Subclavian flap aortoplasty for treatment of coarctation of the aorta in infants less than 3 months of age

Over a period of 3 years, 21 infants under 3 months of age were operated upon for coarctation of the aorta by subclavian flap aortoplasty. Associated intracardiac defects were present in 13 patients (62%), VSD being the most frequently encountered (10 patients, 48%). In 8 patients coarctation of the aorta, with or without patent ductus arteriosus, was the only cardiovascular malformation. The indication for surgical treatment was intractable congestive heart failure despite intensive medical treatment. Eight patients were on mechanical ventilatory support prior to surgery. There was no early operative mortality. One patient died in congestive heart failure due to valvular aortic stenosis 3 months after surgery for correction of the coarctation. During a follow-up of from 2 months to 3 years, 5 patients underwent a second operation for correction of intracardiac defects. Nineteen of the surviving 20 patients are in good clinical condition. One patient has clinical evidence of residual coarctation; a blood pressure difference of more than 10 mmHg between right arm and leg is presented in 4 patients. Early subclavian flap aortoplasty is recommended for patients with coarctation of the aorta, with or without associated intracardiac defects, who remain in congestive heart failure despite medical therapy.     

Histo-anatomical backgrounds of subclavian flap aortoplasty in coarctation of the aorta

After repair of coarctation of the aorta using the technique of resection and end-to-end anastomosis, the internal diameters of the aortic isthmus and descending aorta often fail to increase. Better results seem possible with aortoplasty using the left subclavian flap technique. In order to clarify this matter, we investigated the structure of the left subclavian artery comparing it with that of the descending aorta and aortic isthmus: we studied the internal diameter, the thickness of the tunica media and the packing density of its elastic fibers in these vascular elements using a postmortem material of children with a coarctation of the aorta. The ages ranged from 4 days to 13 months with one child of 8 years. All 16 cases had one or more additional cardiac lesions. Operation had been performed in 3 children: 2 end-to-end anastomoses and one subclavian bypass of the aortic arch. Data were compared with observations on autopsy cases of children without cardiovascular abnormalities. The mean findings were that the calibers of the left subclavian artery and the descending aorta were within normal limits but that the caliber of the aortic isthmus was smaller than in normal children. The measurements on the tunica media showed that although, generally, the thickness of the media of the left subclavian artery was smaller than that of the aortic isthmus and descending aorta of the same individual, it contained relatively more elastic fibers than the matching vessels. This may indicate that the structure of the left subclavian artery is well suited to grow out as a part of the aortic arch.(ABSTRACT TRUNCATED AT 250 WORDS)     

Late aneurysms after patch aortoplasty for coarctation of the aorta in adults

Sixty-eight patch aortoplasties were performed for coarctation of the aorta (CoA) in adult patients from 1967 to 1978 in our hospital. The mortality was 1.5% and the immediate result of the surgical repair seemed good. Long-term follow-up of 2 to 14 years later revealed aneurysm formation at the repair area in 27% of the 62 patients for whom sufficient follow-up data are available. Two aneurysms had ruptured with a fatal outcome. Other repair methods used for coarctation in 106 patients were free from aneurysm complication. Thirteen patients with an aneurysm underwent reoperation without mortality. The etiology of these unexpected aneurysms is discussed.     

Cerebellar infarction secondary to subclavian aortoplasty repair for coarctation of the aorta

A five-year-old boy developed a left cerebellar infarction following repair of coarctation of the aorta by subclavian aortoplasty. At operation a large left vertebral artery had been ligated. If a large vertebral artery is encountered at repair of coarctation of the aorta then consideration should be given to a method of repair which does not sacrifice this vessel.     

Aortic coarctation in the first 3 months of life. Surgical results]

Between January 1973 and September 1989, 51 patients younger than 3 months with coarctation of the aorta underwent surgery. All of them had atrio-ventricular and ventriculo-arterial concordance with well developed ventricular cavities. Thirty-four were male and 17 female. Thirty five had associated anomalies and catheterism was done in 36 before surgical correction. The surgical procedures we used were 19 subclavian plasty (Waldhausen), 13 end-to-end anastomosis, 13 Alvarez technique and three goterex parch. Twelve died (23.5%), three during surgery and the others in a period of 3 to 20 days after surgery. Eight were younger than 17 days, seven had aortic arch hypoplasia associated and six had ventricular septal defect (five with pulmonary hypertension). Other ten developed recoarctation (gradient greater than 20 mmHg) between 10 days and 8 months after first intervention (media = 3 months). Five had previously end-to-end correction (41.6%), two angioplasty with parch (66%), two Alvarez (20%) and one Waldhausen (7%). The correction of the recoarctation required surgery in 4 patients (three with angioplasty with parch and one with end to end correction), and the other six underwent angioplasty with catheter-balloon. None of the 15 patients without previous catheterism died, and neither did those who underwent surgery during the last 4 years. The associated anomalies required a second time surgery. We conclude that morbimortality is related to the aortic arch hypoplasia, pulmonary hypertension and surgery during the first 2 weeks. We recommend surgery without previous catheterism. The recoarctation is more frequent in patients with end to end correction, without an increase of the mortality.     

Outcome of patients operated on for aortic coarctation during the 1st year of life

A coarctectomy performed on infants with congestive heart failure in the first year of life is an emergency procedure due to the "coarctation syndrome". An intracardiac anomaly is also present in the majority of cases. The surgical risk of coarctectomy in the newborn infant or during the first year of life is now low (7 percent in our study), but intermediate-term mortality rates were relatively significant (24 percent in our study), due to intracardiac anomalies and their surgical correction. Without treatment, however, the coarctation syndrome proves fatal in two out of three cases before one year of age. The principal long-term complication is recurrence of the coarctation resulting from the absence of growth at the anastomosis. It occurs in 20 to 50 percent of cases depending on the study, the diagnostic criteria, and length of time since the surgery. This complication is more frequent when the coarctectomy was performed in the first month of life. Another coarctectomy must be undertaken in these cases. Persistent arterial hypertension without recurring coarctation is rarely observed, but is frequently encountered following a coarctectomy in an older child or adult. It should be noted that the systolic arterial blood pressure in almost all infants in our study was between the 50th and 97th percentile for normal children of this age. Aside from the problem of recurring coarctation, the long-term follow-up depends principally on associated valvular lesions, particularly aortic (bicuspid valves are very frequent) and mitral valvular lesions. Even though surgery has greatly improved the prognosis of coarctation in children, these infants must have long-term postoperative surveillance.     

Rapid progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta.

OBJECTIVES. This study was undertaken to evaluate the progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta. BACKGROUND. Previous studies demonstrated a 5% to 25% incidence rate of repair site aneurysm 3 to 18 years after patch aortoplasty repair of coarctation. The natural history of aneurysmal progression in this disease entity has not previously been examined. METHODS. Twenty-nine patients were identified 5.6 +/- 1 years (mean +/- SE) postoperatively and classified into two groups: Group A, aneurysm (n = 7); Group B, no aneurysm (n = 22). The presence of an aneurysm was defined angiographically as a ratio of the repair site diameter to diaphragmatic aortic diameter (aortic ratio) greater than or equal to 1.5. A 23% prevalence (7 of 29) of aortic aneurysm was identified. One patient in Group A underwent semiemergency aneurysmectomy and two patients in Group B were lost to follow-up. The remaining 26 patients were reevaluated 3 to 5 years later by clinical examination and chest radiography. Aortograms were performed in all patients with suspected aneurysm formation or progression. RESULTS. Five of six patients in Group a demonstrated progressive aneurysmal dilation documented by an increase in aortic ratio from 1.64 +/- 0.06 to 2.04 +/- 0.2 (p = 0.03) and an increase in absolute aneurysm diameter from 2.5 +/- 0.3 to 3.6 +/- 0.5 cm (p = 0.006). Only 1 of 20 patients in Group B had evidence of new aneurysmal dilation (p less than 0.05 vs. Group A). Four patients in Group A have undergone elective aneurysmectomy, with equal distribution of true and pseudoaneurysms by pathologic examination. CONCLUSIONS. Aortic aneurysm formation is common after patch aortoplasty repair of coarctation of the aorta. The majority of patients with an aortic ratio greater than or equal to 1.5 will show significant progressive aneurysmal dilation within 3 to 5 years.     

Critical aortic coarctation: patch aortoplasty in infants less than age 3 months.

Twenty-three infants less than age 3 months (mean age 31 days) underwent patch aortoplasty for relief of coarctation of the aorta. All had intractable congestive heart failure, despite aggressive medical therapy. Each infant had other cardiac anomalies, including patent ductus arteriosus (83 percent) and ventricular septal defect (74 percent). All patients underwent closure of the ductus arteriosus and patch angioplasty of the aorta to produce a luminal diameter of at least 16 mm. In addition, 9 of the 17 patients (53 percent) with a large shunt ventricular septal defect underwent pulmonary arterial banding. There was one hospital death 42 days after operation secondary to bowel perforation and sepsis. Hospitalization beyond 21 days postoperatively was always due to other unrepaired cardiac lesions. The three late deaths at 3, 9 and 18 months after operation were associated with additional major anomalies. Fourteen patients have had postoperative catheterization. No gradient was found across the site of coarctation repair, but one patient had a gradient between the left carotid and left subclavian arteries. Surgical repair of critical coarctation of the aorta in infants can safely be offered despite the presence of other cardiac anomalies.     

Evolution of coarctation of the aorta in intrauterine life

The echocardiographic appearances in a case of coarctation of the aorta, first suspected at 21 weeks of intrauterine life, changed progressively during this time. Early right ventricular hypertrophy and increasing aortic arch hypoplasia were evident and suggest the possible sequence of evolution of the coarctation in this case.     

Evolution of coarctation of the aorta in intrauterine life.

The echocardiographic appearances in a case of coarctation of the aorta, first suspected at 21 weeks of intrauterine life, changed progressively during this time. Early right ventricular hypertrophy and increasing aortic arch hypoplasia were evident and suggest the possible sequence of evolution of the coarctation in this case.     

Left subclavian flap aortoplasty for coarctation of the aorta: effects on forearm vascular function and growth

This study evaluated vascular function and growth of the forearm in nine children (mean age 9.2 years) who had undergone left subclavian flap aortoplasty for the infantile type of coarctation of the aorta many years (mean 9.0) earlier. Variables used to investigate bilateral forearm vascular function included forearm blood flow and resistance measured by strain gauge plethysmography under rest conditions, in response to 30 s of static handgrip exercise at 40% maximal voluntary contraction and in response to 10 min of forearm arterial occlusion (that is, the reactive hyperemic blood flow response). Forearm growth was ascertained by measuring right and left forearm volumes, lengths, circumferences and skinfold thickness. Mean arterial pressure at rest in the right and left arms differed by 9% (right 78.2 +/- 2.1, left 71.0 +/- 2.7 mm Hg; p less than 0.05). Forearm blood flow, however, was not significantly different between the surgically altered left arm and the normal right arm under any of the study conditions. Likewise, forearm vascular resistance was not statistically different under any conditions, although the left arm tended to have a lower resistance at rest (right 23.5 +/- 3.2, left 18.7 +/- 2.0 mm Hg.min.100 ml/ml; p = 0.057). Left forearm anthropometric measurements showed a 9% reduction in volume and a 3% reduction in circumference and length. In addition, skinfold thickness tended to be larger on the left arm, suggesting that this limb had a smaller muscle mass. In conclusion, early repair with a subclavian flap does not impair vascular function in the altered limb and is associated with only minor reductions in forearm growth variables. Hence, left subclavian flap aortoplasty appears to be a safe and effective procedure for repair of coarctation of the aorta.     

Improvement in quality of life of dialysis patients during six months of exercise

Quality of life (QOL) assessment has rapidly become an integral variable of outcome in clinical research; over 1,000 new articles each year are indexed under "quality of life" (1). Despite the proliferation of instruments and the burgeoning theoretical literature devoted to QOL evaluation, no unified approach has been derived for its measurement, and little agreement has been attained on what it means (2). Lack of clarity regarding the definition of QOL has led to several related concepts, namely functional status, life-satisfaction, well-being, and health status, being used interchangeably with QOL (3), further contributing to ambiguity. Compared to the general population, patients with end-stage renal disease (ESRD) experience a poorer QOL (4). Questionnaire-based QOL measurement in ESRD has demonstrated that QOL is best in renal transplantation and worst in unit-based haemodialysis. The main determinants of difference are the physical function domains. QOL in ESRD has traditionally been measured by a number of disease-specific, domain-specific and generic instruments, all exhibiting a fixed design. However, the fixed nature of the aforementioned instruments, is problematic in that what is measured is predetermined and hence may not represent the free choice of the individual whose QOL is assessed (5). Questionnaire-based instruments may not reflect individual priorities.     

重症主动脉缩窄的外科治疗

对合并心内畸形、动脉导管来闭和肺动脉高压的重症主动脉缩窄（CA）患儿3例行体外循环下手术矫治。结果：2例顺利完成手术，1例于术后2h突发急性肺水肿死亡。结论：对该类患儿，除年龄过小、心力衰竭难以控制或技术条件限制外，均宜采用体外循环下一次性同期矫治CA及心内畸形。术中降主动脉插管行下半身灌注，可避免因股动脉插管可能引起的灌注量受限、下肢供血不足、术后缺血性改变及术后插管处狭窄。     

单纯主动脉缩窄的外科治疗

目的总结单纯主动脉缩窄外科治疗的经验,评价手术时机和方法。方法1990年6月至2005年8月,手术治疗单纯主动脉缩窄17例,其中行主动脉缩窄切除对端吻合术5例,人工血管移植术3例,补片成形术7例,Vosschulte成形术1例,左锁骨下动脉-降主动脉人工血管转流术1例。结果术毕上下肢平均动脉压的压差<10mmHg者13例,上肢平均动脉压仍高于下肢10～30mmHg者4例。术后早期高血压者14例。随访5个月至10年,下肢血压高于上肢者13例,无明显差异者3例,下肢血压仍明显低于上肢者1例,仍有高血压者5例;成形部位动脉瘤样扩张1例,再缩窄1例。结论早期诊断、早期治疗是提高生存率和减少术后高血压的关键。手术方法应根据患者年龄、病理特征和术者经验选择。