Download - MODERN DAY APPROACH TO AORTIC COARCTATION
MODERN DAY APPROACH MODERN DAY APPROACH TO AORTIC COARCTATIONTO AORTIC COARCTATION
SUSAN VOSLOO CHRISTIAAN BARNARD MEMORIAL HOSPITAL
CAPE TOWN
HISTORYHISTORY
1760 Morgagni 1760 Morgagni Congenital narrowing of aorta Congenital narrowing of aorta
adjacent to attachment of ductusadjacent to attachment of ductus
Uncommon between LCA & LSA, Uncommon between LCA & LSA, or in lower thoracic or abdominal or in lower thoracic or abdominal aortaaorta
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MORPHOLOGYMORPHOLOGY
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COARCTATION COARCTATION SEGMENTSEGMENT
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FETAL CIRCULATIONFETAL CIRCULATION
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CO-EXISTING LEFT HEART CO-EXISTING LEFT HEART ANOMALIES (up to 50%)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 MAJOR COLLATERAL CHANNELSCHANNELS
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AGES AT PRESENTATIONAGES AT PRESENTATION
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1ST OPERATION (92) RECOARCTATION (8)
3
2
3 40(43.5%)
31(33.7%)
19(20.6%)
2(2.2%)
AGES AT CLINICAL AGES AT CLINICAL PRESENTATIONPRESENTATION
NEONATAL PERIOD NEONATAL PERIOD (40) (40) first month of first month of life (12 pre-op vent, inotropes incl 5 life (12 pre-op vent, inotropes incl 5 isolated coarct, 7 co-existing lesions) isolated coarct, 7 co-existing lesions)
INFANCY INFANCY (34) (34) from 1 month - 1 yearfrom 1 month - 1 yearCHILDHOOD CHILDHOOD (21) (21) age 1 – 14 yearsage 1 – 14 yearsADOLESCENTS AND ADULTS ADOLESCENTS AND ADULTS (5)(5)
beyond 14 years beyond 14 years
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SPECIAL SPECIAL INVESTIGATIONSINVESTIGATIONS
ECHOCARDIOGRAPHYECHOCARDIOGRAPHY
CARDIAC CATHETERIZATION OR CARDIAC CATHETERIZATION OR AORTOGRAPHYAORTOGRAPHY
MRIMRICTCT
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MR AORTIC COARCTATIONMR AORTIC COARCTATION
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CT AORTIC COARCTATIONCT AORTIC COARCTATION
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PRIMARY ANGIOPLASTY PRIMARY ANGIOPLASTY vs SURGERY vs SURGERY
OLDER PATIENTS:OLDER PATIENTS: Primary Primary angioplasty & stenting > surgery angioplasty & stenting > surgery with comparable if not superior risk with comparable if not superior risk & recurrence rates& recurrence rates
HIGH RISK INFANTS: HIGH RISK INFANTS: Still better Still better served with surgeryserved with surgery
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Do High-Risk Infants Have a Poorer Outcome From Do High-Risk Infants Have a Poorer Outcome From Primary Repair of Coarctation? Primary Repair of Coarctation? Analysis of 192 Infants Analysis of 192 Infants
Over 20 yrs Over 20 yrs (JG McGuinness,et al, Our Lady’s Childrens Hospital, Dublin, (JG McGuinness,et al, Our Lady’s Childrens Hospital, Dublin,
Ireland, AnnThorac Surg 2010; 90:2023-2027)Ireland, AnnThorac Surg 2010; 90:2023-2027)
Primary angioplasty reports Primary angioplasty reports ( 8 studies last 10 yrs):( 8 studies last 10 yrs):6 studies represented only low risk pts, no initial 6 studies represented only low risk pts, no initial mortality, re-intervention rate of 14-83%mortality, re-intervention rate of 14-83%2 studies included high risk patients:2 studies included high risk patients:- mortality 17 & 21%mortality 17 & 21%- re-intervention 73% in 10 days, 77% by 12 yrsre-intervention 73% in 10 days, 77% by 12 yrs Both studies reported lost femoral pulses 12-18%, Both studies reported lost femoral pulses 12-18%, long term sequelae unknown long term sequelae unknown
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Do High-Risk Infants Have a Poorer Outcome From Do High-Risk Infants Have a Poorer Outcome From Primary Repair of Coarctation? Analysis of 192 Infants Primary Repair of Coarctation? Analysis of 192 Infants
Over 20 yrs Over 20 yrs (JG McGuinness,et al, Our Lady’s Childrens Hospital, Dublin, Ireland, (JG McGuinness,et al, Our Lady’s Childrens Hospital, Dublin, Ireland,
AnnThorac Surg 2010; 90:2023-2027)AnnThorac Surg 2010; 90:2023-2027)
Higher vs lower risk surgical pts Higher vs lower risk surgical pts (pre-op PG, (pre-op PG, ventilation, LV dysfunction, inotropic support) were: ventilation, LV dysfunction, inotropic support) were: -Smaller (3.3 vs 4.2 kg), younger (18 vs 57 days), Smaller (3.3 vs 4.2 kg), younger (18 vs 57 days), PAB (25 vs 15%),PAB (25 vs 15%),- same technique, similar X-clamp times same technique, similar X-clamp times -mortality(7 vs 3%), recurrence (11%) mortality(7 vs 3%), recurrence (11%) -treated easily with single balloon angioplasty,mean treated easily with single balloon angioplasty,mean 3.8 yrs later3.8 yrs later
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SURGICAL HISTORYSURGICAL HISTORY
1944 Crafoord & Nylin1944 Crafoord & Nylin1945 Gross1945 GrossOriginal technique resection with Original technique resection with
end-to-end anastomosis (REE)end-to-end anastomosis (REE)Other techniques followedOther techniques followedChoice of technique mostly based Choice of technique mostly based
on individual preferenceon individual preference
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SURGICAL APPROACHSURGICAL APPROACH
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LEFT THORACOTOMY
SURGICAL TECHNIQUESSURGICAL TECHNIQUES
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ALL OPERATIONS (n=100)
73
14
103
SURGICAL TECHNIQUESSURGICAL TECHNIQUES
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FIRST OPERATION (92) RECOARCTATION (8)
23
3
14
71
7
M/s (9) M/s (2)
SIMPLE RESECTION & END-SIMPLE RESECTION & END-END ANASTOMOSIS (SEE)END ANASTOMOSIS (SEE)
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MONITORING PRE-REPAIRMONITORING PRE-REPAIR
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MONITORING POST-REPAIRMONITORING POST-REPAIR
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EXTENDED RESECTION & END-EXTENDED RESECTION & END-END ANASTOMOSIS (Amato END ANASTOMOSIS (Amato
1977) 1977)
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GROWTH & ARCH RE-GROWTH & ARCH RE-INTERVENTION INTERVENTION
FACTORSFACTORS
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Mortality (8/36) and arch re-intervention (5/36) Mortality (8/36) and arch re-intervention (5/36) common in neonates weighing < 2.5 kgscommon in neonates weighing < 2.5 kgs
SEE (2/3); EEE (3/16); SCF (7/15); patch aortoplasty SEE (2/3); EEE (3/16); SCF (7/15); patch aortoplasty (1/2)(1/2)
Catch-up growth of transverse arch and isthmus Catch-up growth of transverse arch and isthmus does occur post coarctation repair, especially in does occur post coarctation repair, especially in smallest arch parameters, where EEE was favouredsmallest arch parameters, where EEE was favoured
This may be increased using extended rather than This may be increased using extended rather than simple resection and end-to-end anastomosissimple resection and end-to-end anastomosis
(T Karamlou et al: Hosp for Sick Children,Toronto; J Thorac (T Karamlou et al: Hosp for Sick Children,Toronto; J Thorac Cardiovasc Surg 2009; 137: 1163-7)Cardiovasc Surg 2009; 137: 1163-7)
ALTERNATIVE ALTERNATIVE SURGICAL TECHNIQUESSURGICAL TECHNIQUES
Subclavian flap & reversed Subclavian flap & reversed subclavian flapsubclavian flap
Patch aortoplasty (indirect Patch aortoplasty (indirect aortoplasty) & Direct aortoplastyaortoplasty) & Direct aortoplasty
Interposition or Bypass graftsInterposition or Bypass grafts
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SUBCLAVIAN FLAPSUBCLAVIAN FLAPWaldhausen & Nahrwold 1966Waldhausen & Nahrwold 1966
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REVERSED SUBCLAVIAN REVERSED SUBCLAVIAN FLAP FLAP
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DIRECT ISTHMOPLASTYDIRECT ISTHMOPLASTYVosschulte 1957Vosschulte 1957
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PATCH AORTOPLASTYPATCH AORTOPLASTYIndirect IsthmoplastyIndirect Isthmoplasty
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CAUSES OF ANEURYSMCAUSES OF ANEURYSM
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• 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
ANEURYSMS POST ANEURYSMS POST COARCTATION REPAIRCOARCTATION REPAIR
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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
INTERPOSITION INTERPOSITION GRAFTS GRAFTS Schusler 1962 Brom Schusler 1962 Brom
19651965
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BYPASS GRAFTSBYPASS GRAFTSWeldon 1973 Edeie 1975Weldon 1973 Edeie 1975
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MID-TERM OUTCOMES MID-TERM OUTCOMES OF RESECTION & EEEOF RESECTION & EEE
201 pts coarctation without/with VSD (14%)201 pts coarctation without/with VSD (14%) Neonates (53%); pre-op shock(20%)Neonates (53%); pre-op shock(20%) Sternotomy 44 pts (22%); thoracotomy 157 Sternotomy 44 pts (22%); thoracotomy 157
pts (78%)pts (78%) Early mortality 2% (PHT&CDH, MAS, MOF, Early mortality 2% (PHT&CDH, MAS, MOF,
RSV)RSV) Re-intervention 8 pts (3 balloon angioplasty; 5 Re-intervention 8 pts (3 balloon angioplasty; 5
re-ops; 75% in 1re-ops; 75% in 1stst po yr) po yr)(S Kaushal; Children’s Memorial Hosp, Chicago; Ann Thor (S Kaushal; Children’s Memorial Hosp, Chicago; Ann Thor
Surg 2009; 88: 1932-8)Surg 2009; 88: 1932-8)AORTIC COARCTATION
OUTCOME - MORTALITYOUTCOME - MORTALITY
No deaths < 1 month or > 1 yearNo deaths < 1 month or > 1 year 2 early deaths (both hospitalized since birth)2 early deaths (both hospitalized since birth)1. F, ex-prem, 6 weeks, 1.8 kg, pre-op vent, Coarctation & AP 1. F, ex-prem, 6 weeks, 1.8 kg, pre-op vent, Coarctation & AP
Window, po pneumonia, ECMO day 5-19, off ECMO, Window, po pneumonia, ECMO day 5-19, off ECMO, recurrent pneumonia week later, died respiratory failurerecurrent pneumonia week later, died respiratory failure
2. F, ex-prem, 3 months, 2.1 kg, large hydrocephalus, 2. F, ex-prem, 3 months, 2.1 kg, large hydrocephalus, massive pericardial effusion, Klebsiella septicaemia, died massive pericardial effusion, Klebsiella septicaemia, died day 7 poday 7 po
No late deaths, No late deaths, including all subsequent surgery for including all subsequent surgery for intracardiac repairs post palliationintracardiac repairs post palliation
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OUTCOME – EARLY OUTCOME – EARLY MORBIDITYMORBIDITY
Transient Hypertension commonTransient Hypertension commonPO Ventilation > 3 days (3 – PO Ventilation > 3 days (3 – 2 died2 died) ) Phrenic Nerve injury(2)Phrenic Nerve injury(2); Both required ; Both required
diaphragmatic plicationdiaphragmatic plicationChylothorax (2); Chylothorax (2); 1 thoracic duct ligation1 thoracic duct ligationNo postop bleeding, spinal cord No postop bleeding, spinal cord
complicationscomplications
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FACTORS DETERMINING FACTORS DETERMINING SPINAL CORD INJURY RISKSPINAL 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 OUTCOME – LATE MORBIDITYMORBIDITY
PPM (2) – LV dysfunction at 1 & 4 yrs PPM (2) – LV dysfunction at 1 & 4 yrs Late Aneurysms Late Aneurysms – nil – nil Hypertension – Hypertension – continuous anti-HT continuous anti-HT
therapy (2)therapy (2)
RecoarctationRecoarctation ( 8 single balloon ( 8 single balloon angioplasty < 6m; 2 at 4 & 6 yrs po; angioplasty < 6m; 2 at 4 & 6 yrs po; 1 redo surgery REE – patch at 6m)1 redo surgery REE – patch at 6m)
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CAUSES AORTIC CAUSES AORTIC RECOARCTATIONRECOARCTATION
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PATIENTS (n=100)PATIENTS (n=100)
ISOLATED COARCTATION ISOLATED COARCTATION (66) including (66) including 12 pts with stable left heart obstructive 12 pts with stable left heart obstructive lesions, being observedlesions, being observed
CO-EXISTING CARDIAC LESIONSCO-EXISTING CARDIAC LESIONS (34) (34)
M 58; F 42M 58; F 42
PRIMARY OPERATION (92)PRIMARY OPERATION (92)RECOARCTATION (8)RECOARCTATION (8)
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CO-EXISTING CARDIAC CO-EXISTING CARDIAC DEFECTS (n=46/100)DEFECTS (n=46/100)
Bicuspid Aortic Valve (8)Bicuspid Aortic Valve (8)Stable Shone complex (4) Stable Shone complex (4) (12)(12)
Significant LVOTO (5) Significant LVOTO (5) (34)(34)VSD (16)VSD (16)Other (13)Other (13)
DORV (4) TGA&VSD (2) UVH (5) AP-DORV (4) TGA&VSD (2) UVH (5) AP-window (1) IHD (1) window (1) IHD (1)
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COARCTATION PLUS COARCTATION PLUS SIGNIFICANT LVOTOSIGNIFICANT LVOTO (n =5) (n =5)
AORTIC VALVOTOMY (3) AORTIC VALVOTOMY (3)
Aortic valvotomy with aortic coarctation (1), Aortic valvotomy with aortic coarctation (1), Aortic valvotomy at 3 & 5 months post coarct Aortic valvotomy at 3 & 5 months post coarct (2)(2)
PROGRESSIVE LVOTO POST-COARCT REPAIR PROGRESSIVE LVOTO POST-COARCT REPAIR
Ross procedure at 5 yrs (1) Ross procedure at 5 yrs (1)
Resection Subaortic stenosis at 4 yrs,then Ross-Resection Subaortic stenosis at 4 yrs,then Ross-Konno at 10 yrs (1)Konno at 10 yrs (1)
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COARCTATION PLUS COARCTATION PLUS VSDVSD
(n = 16)(n = 16) RECOARCTATIONRECOARCTATION (4) (4)
Primary VSD & coarctation (2)Primary VSD & coarctation (2)
PAB & coarctation; later VSD closure (2)PAB & coarctation; later VSD closure (2) PRIMARY VSD & COARCTATION PRIMARY VSD & COARCTATION (3)(3) PAB & COARCTATION PAB & COARCTATION (9)(9)
CBMH; later VSD closure @ 4-22m age (5)CBMH; later VSD closure @ 4-22m age (5)
RXH; all awaiting definitive procedures (4)RXH; all awaiting definitive procedures (4)
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COARCTATION WITH OTHER COARCTATION WITH OTHER CARDIAC DEFECTS (n=13)CARDIAC DEFECTS (n=13)
Primary repair with coarctation (5)Primary repair with coarctation (5)- APW (1), - APW (1),
- IHD (LIMA – LAD) (1); - IHD (LIMA – LAD) (1);
- TGA & VSD primary ASO & VSD (1), - TGA & VSD primary ASO & VSD (1),
- DORV (2)- DORV (2)
Palliation PAB (8)Palliation PAB (8)- TGA & VSD at 11m (1), TGA & VSD at 11m (1), - DORV at 11 & 15 m(2) DORV at 11 & 15 m(2) - UVH: Glenn (3/5), TCPC (1/3) - Awaiting repairs(2)UVH: Glenn (3/5), TCPC (1/3) - Awaiting repairs(2)
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