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A patient with recurrent coarctation of the aorta was treated by a bypass between ascending and descending aorta performed through a right-sided thoracotomy. The procedure resulted in a normalization of the previously elevated blood pressure. The efficacy and simplicity of the method and the low risk of the access through the right pleural cavity are emphasized.
Coarctation of abdominal aorta constitutes a rare group of vascular abnormalities, including segmental stenoses and extended hypoplasia below the restriction. Usually hypertension is the only clinical evidence. The natural history of the surgically untreated disease foresees a decline of life expectancy; while surgical operation permit an almost complete "restitutio ad integrum". The Authors report a case of coarctation of the abdominal aorta come to their observation whose particularly was determined by the absence of high blood pressure, the aortic stenoses being located under the renal arteries.
A patient, diagnosed with coarctation of the aorta at the age of 59, was found to have a pulmonary mass in his right upper lobe. A chest scan and digital intravenous arteriography revealed a right artery subclavian aneurysm. Such an unusual association is described.
In a patient with coarctation of the aorta, blood pressure and heart rate were measured during graded exercise on a bicycle ergometer. After no treatment, and after oral hydrallazine, exercise produced large rises in systolic and diastolic blood pressures, and in heart rate. During exercise after oral propranolol, systolic and diastolic pressures did not increase, and there was a less marked tachycardia. These results suggest that propranolol should be used to minimize the dangers of elevated blood pressure associated with exercise in patients with coarctation.
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Families of 100 patients with coarctation of the aorta and 50 controls for age, sex, and social status were studied to assess the influence of genetic and environmental variables in the aetiology. A tendency to familial aggregation of the condition and other congenital heart defects compatible with multifactorial inheritance was discerned. Recurrence risk for sibs is approximately 1 in 200 for coarctation of the aorta, and 1% for any form of congenital heart defect. The heritability of coarctation is estimated at 58%. The tendency for other non-cardiac defects to occur in the patients with coarctation does not appear in their sibs and is not so pronounced as in some other congenital heart conditions. Of the several environmental variables examined, there was no definitive association with any other than season of birth, which implies a possible association with maternal infection; there is also a suggestion of a paternal age effect, but these require investigation in a prospective survey.
BACKGROUND: The use of balloon coarctation angioplasty instead of surgery as treatment for unoperated coarctation of the aorta is controversial. The efficacy and complications of the two procedures have not been studied before in a prospective fashion. METHODS AND RESULTS: Thirty-six patients were prospectively randomized to either angioplasty (20 patients) or surgery (16 patients). Immediate results and patient follow-up, including physical examination, angiograms, and magnetic resonance imaging, were compared between groups. Reduction in peak systolic pressure gradient across the coarctation was similar (86%) immediately after both balloon coarctation angioplasty and surgery. On follow-up, aneurysms were seen only in the angioplasty group (20%) and not in the surgery group (0%). No aneurysms have shown progression or required surgery. The incidence of other complications was similar in both groups, although two patients experienced neurological complications after surgery. Although not statistically different, the incidence of restenosis (peak systolic pressure gradient > or = 20 mm Hg) tended to be greater in the angioplasty group (25%) than in the surgery group (6%). Restenosis after angioplasty occurred more frequently in patients with an aortic isthmus/descending aorta diameter ratio < 0.65 and was associated with an immediate catheterization residual peak systolic pressure gradient across the coarctation > or = 12 mm Hg. CONCLUSIONS: Immediate gradient reduction is similar after balloon coarctation angioplasty and surgical treatment of unoperated coarctation of the aorta. The risks of aneurysm formation and possibly restenosis after angioplasty are higher than after surgery, although the risks of other complications are similar. Balloon coarctation angioplasty may provide an effective initial alternative to surgical repair of unoperated coarctation of the aorta in children beyond infancy, particularly in patients with a well-developed isthmus. Further follow-up is necessary to determine the long-term risks of postangioplasty aneurysms.
Six infants with coarctation of the aorta underwent percutaneous balloon angioplasty over a 6-month period ending July 1985. These infants had associated cardiac defects including aortic stenosis, ventricular septal defect, and patent ductus arteriosus. Catheters used carried 5 to 10 mm balloons; 4 to 8 atm pressure was applied for 10 to 15 seconds, and the procedure was repeated at least three times. No significant complications were encountered during the procedure. The mean systolic pressure gradient across the coarctation decreased from 44.2 +/- 4.7 mm Hg to 11.7 +/- 9.4 mm Hg (P less than 0.001) after angioplasty, and the diameter of the coarcted segment increased from 2.9 +/- 0.7 mm to 6.3 +/- 1.2 (P less than 0.001). Long-term follow-up indicated excellent results in four patients; the other two infants required additional treatment (repeat angioplasty and surgical resection, respectively). No aneurysm was seen in any infant. Based on this experience and the reported high mortality and high recurrence rate after surgical repair in neonates and young infants, we recommend balloon angioplasty as the therapeutic procedure of choice for relief of severe, previously unoperated coarctation of the aorta in neonates and young infants.
A healthy 18 months old boy, is referred to our hospital for a thrilling pulsatile mass behind the left ear. Aortography in the ascending aorta shows a severe coarctation with almost interruption of the aorta between the left carotid and left subclavian artery. Both external carotid arteries provide an important collateral pathway through occipital arteries to two dilated vertebral arteries. Descending aorta is feeding by a reverse blood flow into vertebral and subclavian arteries. The child has been operated. This is an original presentation of severe coarctation of the aorta with development of an important and vital collateral pathway.
Repair of coarctation of the aorta may not prevent the subsequent development of elevated systemic blood pressure at rest or with exercise. The correlates of late postoperative resting systolic blood pressure and maximal exercise systolic blood pressure levels were investigated in a retrospective study of 42 patients who had graded exercise tests after correction of coarctation of the aorta. The independent variables studied included height, weight, body surface area, age at surgery, age at exercise testing, the time interval between surgery and exercise testing, the highest systolic blood pressure prior to surgery, gradient across the coarctation at preoperative catheterization, and the residual postoperative gradient across the coarctation. The same combination of independent variables provided the best regression model for explanation of the variance of both postoperative resting and maximal exercise systolic blood pressure. The models included height, highest preoperative systolic blood pressure, and residual gradient. None of the other variables added significant explanatory ability to either model. These findings suggest that the preoperative level of systolic blood pressure may be the best determinant of timing the corrective surgery. It may be possible to defer the operation, as long as blood pressure remains normal, until an age when repair is less likely to result in recurrent coarctation.
Coarctation of the aorta is a constriction of the aorta located near the ligamentum arteriosum and the origins of the left subclavian artery. This condition may be associated with other congenital disease. The mean age of death for persons with this condition is 34 years if untreated, and is usually due to heart failure, aortic dissection or rupture, endocarditis, endarteritis, cerebral hemorrhage, ischemic heart disease, or concomitant aortic valve disease in uncomplicated cases. Symptoms may not be present in adults. Diminished and delayed pulses in the right femoral artery compared with the right radial or brachial artery are an important clue to the presence of a coarctation of the aorta, as are the presence of a systolic murmur over the anterior chest,bruits over the back, and visible notching of the posterior ribs on a chest x-ray. In many cases a diagnosis can be made with these findings. Two-dimensional echocardiography with Doppler interrogation is used to confirm the diagnosis. Surgical repair and percutaneous intervention are used to repair the coarctation; however, hypertension may not abate. Because late complications including recoarctation, hypertension, aortic aneurysm formation and rupture, sudden death, ischemic heart disease, heart failure, and cerebrovascular accidents may occur, careful follow-up is required.
Localised coarctation of the aorta was studied histologically in 45 cases. The age range of the patients, from 2 weeks to 40 years, enabled us to make a comparison between early and late findings. The basic histological architecture of all coarctations was identical. The ridge consisted mainly of thickening plus some infolding of the aortic wall. Ductal tissue formed the inner part of the ridge for more than half of its total circumference. In older cases masses of secondary intimal proliferation were present, which narrowed the residual lumen of the coarctation. The coarctation was located preductally in most young patients and postductally in the majority of older patients. It is concluded that ductal tissue is invariably present in the ridge and that all coarctations develop in a preductal position. Secondary changes include a gradual shift of the ridge from a preductal to a postductal position, and progressive narrowing of the residual lumen by intimal proliferation.
After repair of coarctation, exercise testing was performed in 20 patients with an isolated coarctation (group I) and in 26 with additional congenital cardiac malformations (group II). Ages at time of operation were significantly different in both groups (7.9 +/- 6.0 years in group I; 4.6 +/- 3.8 years in group II; p less than or equal to 0.01). Simultaneous blood pressures were obtained from upper and lower limbs at rest and after exercise. There was no significant difference regarding the systolic blood pressures at rest (122.5 +/- 15.6 mmHg in group I versus 119 +/- 15.8 mmHg in group II). Seven (14%) of the patients were hypertensive; five of them had blood pressure gradients between arms and legs of 15-45 mmHg. But the gradients at rest were found to be significantly different in both groups (9.0 +/- 10.5 mmHg in group I; 18.5 +/- 16.1 mmHg in group II; p less than or equal to 0.05). Six patients, all in group II, had gradients greater than or equal to 30 mmHg at rest. After exercise there were no significant differences in systolic blood pressure and gradients in both groups. Values for blood pressures and gradients at rest and after exercise showed a positive correlation (blood pressure r = 0.76, p less than or equal to 0.001; gradient r = 0.44, p less than or equal to 0.01). Thus exercise testing can provide valuable information about blood pressure and gradient changes during physical activity, but angiography is required to reveal restenosis or residual stenosis.
Balloon angioplasty of native coarctation of the aorta was performed in 35 consecutive adolescents and young adults, aged 14 to 37 years (mean 22.6 +/- 7.1). Twenty-eight (80%) patients had isolated discrete coarctation, six (17.1%) had tubular hypoplasia of the aortic isthmus, and one (2.9%) had hypoplasia of the post-coarctation aorta. The peak systolic pressure gradient decreased from 78.5 +/- 23.9 to 15.7 +/- 11.6 mm Hg (p less than 0.001), and the mean coarctation diameter increased from 4.7 +/- 2.4 to 13.1 +/- 2.7 mm (p less than 0.001) immediately after angioplasty. Patients with discrete-type coarctation had significantly less residual gradient than patients with long-segment tubular coarctation (12.3 +/- 10.7 vs 27.2 +/- 6.6 mm Hg, p less than 0.01). On recatheterization and angiography in 26 patients at 12.6 +/- 1.5 months after dilatation, there was no significant change in gradient (15.5 +/- 13.3 mm Hg) and diameter (13.1 +/- 1.8 mm) from the immediate post-angioplasty results. However, two patients had an increase in gradient and three had small aortic aneurysms with no change in appearance on restudy after 2 years. After 3 to 67 months' (mean 32.7 +/- 19.2) follow-up, all patients showed continued clinical improvement. Hypertension was relieved in 37.5% (12/32) and improved in 59.4% (19/32). Our experience suggests that balloon angioplasty of native aortic coarctation in adolescents and young adults is safe and highly effective with sustained improvement on intermediate-term follow-up.
Coarctation of the aorta can be evaluated reliably and noninvasively by magnetic resonance imaging. However, the value of different imaging planes in the evaluation of restenosis or aneurysm has not previously been studied. Our purpose was to study the relative sensitivity for oblique coronal and oblique parasagittal magnetic resonance imaging to detect restenosis or aneurysm formation in children following surgical repair or balloon angioplasty of coarctation of the aorta. The study included magnetic resonance imaging studies in 27 children. Each exam included ECG gated, spin-echo imaging in oblique coronal and oblique parasagittal planes. Recoarctation was defined as a greater than 50% narrowing of the aorta. Aneurysms were defined as focal dilatation of the aorta in the region of coarctation 20% or greater than the adjacent aortic diameter. Recoarctation was detected in 11 children, but in both views in only five children. Aneurysms were detected in 15 children, but in both views in only three children. Recoarctation and aneurysm detection were both statistically more likely to be detected if oblique coronal and oblique parasagittal views were obtained, indicating that multiple imaging planes are necessary to completely evaluate magnetic resonance imaging of coarctation.
Patent ductus arteriosus and coarctation of the aorta are among the commonest causes of congestive heart failure early in life. When medical therapy fails to control heart failure in these cases, surgical division of the ductus or excision of the coarcted segment can be performed. But the recognition of these anomalies in infancy is more difficult than in childhood or adult life. Retrograde thoracic aortography is a technique which permits positive identification. In the presence of patent ductus arteriosus, opacification of the pulmonary arteries from the descending aorta will be clearly shown; if coarctation is present, its position, severity, and the length of the involved segment can usually be demonstrated. Properly employed, retrograde brachial aortography is a relatively safe and effective diagnostic procedure.
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