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Coarctation of Aorta
Coarctation of Aorta
Coarctation of Aorta
1. Definition
A congenital narrowing of upper descending thoracic aorta
adjacent to the site of attachment of ductus arteriosus
2. History
Morgagni
Bonnett
Crafoord
Vorsschulte
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:
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Coarctation of Aorta
Developmental factor
1. Underdevelopment or hypoplasia of aortic
arch or isthmus
Definition of hypoplasia
* Proximal arch : 60% of ascending aorta
* Distal arch
: 50% of ascending aorta
* Isthmus
: 40% of ascending aorta
2. Presence of ectopic ductal tissue in the aorta
Coarctation of Aorta
Morphology
1. Localized stenosis
* More than 50% reduction in cross sectional area
* Shelf, projection, infolding of aortic media into the
lumen opposite the ductus arteriosus
* Usually intimal hypertrophy ( intimal veil ) extends
the shelf circumferentially and further narrows the
lumen (Rodbard)
2. Tubular hypoplasia
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*
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*
Coarctation of Aorta
Evolution
Coarctation of Aorta
Pathophysiology
Narrowed aorta produces increased left
ventricular afterload and wall stress, left
ventricular hypertrophy, and congestive
heart failure.
Systemic perfusion is dependent on the
ductal flow and collateralization in severe
coarctation
Coarctation of Aorta
Associated pathology
1. Collateral circulation
* Inflow
4. Aortic valve
* bicuspid (27-45%)
* stenosis ( 6 - 7%)
5. Intracranial aneurysm
* berry type intracranial aneurysm in some patients
CoA
Localized
CoA
Tubular Hypoplasia
Distal arch
PDA
Coarctation of Aorta
Natural history
1. Incidence
* 5-8% of CHD (5 per 10000 live births)
* Isolated CoA (82% of total CoA) ; male:female = 2:1
CoA + VSD 11%, COA + other cardiac anomalies 7%
* Complex CoA ; no sex difference
2. Survival of pure CoA
* 15% : CHF in neonate or infancy
* 85% : survive late childhood without operation
* 65% : survive 3rd decade of life (2% at 60 years)
3. Bacterial endocarditis : common in 1st 5 decades
4. Aortic rupture
: 2~3rd decade
5. Intracranial lesion
: subarachnoid hemorrhage(cong. Berry
aneurysm)
Collaterals
in CoA
Coarctation of Aorta
Clinical features & diagnosis
1. Infancy
1) Closure of ductus (7-10 days) produces severe obstruction
2) Ductus arteriosus remains patent - differential cyanosis
3) Associated intracardiac defect - more severe, early onset
4) Degree of collateral circulation
2. Childhood
* Asymptomatic without significant associated lesion
* Hypertension (90%)
* Cardiomegaly (33%)
* Rib notching (15%)
3. Adolescence and adult
* Hypertension ; very common * Valvar heart disease
* Heart failure at 30 years of age
4. Associated syndrome
* Turner syndrome (XO) : 2% * Von Recklinghausens D
* Noonans syndrome or congenital rubella
Coarctation of Aorta
Indications for operation
1. Reduction of luminal diameter greater
than 50% at any age
2. Upper body hypertension over 150mmHg
in young infant ( not in heart failure )
3. CoA with congestive heart failure
at any age
Coarctation of Aorta
Techniques of operation
1. Subclavian flap aortoplasty
Neonate, infant and child up to 10 years
2. End-to-end anastomosis
Preferred in any age group
* Extended end-to-end anastomosis
* Radically extended end-to-end anastomosis
Prevention of Recoarctation
Ideal operative procedure
Successfully address transverse arch hypoplasia (if
present),
Resection of all ductal tissue, and
Prevention of residual circumferential scarring at the
aortic anastomotic sit.
Factors
Younger age at operation
Presence of aortic arch hypoplasia remain risk factors
for recoarctation
CoA
Exposure
CoA
LSCA flap
CoA
Coactation of Aorta
Resection and Anastomosis
Coactation of Aorta
Resection & Extended end-to-end Anastomosis
Coarctation of Aorta
End-to-Side Anastomosis
Coarctation of Aorta
Enlargement of VSD, Resection of Conal Septum
Coarctation of Aorta
End-to-Side Anastomosis
Opening of Resected Segment
Coactation of Aorta
Operative results
Hospital mortality
Causes of early death are
acute and chronic cardiac failure or severe
pulmonary insufficiency
Coactation of Aorta
Operative results
Mobidity
1) Paraplegia (0.2 ~ 1.5%)
2) Hypertension and abdominal pain
3) Persistent or recurrent coarctation
- more than 20mmHg
- high incidence in young
4) Upper body hypertension without resting gradient
- increased vascular activity in the forearm
- age at operation is risk factor
5) Late aneurysm formation
- higher in onlay patch technique
6) Valvular disease
7) Congestive heart failure with hypertension
8) Bacterial endocarditis
Coactation of Aorta
Special features of postoperative care
1. Systemic arterial hypertension
Usually, but infant or young child doesnt
need to be treated.
2. Abdominal pain
Usually mild abdominal discomfort for a few days,
and prominent in 5 - 10%.
Control hypertension, nasogastric decompression,
IV maintain
3. Chylothorax
5%
Coactation of Aorta
Special situation & controversies
1. CoA proximal to left subclavian artery
* 1% of all COA
* reverse subclavian flap
* abdominal CoA : 0.5 ~ 2%
2. Mild or moderate coarctation
* degenerative change prone to occur
3. Prevention of paraplegia
* Collateral circulation, hypothermia(< 45min at 33 deg C)
* Descending aortic pressure under 50mmHg after clamp
4. Recurrent coarctation
Increased mortality and morbidity
5. CoA with VSD or other anomalies
Increased mortality and morbidity
Coactation of Aorta
Balloon dilatation
The role of balloon dilatation is controversial because of
early restenosis, the need for multiple interventions,
potential limb ischemia, and the increased risk of
aneurysm formation
The mechanism for early restenosis in neonates may be
related to multiple factors including ductal tissue
constriction or recoil, isthmus hypoplasia, intimal
hyperplasia as a result of smooth muscle cell
proliferation, and matrix protein production with
arterial remodeling are involved in restenosis