Transcatheter Intervention for Late Complications after Aortic Coarctation Surgical Repair
Aortic coarctation (CoA) is not uncommon congenital cardiac disease. Surgical repair of native CoA is nowadays a common and safe procedure at early childhood. However, late complications, including re-CoA and aneurysm formation, are not uncommon. The incidence of these complications is dependent on the type of the initial operation. Both transcatheter and surgical repair play important roles in the treatment of late surgical complications. This article will review the incidence of late complications after CoA repair and will discuss the transcatheter treatment options for such complications in the view of recent advancement in transcatheter therapy.
CoA is the sixth most common congenital heart disease (CHD) accounting for 4–8% of all CHD and occurs in 4 out of 1,000 live births with a male predominance. CoA can occur as an isolated lesion, but is often associated with other cardiovascular lesions, such as bicuspid aortic valve (BAV) in 50–75% of the cases, aortic arch hypoplasia, subaortic stenosis, mitral valve abnormalities, ventricular and atrial septal defects and patent ductus arteriosus (PDA). The most important non-cardiac associated lesion is cerebral aneurysm present in up to 10% of patients, which is approximately 5 times higher than that in the general population. It may cause isolated hypertension, aortic aneurysm or dissection, intracranial bleeding, coronary artery disease, congestive heart failure and endocarditis. Without treatment, the outcome for patients with CoA is poor. Historical data on the natural history of patients with CoA who survived beyond infancy showed a mean age of death of 34 years and 75% mortality by age 43 years. Therefore, most patients that require intervention undergo repair early in life or when initial diagnosis is made.
Surgical correction of CoA has been the standard treatment in infants and adolescents to prevent either the early or late complications related to the obstruction. The first successful surgical repair of CoA was performed by Crafoord in 1944. The surgical repair technique quickly spread worldwide and was advanced by the introduction of diverse techniques. Survival after childhood repair is reported as 89% at 15 years and 83% at 25 years. Adults repaired between age 20 and 40 years have a 75% 25-year survival, whereas older patients have only a 50% 15- year survival. Webb reported 72% to 82% 30-year survival overall. Whatever the surgical technique, late post-repair complications are not uncommon, often decades later. The most important long-term complications include persistent systemic hypertension which has been reported to be 35–68%, aortic re CoA which has been reported to be 10% to 41%, aneurysm at the treated segment which has been reported to be 5% and 51% and pseudoaneurysm formation at the anastomotic site (around 10% of cases overall). In addition to conventional open repair, transcatheter therapy with balloon angioplasty (BA) and/or stenting emerged as treatment alternatives for older children and adults with discrete area of native CoA. Late complications such as re-CoA, aneurysm and pseudoaneurysm formation can occur after transcatheter therapy, which may need further interventions.
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Journal of Clinical Trials