Coarctation of the aorta in adults: surgical results and long-term follow-up

doi:10.1016/S0003-4975(00)01999-8

The Annals of Thoracic Surgery

Volume 70, Issue 5, November 2000, Pages 1483-1488

Presented at the Thirty-sixth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 31–Feb 2, 2000.

https://doi.org/10.1016/S0003-4975(00)01999-8 Get rights and content

Abstract

Background. The aim of this retrospective study was to determine the impact of coarctation surgical repair on arterial blood pressure in adults more than 20 years of age.

Methods. Thirty-five adults (23 men), mean age 28.1 ± 5.7 years (range, 21 to 52 years), underwent coarctation surgical repair between 1977 and 1997. All patients had preoperative hypertension. Mean systolic blood pressure was 178 ± 37 mm Hg (range, 110 to 230 mm Hg). Thirty-three patients were taking at least one hypertension medication at the time of operation. All patients had preoperative catheterization and angiography (mean gradient across the coarctation was 62 ± 27 mm Hg [range, 32 to 130 mm Hg]). Operative technique was resection and end-to-end anastomosis for 30 patients, resection with Dacron (C. R. Bard, Haverhill, MA) graft for 4 patients, and a prosthetic bypass graft for 1 patient. There were no hospital deaths and no late morbidity.

Results. All patients were reviewed. Follow-up was 165 ± 56 months (range, 25 to 240 months). Of the 35 patients with preoperative hypertension, 23 were normotensive (systolic blood pressure ≤ 140 mm Hg, diastolic blood pressure ≤ 90 mm Hg) with no medication. Twelve patients were receiving medication: 6 required single-drug therapy and 6 patients required two drugs. Exercise testing was performed at an average of 6 ± 4 months after repair and revealed hypertensive response to exercise in 8 of the 23 patients who were normotensive at rest and without medication. There were no recoarctation or repeat operations. Six aortic valve diseases were observed: three aortic incompetences (two bicuspid valves) treated by two valve replacements and one Bentall procedure, and three aortic stenoses (two valve replacements). No patient had evidence of a cerebrovascular accident.

Conclusions. Surgical repair of coarctation in adults has proved to be an effective procedure and significantly reduces arterial hypertension. However, long-term surveillance is mandatory and should include exercise testing to identify patients with potential hypertension.

Section snippets

Material and methods

Between 1977 and 1997, 35 adult patients older than 20 years underwent repair of aortic isthmic coarctation. There were 23 men and 12 women with a mean age of 30.8 ± 5.7 years (range, 21 to 52 years). Preoperative findings are summarized in Table 1. Eleven patients (31%) presented with at least one symptom. For the other 24 patients, the diagnosis made by physical examination was prompted by the discovery of high blood pressure. Clinical findings were a systolic murmur in 4 patients, and

Postoperative follow-up

There was no surgical mortality. Morbidity included two recurrent nerve palsies and one reoperation for bleeding. The mean length of follow-up was 13.8 ± 4.6 years (range, 1.4 to 22 years). One patient was lost to follow-up. At the most recent follow-up, all patients were alive. Thirty-two patients (94%) were symptom free (New York Heart Association class I) and leading a normal lifestyle; only 5 patients were unemployed. Two patients had angina pectoris and 1 patient had myocardial infarction.

Natural history

The natural history of coarctation has been well documented by Campbell [11], who demonstrated that 50% of untreated patients were dead by the age of 30 years, 75% at 46 years, and 90% at 58 years. Comparing these data with normal life expectancy tables we observed that there was a high increase in mortality during the third to fifth decades of life. Presbitero and coworkers [3], whose postoperative follow-up ranged from 15 to 30 years, reported improved life expectancy after operation.

Operative procedure

In this

Acknowledgements

We thank Richard Medeiros for his valuable advice on editing the manuscript.

References (25)

C. Crafoord et al.
Congenital coarctation of the aorta and its surgical treatment
J Thorac Surg
(1945)
W.J. Wells et al.
Repair of coarctation of the aorta in adultsthe fate of systolic hypertension
Ann Thorac Surg
(1996)
R.M.H.J. Brouwer et al.
Influence of age on survival, late hypertension, and recoarctation in elective coarctation repair. Including long-term results after elective coarctation repair with a follow-up from 25 to 44 years
J Thorac Cardiovasc Surg
(1994)
A. Aris et al.
Repair of aortic coarctation in patients more than 50 years of age
Ann Thorac Surg
(1999)
L. Bergdahl et al.
Surgical correction of coarctation of the aorta. Influence of age on late results
J Thorac Cardiovasc Surg
(1983)
J.M. Grinda et al.
Bypass graft for complex forms of isthmic aortic coarctation in adults
Ann Thorac Surg
(1995)
P.V. Fragola et al.
Precursors of established hypertension in borderline hypertensives. A two year follow-up
Int J Cardiol
(1993)
J. Guenthard et al.
Exercise-induced hypertension in the arms due to impaired arterial reactivity after successful coarctation resection
Am J Cardiol
(1995)
B.S. Alpert et al.
Role of the renin-aldosterone system in hypertensive children with coarctation of the aorta
Am J Cardiol
(1979)
M. Cohen et al.
Coarctation of the aortalong-term follow-up and prediction of outcome after surgical correction
Circulation
(1989)

P. Presbitero et al.

Long-term results (15–30 years) of surgical repair of aortic coarctation

Br Heart J

(1987)

B.J. Maron et al.

Prognosis of surgically corrected coarctation of the aortaa 20-year postoperative appraisal

Circulation

(1973)

Cited by (110)

Incidental aortic coarctation in traumatic subclavian artery injury
2021, Trauma Case Reports
Subclavian artery injuries are complex and challenging due to anatomy and exposure during surgery. The surgical management depends on the mechanism of injury, the patient's haemodynamic stability and other injuries sustained. If control of bleeding is lost during surgery, it results in immediate exsanguination, with high mortality and morbidity rates. New techniques with endovascular surgery have changed the approach and outcome of these injuries. In this case report, an incidental finding of coarctation of the aorta in a 32-year-old man after sustaining a gunshot to the chest, with a subsequent subclavian artery injury is reported.
Surgery for Adult Congenital Heart Disease
2020, Cardiology Clinics
Elimination of Transcoarctation Pressure Gradients Has No Impact on Left Ventricular Function or Aortic Shear Stress After Intervention in Patients With Mild Coarctation
2016, JACC: Cardiovascular Interventions
This study sought to investigate the impact of transcatheter intervention on left ventricular function and aortic hemodynamics in patients with mild coarctation of the aorta (COA).
The optimal method and timing of transcatheter intervention for COA remains unclear, especially when the severity of COA is mild (peak-to-peak transcoarctation pressure gradient <20 mm Hg). Debate rages regarding the risk/benefit ratio of intervention versus long-term effects of persistent minimal gradient in this heterogeneous population with differing blood pressures, ventricular function, and peripheral perfusion.
We developed a unique computational fluid dynamics and lumped parameter modeling framework based on patient-specific hemodynamic input parameters and validated it against patient-specific clinical outcomes (before and after intervention). We used clinically measured hemodynamic metrics and imaging of the aorta and the left ventricle in 34 patients with mild COA to make these correlations.
Despite dramatic reduction in the transcoarctation pressure gradient (catheter and Doppler echocardiography pressure gradients reduced by 75% and 47.3%, respectively), there was only modest effect on aortic flow and no significant impact on aortic shear stress (the maximum time-averaged wall shear stress in descending aorta was reduced 5.1%). In no patient did transcatheter intervention improve left ventricular function (e.g., stroke work and normalized stroke work were reduced by only 4.48% and 3.9%, respectively).
Transcatheter intervention that successfully relieves mild COA pressure gradients does not translate to decreased myocardial strain. The effects of the intervention were determined to the greatest degree by ventricular–vascular coupling hemodynamics and provide a novel valuable mechanism to evaluate patients with COA that may influence clinical practice.
Comparison of surgical repair and percutaneous stent implantation for native coarctation of the aorta in patients ≥ 15 years of age
2016, International Journal of Cardiology
Middle aortic coarctation: A rare vascular disorder
2015, Journal des Maladies Vasculaires
La coarctation de l’aorte thoracique descendante est une anomalie vasculaire rare. Son étiologie est controversée. Elle se manifeste le plus souvent par une hypertension artérielle sévère. Plus rarement, elle peut se traduire par une claudication intermittente. En dépit de sa complexité, le traitement chirurgical demeure le traitement de choix des coarctations longues et offre de bons résultats à court et à long termes.
Nous rapportons trois cas de coarctation aortique descendante opérés sur une période de deux ans (janvier 2012–décembre 2013). Le suivi comportait une surveillance de la pression artérielle et des angioscanners aortiques.
L’âge moyen des patientes était de 19 ans et le suivi moyen était de 16 mois. L’hypertension artérielle était la présentation clinique habituelle. Le diagnostic a été posé par l’angiographie. Deux cas ont été traités chirurgicalement par un pontage aorto-aortique et un cas par un pontage sous-clavio-aortique. Les suites opératoires ont été simples. La pression artérielle a été contrôlée sous deux antihypertenseurs et les signes fonctionnels ont disparu chez toutes les patientes.
La coarctation de l’aorte thoracique descendante est une entité rare. L’étiologie peut être congénitale ou acquise d’origine inflammatoire. En l’absence de traitement, l’évolution est souvent fatale du fait des complications de l’hypertension artérielle. Le traitement chirurgical s’impose quasi-constamment. Il offre de bons résultats et fait appel le plus souvent à un pontage aorto-aortique associée ou non à une revascularisation rénale.
Coarctation of the descending thoracic aorta is uncommon, with controversial etiology. Usually, severe hypertension is the main symptom; lower extremity claudication is less often found. Surgical management remains the standard for long coarctation and provides good results.
We report three cases of coarctation of the descending aorta operated at our department of cardiovascular surgery of Hospital La Rabta between January 2012 and December 2013.
The median age was 19 years and the median follow-up was 16 months. Hypertension was the most common clinical manifestation. The diagnosis was made by computed tomography angiography. Two cases were treated by an aorto-aortic bypass and one by subclavian-descending aorta bypass. Recovery was excellent, with a decrease in antihypertensive medications (four to two) and restoration of all distal pulses.
Middle aortic coarctation is a rare entity. Etiologies include congenital, acquired, inflammatory and infectious causes. The condition is considered a life-threatening emergency as a result of the complications associated with severe hypertension. Depending on technical considerations, open surgical bypass remains the standard repair for mid-aortic syndrome.
Open repair of adult aortic coarctation mostly by a resection and graft replacement technique
2015, Journal of Vascular Surgery
Citation Excerpt :
Roselli compared 60 endovascular repairs with 40 open repairs with a variety of techniques including two REE, two patch aortoplasty, 16 RIPG, and 20 extra-anatomic repairs.17 Like other authors,15-19 we report low perioperative major morbidity and no repair-related mortality. Our preferred technique of open repair in adults, especially with aneurysm, is with RIPG (93%).
We report on our experience with treatment of adults requiring de novo or redo open aortic coarctation repair mostly by a resection and interposition graft technique.
We retrospectively reviewed all patients older than 16 years requiring open repair of aortic coarctation. Indications for repair, operative details, and outcomes were analyzed.
Between 1996 and 2011, we treated 29 adult aortic coarctation patients with open repair. The mean age was 42 years (range, 17-69 years), and there were 15 men. Nine patients had previous repair with recurrence; the remaining 20 had native coarctation. Thoracic aortic aneurysms were present in 22 patients (76%), ranging in size from 3.0 to 9.6 cm (mean, 4.8 cm). Four patients had intercostal artery aneurysms (range, 1.0-2.5 cm), four had left subclavian artery aneurysms, and four had ascending/arch aneurysms. The most common repair was resection of aortic coarctation with interposition graft replacement (93%). Two patients without aneurysm had bypasses from the proximal descending thoracic aorta to the infrarenal aorta without aortic resection. There was no in-hospital mortality, stroke, or paraplegia. Long-term survival was 89% during a median follow-up of 81 months (interquartile range, 47-118 months), with no patient requiring reoperation on the repaired segment.
Open repair of native and recurrent adult aortic coarctation has acceptable morbidity and low mortality. Especially in patients with concomitant aneurysm, resection with interposition graft replacement provides a safe and durable repair option.

View all citing articles on Scopus

View full text

Original article: cardiovascularCoarctation of the aorta in adults: surgical results and long-term follow-up

Abstract

Section snippets

Material and methods

Postoperative follow-up

Natural history

Operative procedure

Acknowledgements

J Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Int J Cardiol

Am J Cardiol

Am J Cardiol

Coarctation of the aortalong-term follow-up and prediction of outcome after surgical correction

Circulation

Long-term results (15–30 years) of surgical repair of aortic coarctation

Br Heart J

Prognosis of surgically corrected coarctation of the aortaa 20-year postoperative appraisal

Circulation

Original article: cardiovascular
Coarctation of the aorta in adults: surgical results and long-term follow-up