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MODERN DAY APPROACH TO
AORTIC COARCTATION
SUSAN VOSLOO
CHRISTIAAN BARNARD MEMORIAL HOSPITAL
CAPE TOWN
HISTORY
 1760 Morgagni
 Congenital narrowing of aorta
adjacent to attachment of ductus
 Uncommon between LCA & LSA, or
in lower thoracic or abdominal aorta
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MORPHOLOGY
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COARCTATION SEGMENT
AORTIC COARCTATION
FETAL CIRCULATION
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CO-EXISTING LEFT HEART
ANOMALIES (up to 50%)
 Supravalvar mitral ring
 Mitral stenosis with or without a single
papillary muscle (parachute mitral valve)
 Endomyocardial fibrosis
 Left ventricular hypoplasia or hypertrophy
 Aortic atresia and hypoplasia of ascending
aorta
 Supra-valvar, valvar, sub-valvar aortic stenosis
or hypoplasia
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MAJOR COLLATERAL
CHANNELS
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AGES AT PRESENTATION
1ST OPERATION (92)
RECOARCTATION (8)
(2.2%)
2
19
(20.6%)
3
40
(43.5%)
31
(33.7%)
3
2
AORTIC COARCTATION
AGES AT CLINICAL
PRESENTATION
 NEONATAL PERIOD (40) first month
of life (12 pre-op vent, inotropes incl 5
isolated coarct, 7 co-existing lesions)
 INFANCY (34) from 1 month - 1 year
 CHILDHOOD (21) age 1 – 14 years
 ADOLESCENTS AND ADULTS (5)
beyond 14 years
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SPECIAL
INVESTIGATIONS
 ECHOCARDIOGRAPHY
 CARDIAC CATHETERIZATION OR
AORTOGRAPHY
 MRI
 CT
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MR AORTIC COARCTATION
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CT AORTIC COARCTATION
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PRIMARY ANGIOPLASTY
vs SURGERY
OLDER PATIENTS: Primary
angioplasty & stenting > surgery with
comparable if not superior risk &
recurrence rates
HIGH RISK INFANTS: Still better
served with surgery
AORTIC COARCTATION
Do High-Risk Infants Have a Poorer Outcome From Primary
Repair of Coarctation? Analysis of 192 Infants Over 20 yrs
(JG McGuinness,et al, Our Lady’s Childrens Hospital, Dublin, Ireland,
AnnThorac Surg 2010; 90:2023-2027)
Primary angioplasty reports ( 8 studies last 10 yrs):
 6 studies represented only low risk pts, no initial
mortality, re-intervention rate of 14-83%
 2 studies included high risk patients:
- mortality 17 & 21%
- re-intervention 73% in 10 days, 77% by 12 yrs
 Both studies reported lost femoral pulses 12-18%,
long term sequelae unknown
AORTIC COARCTATION
Do High-Risk Infants Have a Poorer Outcome From Primary
Repair of Coarctation? Analysis of 192 Infants Over 20 yrs
(JG McGuinness,et al, Our Lady’s Childrens Hospital, Dublin, Ireland,
AnnThorac Surg 2010; 90:2023-2027)
Higher vs lower risk surgical pts (pre-op PG,
ventilation, LV dysfunction, inotropic support) were:
-Smaller (3.3 vs 4.2 kg), younger (18 vs 57 days), PAB
(25 vs 15%),
- same technique, similar X-clamp times
-mortality(7 vs 3%), recurrence (11%)
-treated easily with single balloon angioplasty,mean 3.8
yrs later
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SURGICAL HISTORY
 1944 Crafoord & Nylin
 1945 Gross
 Original technique resection with
end-to-end anastomosis (REE)
 Other techniques followed
 Choice of technique mostly based on
individual preference
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SURGICAL APPROACH
LEFT THORACOTOMY
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SURGICAL TECHNIQUES
ALL OPERATIONS (n=100)
10
3
14
73
AORTIC COARCTATION
SURGICAL TECHNIQUES
FIRST OPERATION (92)
14
RECOARCTATION (8)
7
REE
SCF
71
M/s (9)
Patch
Graft
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2
3
3
M/s (2)
SIMPLE RESECTION & ENDEND ANASTOMOSIS (SEE)
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MONITORING PRE-REPAIR
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MONITORING POST-REPAIR
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EXTENDED RESECTION & ENDEND ANASTOMOSIS (Amato 1977)
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GROWTH & ARCH REINTERVENTION FACTORS
 Mortality (8/36) and arch re-intervention (5/36)
common in neonates weighing < 2.5 kgs
 SEE (2/3); EEE (3/16); SCF (7/15); patch
aortoplasty (1/2)
 Catch-up growth of transverse arch and isthmus
does occur post coarctation repair, especially in
smallest arch parameters, where EEE was favoured
 This may be increased using extended rather than
simple resection and end-to-end anastomosis
(T Karamlou et al: Hosp for Sick Children,Toronto; J Thorac
Cardiovasc Surg 2009; 137: 1163-7)
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ALTERNATIVE SURGICAL
TECHNIQUES
 Subclavian flap & reversed subclavian
flap
 Patch aortoplasty (indirect aortoplasty)
& Direct aortoplasty
 Interposition or Bypass grafts
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SUBCLAVIAN FLAP
Waldhausen & Nahrwold 1966
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REVERSED SUBCLAVIAN
FLAP
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DIRECT ISTHMOPLASTY
Vosschulte 1957
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PATCH AORTOPLASTY
Indirect Isthmoplasty
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CAUSES OF ANEURYSM
• Accelerated proximal aortic wall growth due
to compliance mismatch
• Cystic medial necrosis in aortic wall adjacent
to coarctation
• Disruption of intima or sub-intima with or
without patch aortoplasty
• Infection
AORTIC COARCTATION
ANEURYSMS POST
COARCTATION REPAIR
Predictors of aneurysm formation after surgical correction
of aortic coarctation
(Y von Kodolitsch, Hamburg, Germany, J Am Coll Cardiol,
2002; 39:617-624)
Reported 25 aneurysms (9% of coarctation repairs),8
ascending, 17 local aneurysms, with 36% mortality if left
untreated
Independent predictors for aneurysm formation:
* Higher age at repair (72% had surgery after age 13.5 yrs)
* Patch graft technique
* Higher pre-op gradient & bicuspid aortic valve favoured
ascending aneurysm formation
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INTERPOSITION GRAFTS
Schusler 1962 Brom 1965
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BYPASS GRAFTS
Weldon 1973 Edeie 1975
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MID-TERM OUTCOMES
OF RESECTION & EEE
 201 pts coarctation without/with VSD (14%)
 Neonates (53%); pre-op shock(20%)
 Sternotomy 44 pts (22%); thoracotomy 157 pts
(78%)
 Early mortality 2% (PHT&CDH, MAS, MOF, RSV)
 Re-intervention 8 pts (3 balloon angioplasty; 5 reops; 75% in 1st po yr)
(S Kaushal; Children’s Memorial Hosp, Chicago; Ann Thor Surg
2009; 88: 1932-8)
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OUTCOME - MORTALITY
 No deaths < 1 month or > 1 year
 2 early deaths (both hospitalized since birth)
1. F, ex-prem, 6 weeks, 1.8 kg, pre-op vent, Coarctation & AP
Window, po pneumonia, ECMO day 5-19, off ECMO, recurrent
pneumonia week later, died respiratory failure
2. F, ex-prem, 3 months, 2.1 kg, large hydrocephalus, massive
pericardial effusion, Klebsiella septicaemia, died day 7 po
 No late deaths, including all subsequent surgery for
intracardiac repairs post palliation
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OUTCOME – EARLY
MORBIDITY
 Transient Hypertension common
 PO Ventilation > 3 days (3 – 2 died)
 Phrenic Nerve injury(2); Both required
diaphragmatic plication
 Chylothorax (2); 1 thoracic duct ligation
 No postop bleeding, spinal cord complications
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FACTORS DETERMINING
SPINAL CORD INJURY RISK
 The location and length of
narrowing
 The presence of the collateral
circulation
 The clamping time required for the
procedure
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OUTCOME – LATE
MORBIDITY
 PPM (2) – LV dysfunction at 1 & 4 yrs
 Late Aneurysms – nil
 Hypertension – continuous anti-HT
therapy (2)
 Recoarctation ( 8 single balloon
angioplasty < 6m; 2 at 4 & 6 yrs po; 1
redo surgery REE – patch at 6m)
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CAUSES AORTIC
RECOARCTATION
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PATIENTS (n=100)
 ISOLATED COARCTATION (66) including 12
pts with stable left heart obstructive lesions,
being observed
 CO-EXISTING CARDIAC LESIONS (34)
 M 58; F 42
 PRIMARY OPERATION (92)
 RECOARCTATION (8)
AORTIC COARCTATION
CO-EXISTING CARDIAC
DEFECTS (n=46/100)
 Bicuspid Aortic Valve (8)
 Stable Shone complex (4)
(12)
 Significant LVOTO (5)
(34)
 VSD (16)
 Other (13)
DORV (4) TGA&VSD (2) UVH (5) APwindow (1) IHD (1)
AORTIC COARCTATION
COARCTATION PLUS
SIGNIFICANT LVOTO (n =5)
 AORTIC VALVOTOMY (3)
Aortic valvotomy with aortic coarctation (1),
Aortic valvotomy at 3 & 5 months post coarct (2)
 PROGRESSIVE LVOTO POST-COARCT REPAIR
Ross procedure at 5 yrs (1)
Resection Subaortic stenosis at 4 yrs,then RossKonno at 10 yrs (1)
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COARCTATION PLUS VSD
(n = 16)
 RECOARCTATION (4)
Primary VSD & coarctation (2)
PAB & coarctation; later VSD closure (2)
 PRIMARY VSD & COARCTATION (3)
 PAB & COARCTATION (9)
CBMH; later VSD closure @ 4-22m age (5)
RXH; all awaiting definitive procedures (4)
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COARCTATION WITH OTHER
CARDIAC DEFECTS (n=13)
 Primary repair with coarctation (5)
-
APW (1),
IHD (LIMA – LAD) (1);
TGA & VSD primary ASO & VSD (1),
DORV (2)
 Palliation PAB (8)
-
TGA & VSD at 11m (1),
DORV at 11 & 15 m(2)
UVH: Glenn (3/5), TCPC (1/3) - Awaiting repairs(2)
AORTIC COARCTATION
THANK YOU!