Tratamento intervencionista das cardiopatias congênitas: estado da arte / Interventionist treatment of congenital heart defects: state of the art

Os avanços na tecnologia nas últimas décadas em relação ao tratamento intervencionista das cardiopatias congênitas têm permitindo excelentes resultados, em termos de morbimortalidade, a curto e longo prazo para este grupo especial de pacientes.Este artigo descreve os principais tratamentos disponíveis realizados com cateterismo intervencionista neste grupo de pacientes.

Technological advances in recent decades, in relation to interventionist treatment of congenital heart defects, have enabled excellent short- and long-term results for this group of patients, in terms of morbidity and mortality. This article describes the main treatmentsavailable involving interventionist catheterization in this group of patients.

Uso de stents recobertos no tratamento da coarctação da aorta / Use of covered stents in the treatment of aortic coarctation

Introdução: A ampla variedade morfológica das coarctações da aorta (CoA) e algumas complicações derivadasdo implante de stents convencionais tornam desejáveis a utilizaçào de stents recobertos (SR). Descrevemos aexperiência com o uso de SR para tratar CoA em crianças e adultos. Métodos: Foram revisados, retrospectivamente, os registros dos pacientes nos quais foram utilizados os SR. Os procedimentos foram realizados segundo a técnica consagrada. Foram estudados casos em que os SRforam utilizados como primeiro tratamento e também aqueles realizados em complicações derivadas doprocedimento inicial. Resultados: Entre 2007 e 2014, foram utilizados SR em 14 pacientes, sendo 9 (64,3%) do sexo masculino. A média de idades foi 19,5 ± 10,5 anos, e a média dos pesos, 61,7 ± 25,5 kg. Valva aórtica bicúspide estavapresente em 74% dos casos, e dois apresentaram persistência do canal arterial. Coarctações subatréticasforam encontradas em cinco pacientes. Onze pacientes apresentaram hipertensão arterial sistêmica, e73% normalizaram as cifras tensionais após a dilatação com stents. O implante foi possível em todos os casos. Foram realizados implantes primários em dez (71,4%) pacientes portadores de coarctações nativas e em quatro como segundo dispositivo, para corrigir problemas derivados de procedimentos anteriores. O tempo médio de seguimento foi de 51,7 ± 29,8 meses. Três complicações menores estiveram relacionadas aos procedimentos, e não houve registro de óbito. Conclusões: O uso de SR foi seguro e eficaz na nossa pequena série de casos. Mais estudos, enfocando a evolução de longo prazo e a possibilidade de redilatação dos SR, são necessários para corroborar seu uso em crianças.

Background: The wide morphological variety of coarctation of the aorta (CoA) and some complications resulting from the implantation of conventional stents has made the utilization of covered stents (CS) desirable. We describe our experience with the use of CS to treat CoA in children and adults. Methods: The records of patients that received CS were retrospectively reviewed. The procedures were performed according to the established technique. Use of CS as primary treatment were assessed, as well as those deployed due to complications resulting from the initial procedure. Results: Between 2007 and 2014, CS were used in 14 patients, 9 (64.3%) of whom were males. The meanage was 19.5 ± 10.5 years, and the mean weight 61.7 ± 25.5 kg. Bicuspid aortic valve was present in 74% ofcases, and two patients had patent ductus arteriosus. Subatretic aortic coarctations were found in five patients. Eleven patients had systemic arterial hypertension, and 73% had normalized blood pressure levelsafter stent dilation. Implantation was possible in all cases. Primary implants were performed in ten (71.4%)patients with native coarctation and in four patients as a second device to correct problems originating from previous procedures. The mean time of follow-up was 51.7 ± 29.8 months. Three minor complicationswere related to procedures, and there were no deaths. Conclusions: The use of CS was safe and effective in this small case series. Further studies focusing on the long-term evolution and the possibility of CS redilation are needed to support its use in children.

Levosimendan in a neonate with severe coarctation of aorta and low cardiac output syndrome.

We report successful use of levosimendan after failed balloon angioplasty in a critically ill neonate with coarctation of aorta (CoA) and severe low cardiac output syndrome (LCOS). Treatment with levosimendan improved left heart function, and decreased lactate and brain natriuretic peptide levels. To our knowledge, this is the first report on the safe and successful use of levosimendan in the management of LCOS due to severe CoA in a neonate awaiting surgical repair.

Adult Coarctation of Aorta with Bicuspid Aortic Valve.

Coarctation of the aorta is a congenital cardiac malformation that can go undiagnosed with only hypertension as a marker of its presence, because clinical signs can be subtle and overlooked if a complete physical examination is not performed. Here we present a case report of 20 year old young male patient with hypertension who was diagnosed to have Coarctation of Aorta and Bicuspid aortic Valve.Our patient was relatively asymptomatic until he presented with headache and exertional dyspnoea.

Cervical mass following carotid attempt at interventional repair of aortic coarctation: a case report

A 4-month-old boy was admitted to our hospital following an unsuccessful attempt at interventional repair of aortic coarctation via the right carotid artery, which seemed to have given rise to the formation and growth of a cervical mass overlying the entry site, Despite the initial anticipation of difficulty during intubation due to the pressure effect of the mass, anesthesia progressed uneventfully, the mass, which was a hematoma, was evacuated, and the coarctation was repaired The patient was discharged after the operation. At three weeks' follow-up, there was no significant lesion in the neck and transthoracic echocardiography demonstrated no residual coarctation

Primary stenting in a young adult with aortic coarctation

A young male adult with significant aortic coarctation was initially referred to our clinics due to uncontrolled blood pressures. On evaluation the diagnosis of aortic coarctation was evident and confirmed with Magnetic Resonance Angiography (MRA). After discussing treatment options with the patient and his parents they opted for the least invasive procedure possible. Primary stenting of a simple discrete aortic coarctation was performed successfully. The following is a report on the methods used and immediate results.

Balloon expandable stents for coarctation of the aorta: current status and technical considerations: case report.

BACKGROUND: Balloon expandable stents have been used to manage coarctation of the aorta (Co) in selected patients with very encouraging results. MATERIAL AND METHOD: The authors report here the first group of patients with Co who underwent a successful implantation of the new Palmaz Genesis stent with intermediate term follow up. RESULTS: There were 5 patients with an age range from 14 to 23 years old. All of them had significant Co and were receiving multiple anti-hypertensive medications. Primary stenting was performed in all patients. All of them had an immediate relief of the gradient. All antihypertensive medications were discontinued immediately in 4 patients. All patients had one year follow up which revealed a minimum gradient. One patient continues to receive oral antihypertensive medication. CONCLUSION: In patients with coarctation of the aorta (native or recoarctation of aorta), stent implantation may be a feasible and improved option to relieve the stenosis. Short and mid term followup of these patients have shown encouraging results.

Análise dos resultados imediatos e tardios do tratamento percutâneo da coartação da aorta em adolescentes e adultos: comparação entre balões e stents / Analysis of the immediate and late results of percutaneous treatment of coarctation of the aorta in adolescents and adults: comparison between balloons and stents

Mais informações são necessárias para definir se o tratamento percutâneo da coartação da aorta com stents é superior à angioplastia com cateter-balão. De julho de 2000 a maio de 2003, 21 adolescentes e adultos com coartação da aorta focal e média de idade de 24 anos (DP 11 anos) foram submetidos, consecutivamente, a implante de stents (grupo 1). Os resultados foram comparados com os obtidos em um grupo histórico de 15 pacientes com média de idade de 18 anos (DP 10 anos) (p = 0,103) submetidos a angioplastia (grupo 2) nos últimos 18 anos. Após o procedimento, a redução do gradiente sistólico foi maior (99% [DP 2%] versus 87% [DP 17%]; p = 0,015), o gradiente residual foi menor (0,4 mmHg [DP 1,4 mmHg] versus 5,9 mmHg [DP 7,9 mmHg]; p = 0,019), o ganho no local da coartação foi maior (333% [DP 172%] "versus" 190% [DP 104%]; p = 0,007) e o diâmetro da coartação foi maior (16,9 mm [DP 2,9 mm] versus 12,9 mm [DP 3,2 mm]; p < 0,001) no grupo 1. Alterações da parede da aorta, incluindo dissecções, abaulamentos e aneurismas, foram observadas em oito pacientes do grupo 2 (53%) e em um do grupo 1 (7%) (p < 0,001). Não houve complicações maiores. Cateterismo (n = 33) ou ressonância magnética (n = 2) de controle foram realizados em seguimento mediano de um ano para o grupo 1 e um ano e meio para o grupo 2 (p = 0,005). A redução do gradiente sistólico persistiu em ambos os grupos; entretanto, gradientes tardios mais altos foram observados no grupo 2 (mediana de 0 mmHg para o grupo 1 versus 3 mmHg para o grupo 2; p = 0,014). Não houve perdas no diâmetro da coartação no grupo 1 e houve ganho tardio no grupo 2 (16,7 mm [DP 2,9 mm] versus 14,6 mm [DP 3,9 mm]; p = 0,075). No grupo 1, dois pacientes necessitaram de novo implante de stent em decorrência da formação de aneurisma ou fratura da malha do stent. No grupo 2, as anormalidades da parede aórtica não progrediram e um paciente necessitou de redilatação em decorrência da recoartação. A pressão arterial sistêmica...

More information is needed to define whether stenting is superior to balloon angioplasty for coarctation of the aorta. From July/2000 to May/2003, 21 adolescents and adults with discrete coarctation underwent consecutive stent implantation at a mean age of 24 years (SD 11 years) (group 1). The results were compared to those achieved by balloon angioplasty performed in the last 18 years in a historical group of 15 patients at a mean age of 18 years (SD 10 years) (p = 0.103) (group 2). After the procedure, systolic gradient reduction was higher (99% [SD 2%] vs. 87% [SD 17%]; p = 0.015), residual gradients lower (0.4 mmHg [SD 1.4 mmHg] vs. 5.9 mmHg [SD 7.9 mmHg); p = 0.019), gain at the coarctation site higher (333% [SD 172%] vs. 190% [SD 104%]; p = 0.007) and coarctation diameter larger (16.9 mm [SD 2.9 mm] vs.12.9 mm [SD 3.2 mm]; p < 0.001) in group 1. Aortic wall abnormalities, including dissections, bulges and aneurysms, were observed in eight patients in group 2 (53%) and in one in group 1 (7%) (p < 0.001). There was no major complication. Repeat catheterization (n = 33) or magnetic resonance imaging (n = 2) was performed at a median follow-up of 1.0 year for group 1 and 1.5 year for group 2 (p = 0.005). Gradient reduction persisted in both groups, although higher late gradients were observed in group 2 (median of 0 mmHg for group 1 vs. 3 mmHg for group 2; p = 0.014). There was no late loss in the coarctation diameter in group 1 and there was a late gain in group 2 (16.7 mm [SD 2.9 mm] for group 1 vs. 14.6 mm [SD 3.9 mm] for group 2; p = 0.075). Two patients required late stenting due to aneurysm formation or stent fracture in group 1. Aortic wall abnormalities did not progress and one patient required redilation due to recoarctation in group 2. Blood pressure was similar in both groups at follow-up (systolic: 126 mmHg [SD 12 mmHg] in group 1 vs. 120 mmHg [SD 15 mmHg] in group 2; diastolic: 81 mmHg...

Balloon angioplasty in aortic coarctation: a multicentric study in Mexico

OBJECTIVES: To analyze immediate and long-term results of balloon dilation for aortic coarctation in a three-center experience in Mexico, and to determine factors associated with increased risk. BACKGROUND: Results demonstrated that the procedure is effective and safe, however its use in some groups is still controversial, specially in neonates and infants. METHODS: In a ten-year period, 333 patients with aortic coarctation on underwent balloon dilation with an immediate success rate of 93.7 and a major complication incidence of 1.8. Of the total cohort, 272 patients were followed for a period of 24.3 +/- 20 months. Demographic and procedural data were analyzed to determine factors related to a poor outcome or to sustained high blood pressure. RESULTS: Cox regression analysis found age (risk ratio 3.42 p = 0.0001), isthmic hypoplasia (risk ratio 4.64, p < 0.0001), and post-dilation gradient (risk ratio 2.19, p = 0.0113) as independent risk factors for a follow-up event, mainly restenosis. Age at dilation was the only independent factor related to sustained hypertension with a seven-fold increase in the risk. CONCLUSIONS: Balloon dilation is an effective and safe alternative to treat aortic coarctation. Patients younger than one year of age, with severe isthmic hypoplasia and a post-dilation gradient > 20 mmHg have the highest risk to develop an event in the follow-up period. When the dilation procedure is performed in patients older than 10 years of age, and specially those older than 20 years, the probability that they remain or develop high blood pressure is increase.

Corrección quirúrgica de la coartación de la aorta : experiencia quirúrgica durante 30 años en el Hospital México / Correction of the aortic coarctation : surgical experience during 30 years in the Mexico Hospital

Presentamos aquí la experiencia quirúrgica en el tratamiento de la coartación aórtica acumulada a lo largo de 30 años en el Hospital ....

Aortoplastía en coartación aórtica congénita del adulto con balón y prótesis endovascular: resultados inmediatos y seguimiento a 6 meses / Aortoplasty in adults with congenital aortic coarctation using balloon and stent placement: a 6 months follow-up

Hasta 1982 el tratamiento de la Coartación Aórtica había sido quirúrgico, con una incidencia de recoartación del 39 por ciento. Desde 1984 se ha practicado exitosamente la aortoplastía con balón en adolescentes y adultos. Presentamos los resultados inmediatos y el seguimiento a más de 6 meses, de 5 pacientes masculinos y un femenino con edad promedio de 28.6 años (15-46), en 4 de ellos se colocó una prótesis. La presión sistólica de aorta ascendente disminuyó de 187.1 mm de Hg (ñ 41.8) a 128 (ñ 25.4) y el gradiente transcoartación de 66 mm de Hg (ñ 21.8) a 4.8 (ñ 7.6). El diámetro luminal de la coartación aumentó de 4.6 mm (ñ 1.41) a 14.3 (ñ 3) en la dilatación con balón, y a 17.8 mm en los pacientes con prótesis, p = NS. En 3 pacientes con prótesis, la angiografía a 6 meses no mostró reestenosis; todos los pacientes tienen menor o ningún requerimiento de medicamentos antihipertensivos. Se trata de un procedimiento simple y exitoso. Está aún por determinarse el índice de complicaciones agudas y crónicas, porcentaje y tiempo de reestenosis, los resultados a largo plazo y el posible beneficio de las prótesis.

Aneurisma intracraniano associado à coartaçäo da aorta em paciente de 13 anos / Intracranial aneurysm associated with aortc coarctartion in a 13-year-old patient

Este caso relata o caso de uma menina de 13 anos de idade com um quadro de hemorragia intracraniana devido a um aneurisma gigante da artéria silviana associado a uma cardiopatia congênita, uma coartaçäo aórtica que foi descoberta coincidentemente durante realizaçäo de angiografia na investigaçäo da hemorragia subaracnóide. O aneurisma cerebral foi clipado e em seguida, 15 dias após, foi corrigida a estenose aórtica, e a paciente teve uma excelente recuperaçäo. Aneurismas intracranianos, a rotura dos mesmos e mais ainda a sua associaçäo com coartaçäo da aorta säo casos raros especialmente nessa faixa etária. Os autores apresentam os achados clínicos e radiológicos do caso e, além disso, discutem a etiopatogênese, a terapêutica, o prognóstico e a evoluçäo do caso.

Interventional cardiology in congenital heart disease / Cardiología intervencionista en cardiopatías congénitas

Los procedimientos intervencionistas para las cardiopatías congénitas han evolucionado dramáticamente en la última década, iniciando con la valvulotomía pulmonar y aórtica. Actualmente se colocan prótesis endovasculares y diversos dispositivos dentro del corazón y los vasos para tratar paliativa o correctivamente diferentes defectos cardiacos congénitos. La presente comunicación resume la experiencia del Instuto Nacional de Cardiología "Ignacio Chávez" dentro de la cardiología intervencionista pediátrica durante los últimos cinco años

Stents en coartación aórtica. Resultados inmediatos / Stents in aortic coarctation

De septiembre de 1996 a marzo de 1997 se colocaron stents tipo Palmaz (P-308 Johnson & Johnson) a 6 pacientes con el diagnóstico de coartación aórtica: 3 del sexo femenino y 3 del sexo masculino con edades entre 13 y 30 años (m=20). En ningún caso fue necesaria la dilatación del sitio coartado antes de colocar el stent. El globo utilizado para el implante fue de 12 mm en dos casos y de 15 mm en 4 casos y para la implantación final varió de 14 a 20 mm en 5 casos. En un paciente fue necesario la dilatación final con un globo dual de 15 + 15 mm. El gradiente pre-stent varió de 30 a 65 mmHg (m=44) y disminuyó a 0 en 5 casos y en uno fue de 4 mmHg(m=1). La presión sistólica de la aorta ascendente disminuyó de 135 a 117 mmHg en promedio post colocación del stent. No se presentó ninguna complicación significativa o mortalidad. En ningún caso se observó imagen de disección o formación de aneurisma. En conclusión, pensamos que la colocación de stents en coartación aórtica en este grupo de pacientes parece ser una alternativa excelente al tratamiento quirúrgico convencional e incluso a la angioplastía con globo, al ofrecer una corrección anatómica muy favorable del sitio coartado, eliminar el gradiente, mínimo morbimortalidad, la incidencia de disección y formación de aneurismas pensamos será menor, y como todos los procedimientos vía percutánea, elimina la necesidad de una toracotomía. La reestenosis tardía no puede ser determinada por el momento pero se espera mínima principalmente en vista del gran diámetro luminal obtenido y posiblemente a que la velocidad del flujo a este nivel es alta

Angioplastía transluminal percutánea con catéter balón en coartación aórtica nativa: experiencia a largo plazo / Long term study of percutaneous angioplasty in native aortic coarctation

De agosto de 1988 a octubre de 1993, 19 pacientes portadores de coartación aórtica nativa (CoAo) fueron sometidos a angioplastía transluminal percutánea con balón (ATPB). Doce fueron hombres (63.1 por ciento) y 7 mujeres (36.9 por ciento), con edad promedio de 22 ñ 7.7 años (extr. 16-52). Todos eran portadores de hipertensión arterial al momento del procedimiento, con una presión sistólica de 190 ñ 32.3 mmHg (extr. 160-240). El gradiente de presión sistólica (GPS) fue de 77 ñ 24 mmHg (extr. 45-130), un diámetro del anillo de coartación de 4.2 ñ 0.9 mm, el diámetro promedio de los catéteres balón utilizados fue de 18.3 ñ 1.7 mm (extr. 15-20). En todos los pacientes, el procedimiento se efectuó bajo anestesia local y con la técnica habitual de Seldinger. Después de efectuar el procedimiento, el GPS así como la presión arterial descendieron a 5.0 ñ 4.1 mmHg y 130 ñ 20.6 mmHg respectivamente y la ampliación del anillo presentó un aumento de 4.2 ñ 0.9 a 14.1 ñ 1.6 mm. En ninguno de los procedimientos se presentaron complicaciones: en el seguimiento 11 pacientes se han vuelto a cateterizar en un lapso de 24.7 ñ 12.6 meses (extr. 10-48) con un GPS de 5 ñ 2 mmHg y se observó un aumento en el diámetro del anillo a 15.4 ñ 1.2 mm. En estos sujetos vueltos a estudiar no se evidenciaron aneurismas en el sitio de la dilatación; el resto de los sujetos intervenidos llevan un control por consulta externa: 17 de ellos se mantienen normotensos sin tratamiento médico y dos únicamente han requerido de terapia antihipertensiva con mejor control a dosis bajas. Nuestra experiencia sugiere que la ATPB en CoAo tipo diafragma a cualquier edad es segura y muy efectiva con mejoría sostenida a mediano y largo plazo