On the role of balloon angioplasty in infantile and childhood coarctation of aorta

Fuente: https://www.sciencedirect.com/

Autores: Sinan Abdulrazzaq Ibrahima, Abd El-Salam Al-Ethawi b, Sadiq Al-Hamashc, Ban Al-Kaaby

Introduction

Coarctation of the aorta (CoA) is the fifth most common congenital heart disease (CHD), with an incidence of 1 in 2500 births, and account for 4–6% of all congenital heart defects.

The first reported surgical repair of CoA was done by Crafoord and Nylin in 19443 and involved resection and end-to-end anastomosis. It remained the only viable option for around 40 years until Singer et al. performed balloon angioplasty (BA) in 1982. Since then, BA was regarded as safer and less invasive, and thus widely adopted for CoA.

Both BA and surgical repair for CoA are well-studied and widely available treatment options. Furthermore, BA, nowadays, has become routine for re-coarctation and is widely accepted, along with implantation of stents, as a preferable alternative to surgical correction for ‘native’ CoA in older children, adolescents, and adults.

Having said that, BA for ‘native’ CoA in neonates, infants, and young children remains controversial and there is no general consensus. In this study, we aim to evaluate our immediate and mid-term outcome of BA in that set of children and to contribute this research to the growing body of information in this context.

Methods

Design, setting and participants

In this prospective, interventional study, conducted at a tertiary, high-volume cardiac centre, we enrolled all patients who were diagnosed with ‘native’ CoA and scheduled for balloon angioplasty upon decisions taken by the attending paediatric cardiologist, over a 30-month period ending May 2017.

The presence of one or more of the following seven ‘inclusion criteria’ was considered an indication to enrolment in this study: upper-to-lower limb systolic pressure gradient ≥20 mmHg, upper limb hypertension plus CoA flow turbulence on echocardiography (echo), peak instantaneous systolic pressure gradient (PG) ≥40 mmHg, mean Doppler echo PG ≥20 mmHg, peak-to-peak catheterization (cath) PG ≥20 mmHg, diastolic ‘tailing’ of Doppler echo flow across CoA segment and, lastly, left ventricular (LV) dysfunction with CoA regardless of the PG.

On the other hand, the ‘exclusion criterion’ included CoA cases associated with cardiovascular lesions requiring surgical intervention. These include univentricular heart (single ventricle), atrioventricular (AV) canal defects, and D-transposition of great arteries (D-TGA).

Informed consent was taken from the patients’ parents. The study was approved by the Institutional Ethics Committee of the Iraqi Board for Medical Specializations (Issue No. 2745; 27 July 2017).

Once recruited, initial, preoperative history was taken. In addition, the following characteristics were recorded: patient’s age, gender, body weight (BW), height (Ht), height centile, limbs pulses (including brachio-femoral delay), blood pressure (BP) in all four limbs, oxygen saturation (SPO2) in the upper and lower limbs, and cardiac auscultation.

Different references and charts have been used. Height centile was measured using the Centers for Disease Control (CDC) growth Charts.12 For BP measurement and interpretation, we used the technique and analysis recommended by the working group of the National High Blood Pressure Education Program (NHBPEP) in 2004. Both the brachial and popliteal arteries were used. Hypertension is said to be present when the systolic and/or diastolic BP
was greater than the 95th percentile for age and sex on at least three occasions. While hypotension is present when these readings were less than the 5th percentile. Initial trans-thoracic echocardiography (TTE) was done to ‘all’ recruited patients. We used a GE Vivid E9 ultrasonic machine (General Electric, Norway), with 3 and 5 MHz probes. We evaluate the aortic arch with 2D mode using suprasternal, high parasternal long axis, and subcostal view – with special consideration to the CoA length, diameters of the ascending aorta, arch, isthmus, and descending aorta. We used continuous wave (CW) Doppler (peak and mean)to assess the severity of CoA. Further, LV function assessment – using an ejection fraction (EF) in the parasternal long axis view – and search for any additional lesion were performed. LV dysfunction was graded as mild, moderate, and severe when the EF is 45–55, 30–44, and <30%, respectively.14 Initial preoperative imaging (like CT scan or MRI) of the aortic arch was not routine. It was ordered only in cases were echo was inconclusive.

Procedure

Initially, we performBAprocedure as described by Holzer et al. We took angiographic measurements of different parts ofthe aorta. The diameters of the CoA site, transverse aortic arch (just proximal to the left subclavian artery), aortic isthmus (just distal to the left subclavian artery), and the descending aorta (at the level of the diaphragm) are measured.

The following definitions are considered. ‘Discrete’ CoA when the angiographic length is ≤5 mm. Any length more than this was regarded as a ‘long-segment’ lesion. Furthermore, isthmus and aortic arch hypoplasia were present when the isthmus and the transverse arch were less than 40% and 50%, respectively.

Once the anatomy has been clarified well, a balloon is chosen. We used a low-profile balloon (Tyshak II, NuMED) whose diameter is three times the CoA segment; not exceeding the descending aorta, atthe diaphragm, or 1–2 mm larger than the aortic isthmus whichever is smaller. To optimize the results, we did three inflations, for 10–15 s each. After deflation, the balloons are withdrawn carefully, outside the body. All the manipulations of the catheters
and balloons are done over guidewires kept across the CoA site during the procedure.

‘Immediate procedural success’ is present when one or both of the followings were achieved – a decline in PG (echo or cath) to less than or equal to 50% of the initial preoperative reading, and ≥90% angiographic improvement at the CoA.

We actively searched for postoperative complications.An ‘aortic aneurysm’ was said to be present when there is a discrete protrusion, at the intervention site, outside the aortic adventitial plane by more than three millimetres, or 50% of the descending aorta, detected by postoperative aortogram. To detect a ‘dissection flap’, we depend on angiogram initially. However, in the case of uncertainty, we do echocardiography or CT scan.

Follow-up

Once the procedure was finished, we re-assess BP and check for symptoms of hypertensive crises. We defined a patient as having ‘hypertensive urgency or emergency’ when systolic and diastolic BP ≥95th centile plus 12 mmHg, or ≥140/90 mmHg, whichever is lower. For any patient, the lower limbs are examined carefully. We check the vascular access site (for bruises or haematoma formation), distal pulses and temperature.

Echocardiography is performed in the first postoperative day. Special attention is paid to LV function, and to the CoA site for any residual narrowing or development of complications. All the patients – then after – would be scheduled for the next clinical (including echo) evaluation at 1 month, 3 months, 6 months, and 1–2 years after the procedure. Spiral CT scanning is performed routinely to all postoperative patients at 1 month after the procedure and every 1–2 years then after, accordingly. ‘Recurrent CoA’ is defined as re-stenosis after an initially successful BA.

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