with 2V anatomy (17.8%) and 35 patients with SV anatomy (9.7%) required intervention for recurrent coarctation at a median of 0.5 years (interquartile range [IQR], 0.3-1.2 years) after the initial operation. Independent risk factors associated with recurrent coarctation in patients with 2V anatomy included weight less than 2.5kg (hazard ratio [HR], 6.05; p= 0.001) and peak aortic arch gradient (PAAG) on the discharge echocardiogram greater than 10 mm Hg (HR, 3.07; p= 0.03). In patients with SV anatomy, shunt type (HR, 6.42; p < 0.0001 for right ventricle to pulmonary artery [RV-PA] shunt compared with others) and peak gradient on the discharge echocardiogram greater than 10 mm Hg were found to be significant (HR, 7.40; p < 0.0001). There was no survival difference in patients with and those without recurrent coarctation. Recurrent coarctation is common after NTAR. Small patient size and shunt type were found to be independent risk factors for recurrent coarctation in the 2V and SV populations, respectively, and discharge aortic arch gradient was a significant risk factor in both populations.

Use of the AndraStent XL and XXL for the treatment of coarctation of the aorta in children and adults: immediate and midterm results.

The aim of this study is to present our experience with a new type of extra-large stent, namely the AndraStent XL/XXL. AndraStents were implanted in 46 patients, 38 with native coarctation of the aorta (CoA) and eight with recurrent coarctation of the aorta following previous surgery (ReCoA). All patients had arterial hypertension in the upper limbs, absent or weak femoral pulses, and continuous flow in the abdominal aorta on Doppler examination. The median age of patients was 25 years (range from nine to 65). The stents (cobalt-chromium with semi-open cell design) were manually mounted on balloon catheters and delivered through 10 to 14 Fr Mullins sheaths using a conventional femoral approach. All procedures were successful (no stent migration, proper expansion, no aorta dissection/rupture, major bleeding or major vessel injury). The systolic gradient across the aorta decreased from 40.6 mmHg before the procedure to 11.6 mmHg after the procedure (p<0.001). The mean fluoroscopy time was 5.7 minutes. Imaging examinations were scheduled and performed between six and 12 months after the initial procedure in 40 patients (angiography or angio CT or both). Procedural outcome remained favourable during a mean 2.4 years of follow-up. Neither stent fracture nor dislocation was observed in any patient at follow-up. In two patients, small aneurysm formation was observed six and eight months after the procedure -they were treated successfully with subsequent covered stent implantation. Re-dilatation of the implanted stent was performed between four and 26 months in 14 patients. Implantation of new large cobalt-chromium stents is a good therapeutic option for the treatment of native and recurrent CoA.

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.