Cardiac Case 9/15/07. Coarctation of the Aorta Congenital narrowing of the thoracic aorta; typically...
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Transcript of Cardiac Case 9/15/07. Coarctation of the Aorta Congenital narrowing of the thoracic aorta; typically...
Cardiac Case
9/15/07
Coarctation of the Aorta
• Congenital narrowing of the thoracic aorta; typically distal to the left subclavian artery.
• M:F – 2:1
• 6-8% in pts with congenital heart disease
• Associated anomalies– Bicuspid aortic valve (50-60%); VSD (25%);
PDA; TGA
• Increased incidence in Turner’s (10-15%)
Pathophysiology
• 1. Hemodynamic Theory– Lesions which decrease blood flow through left
ventricular outflow in the fetus causes a decrease flow across the aortic isthmus
– e.g. assoc anomalies – VSD, biscuspid aortic valve, LV outflow obstruction
• 2. Ductal Sling Theory– Secondary to migration of ductus smooth
muscle cells into the periductal aorta• Ductal smooth muscle cells seen on histo
• Arches 1 and 2– Stapedial Artery
• Arch 3– Internal Carotid Arteries
•Arch 4– right arch forms the right subclavian
artery – left arch constitutes the arch of the aorta
between the origin of the left carotid artery and the termination of the ductus arteriosus.
• Arch 5– disappears
•Arch 6– right arch disappears
– left arch gives off the pulmonary arteries and forms the ductus arteriosus
Indications for treatment
• Decrease in lumen diameter by > 50% at the site of coarctation
and/or
• Pressure gradient > 20 mm Hg at rest
Treatment Options
• Surgery– End to End (extended) Anastamosis– Bypass graft – Left subclavian flap aortoplasty– Prosthetic patch aortoplasty
• Angioplasty
• Angioplasty with Stent
Complications of Surgical Repair
• Post-op paradoxical hypertension
• Recurrent laryngeal nerve or phrenic nerve inury
• Steal phenomenon (w/ subclavian flap)
• Aneurysm (w/ patch aortoplasty)
• Recoarctation (5-10%)
Complications of Stents• Technical
– Stent migration or fracture; baloon rupture, overlap of brachiocephalic vessels
• Aortic– Intimal tears, dissection, rupture
• Peripheral– CVA, peripheral emboli, access vessel injuries
• Recoarctation (less than angioplasty alone)
Other Late Complications
• Vascular remodeling resulting in systemic hypertension– Impaired vasoreactivity– Increased intima-media thickness– Possibly associated with arch type
Recommendations
• < 6 months– Surgery
• 6 mo – 5 yrs (<25kg)– Surgery or Angioplasty– ?angioplasty for recurrent coarctation
• > 5yrs (>25kg)– Stent
References
• Ou, P., Celermajer, D., et al. Vascular Remodeling After Successful Repair of Coarctation. Journal of the American College of Cardiology. Vol 49, No. 8, 2007.
• Agarwala, B., Bacha, E., et al. Management of Coarctation of the Aorta. UpToDate 2007.
• Shih, M., Tholpady, A., et al. Surgical and Endovascular Repair of Aortic Coarctation: Normal Findings and Appearance of Complications on CT Angiography and MR angiography. American Journal of Radiology, Vol 187, 2006.
• Abbruzzese, P., Aidala, E. Aortic Coarctation: An overview. Journal of Cardiovascular Medicine 2007, 8:123-128.
• Golden, A., Hellenbrand, W., Coarctation of the Aorta: Stenting in Children and Adults. Catheterization and Cardiovascular Interventions. 69: 289-299, 2007.