Repair of coarctation of the aorta during infancy minimizes the risk of late hypertension

doi:10.1016/S0003-4975(98)00595-5

The Annals of Thoracic Surgery

Volume 66, Issue 4, October 1998, Pages 1378-1382

https://doi.org/10.1016/S0003-4975(98)00595-5 Get rights and content

Abstract

Background. Recent surgical reports on coarctation of the aorta have primarily focused on the relative merits of various operative techniques. However, appropriate timing for elective repair remains unclear.

Methods. In a retrospective analysis we examined the surgical outcomes in 176 consecutive patients undergoing repair of coarctation of the aorta in our institution over a 25-year period. Ninety-nine percent of the patients had follow-up for a median of 7.5 years.

Results. A total of 13 patients have died (7.4% overall mortality). Nine of these patients had associated complex intracardiac anomalies. There was no mortality in the 113 patients with isolated coarctation. Residual or recurrent coarctation occurred in 27 patients (15.3%). The age at operation and the type of surgical repair did not have an effect on the incidence of recurrence. Persistent or late hypertension was identified in 18 of the 107 patients who have been followed up for more than 5 years (16.8%). A total of 48 patients operated on during infancy have been followed up for more than 5 years. Only 2 have developed late hypertension (4.2%). Both of these patients had recurrence. In contrast, 16 of the 59 patients operated on after a year of age had late hypertension (27.1%).

Conclusions. To minimize the risk of persistent hypertension, elective repair of coarctation should be performed within the first year of life.

Section snippets

Material and methods

The records of the 176 consecutive patients undergoing a surgical procedure for coarctation of the aorta between 1969 and 1995 were reviewed. This retrospective study reviewed operative notes, follow-up clinic visits, and postoperative echocardiographic and cardiac catheterization data. Ninety-nine percent of the patients have been followed up for a mean of 7.5 years (range, 6 months to 24 years).

The median age at operation was 11 months (range, 1 day to 33 years). The patients were grouped

Mortality

Six patients died within 30 days of the operation, for an operative mortality of 3.4%. An additional 7 patients died between 3 months and 6 years after the operation, for an overall mortality of 7.4%. Survival was in part determined by associated cardiac anomalies. There were no deaths in the 113 patients with isolated coarctation (class 1). Two of the 27 class 2 patients (7.4%) died. Eleven of the 36 class 3 patients (30.6%) died. Univariate analysis showed that determinants of mortality

Surgical techniques

The evolving operative approaches used to repair coarctation of the aorta in our institution during the past 25 years have reflected our attempts to establish the optimal surgical procedure. We could not demonstrate an advantage for any of the surgical approaches in minimizing mortality, recurrence, or late hypertension. These findings are similar to those reported by other investigators 12, 13, 14, 16, 25. In the absence of a large, randomized study, superiority of one technique over another

Summary

In summary, the findings in this study indicate that the optimal age for elective surgical relief of coarctation of the aorta is during the first year of life. Although the incidence of recurrence was relatively low and unrelated to the surgical approach, identification and proper treatment of recoarctation at an early age are imperative to minimize the development of late hypertension.

References (33)

I.L Kron et al.
Incidence and risk of reintervention after coarctation repair
Ann Thorac Surg
(1990)
A.P Kappetein et al.
More than thirty-five years of coarctation repairan unexpected high relapse rate
J Thorac Cardiovasc Surg
(1994)
L.W.E Van Heurn et al.
Surgical treatment of aortic coarctation in infants younger than three months: 1985 to 1990Success of extended end-to-end arch aortoplasty
J Thorac Cardiovasc Surg
(1994)
R.R Liberthson et al.
Coarctation of the aortareview of 234 patients and clarification of management problems
Am J Cardiol
(1979)
P.M Clarkson et al.
Results after repair of coarctation of the aorta beyond infancya 10 to 28 year follow-up with particular reference to late systemic hypertension
Am J Cardiol
(1983)
L Bergdahl et al.
Surgical correction of coarctation of the aortainfluence of age on late results
J Thorac Cardiovasc Surg
(1983)
F Lacour-Gayet et al.
Hypoplastic transverse arch and coarctation in neonatesSurgical reconstruction of the aortic arch: a study of sixty-six patients
J Thorac Cardiovasc Surg
(1990)
J.J Amato et al.
Role of extended aortoplasty related to the definition of coarctation of the aorta
Ann Thorac Surg
(1991)
J.M Quaegebeur et al.
Outcomes in seriously ill neonates with coarctation of the aortaa multiinstitutional study
J Thorac Cardiovasc Surg
(1994)
S Conte et al.
Surgical management of neonatal coarctation
J Thorac Cardiovasc Surg
(1995)

H.A Rajasinghe et al.

Coarctation repair using end-to-side anastomosis of descending aorta to proximal aortic arch

Ann Thorac Surg

(1996)

J.P Pfammatter et al.

Isolated aortic coarctation in neonates and infantsresults of resection and end-to-end anastomosis

Ann Thorac Surg

(1996)

J.J Amato et al.

A method of enlarging the distal transverse arch in infants with hypoplasia and coarctation of the aorta

Ann Thorac Surg

(1977)

J.A Waldhausen et al.

Repair of coarctation of the aorta with a subclavian flap

J Thorac Cardiovasc Surg

(1966)

D.B Campbell et al.

Should elective repair of coarctation of the aorta be done in infancy?

J Thorac Cardiovasc Surg

(1984)

F Trinquet et al.

Coarctation of the aorta in infantswhich operation?

Ann Thorac Surg

(1988)

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Coarctation of the aorta: Prenatal assessment, postnatal management and neonatal outcomes
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At many large scale surgical centers, these criteria are ascribed to the neonatal setting. Data on the importance of intervention in infancy or early childhood to prevent long-term systemic hypertension and the low mortality rate in neonatal period support this approach.46,47 However, in pre-term or particularly young infants, the risk of intervention is higher and must be balanced with the severity of coarctation.48
Coarctation of the aorta (Coa) is a potentially life threatening diagnosis. It occurs in 0.3 per 1000 live births and accounts for 6-8% of all infants with congenital heart defects. Neonates with severe Coa may be completely asymptomatic at birth, as the ductus arteriosus can provide flow to the lower body. Those who are not diagnosed prenatally may be diagnosed only after constriction of the ductus arteriosus, when they present in cardiogenic shock. This group has a higher risk for mortality and morbidity relative to those diagnosed prenatally. Despite the increasing practice of universal pulse oximetry screening, many cases with significant coarctation of the aorta still go undiagnosed in the newborn period. In this article, we present the pathophysiology, diagnosis, presentation, treatment and outcomes of Coa.
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Congenital abnormalities of the aorta can occur in isolation (coarctation of the aorta, interrupted aortic arch) or as part of more complex morphological associations (hypoplastic left heart). It is also increasingly recognized that patients with congenital heart disease (CHD) predominately affecting the right heart, such as tetralogy of Fallot, experience progressive aortic root dilatation throughout life. Histological data indicate the presence of significant aortic wall abnormalities in patients with diverse forms of CHD. Moreover, surgical interventions to repair congenitally abnormal aortas have the unintended consequence of changing regional material properties by scar formation and use of patch material. These repaired aortas differ from normal in terms of geometric shape and material properties, which results in abnormal arterial stiffness and pulsatile hemodynamics. Despite excellent short- and medium-term outcomes, there is an excess of late cardiovascular morbidity and mortality in these patients. Increased aortic stiffness and vascular impedance has emerged as an important possible mechanism underlying these poor long-term cardiovascular outcomes.
Maternal Congenital Heart Disease in Pregnancy
2018, Obstetrics and Gynecology Clinics of North America
Citation Excerpt :
Aortic coarctation is found in approximately 4% to 6% of congenital cardiac anomalies and can be associated with aortic dilatation, bicuspid aortic valve, and aortic stenosis.30 Typically, coarctation repair is recommended early in life or at the time of diagnosis in order to prevent systemic hypertension31; thus, most pregnant women will have a repaired coarctation. Signs of significant aortic coarctation include hypertension isolated to the upper body or decreased femoral pulses.30
Outcomes of thoracic endovascular aortic repair in adult coarctation patients
2018, Journal of Vascular Surgery
Aortic 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.
All 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.
A 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.
Adult 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.
Coarctation of the aorta
2018, Critical Heart Disease in Infants and Children
Coarctation of the aorta is a common form of congenital heart disease. Presentation, evaluation, and treatment of coarctation of the aorta is different in neonates and infants compared with older children. Neonates may present in shock and require prostaglandin E₁ to maintain ductal patentcy until the time of surgical repair. Older children usually present with upper extremity hypertension or murmur. The approach to surgical repair of coarctation in neonates and infants depends on the presence or absence of concomitant defects and the degree of associated arch hypoplasia. For older children, robust collaterals and limited mobility of the aorta may mandate patch repair, interposition graft, or bypass of the coarctation segment. Percutaneous techniques, including angioplasty and stent placement, are often viable options for older children and adolescents with native or recurrent coarctation. Surgical and interventional outcomes have improved over time. Reliable repair may be anticipated with a very low rate of morbidity and mortality, although lifetime follow-up is recommended.
Severe and resistant hypertension in an older woman with claudication
2017, Journal of the American Society of Hypertension
Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.

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Original ArticlesRepair of coarctation of the aorta during infancy minimizes the risk of late hypertension

Abstract

Section snippets

Material and methods

Mortality

Surgical techniques

Summary

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Original Articles
Repair of coarctation of the aorta during infancy minimizes the risk of late hypertension