Allen D. Wilson

Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children

OBJECTIVES To evaluate the usefulness of balloon angioplasty for relief of native aortic coarctation, we reviewed our experience with this procedure, with special emphasis on follow-up results. BACKGROUND Controversy exists with regard to the role of balloon angioplasty in the treatment of native aortic coarctation. METHODS During an 8.7-year period ending September 1993, 67 neonates, infants and children underwent balloon angioplasty for native aortic coarctation. A retrospective review of this experience with emphasis on long-term follow-up forms the basis of this study. RESULTS Balloon angioplasty produced a reduction in the peak-to-peak coarctation gradient from 46 +/- 17 (mean +/- SD) to 11 +/- 9 mm Hg (p < 0.001). No patient required immediate surgical intervention. At intermediate-term follow-up (14 +/- 11 months), catheterization (58 patients) and blood pressure (2 patients) data revealed a residual gradient of 16 +/- 15 mm Hg (p > 0.1). When individual results were scrutinized, 15 (25%) of 60 had recoarctation, defined as peak gradient > 20 mm Hg. Recoarctation was higher (p < 0.01) in neonates (5 [83%] of 6) and infants (7 [39%] of 18) than in children (3 [8%] of 36), respectively. Two infants in our early experience had surgical resection with excellent results. Three patients had no discrete narrowing but had normal arm blood pressure and had no intervention. The remaining 10 patients had repeat balloon angioplasty with reduction in peak gradient from 52 +/- 13 to 9 +/= 8 mm Hg (p < 0.001). Reexamination 31 +/- 18 months after repeat angioplasty revealed a residual gradient of 3 to 19 mm Hg (mean 11 +/- 6). Three (5%) of 58 patients who underwent follow-up angiography developed an aneurysm. Detailed evaluation of the femoral artery performed in 51 (88%) of 58 patients at follow-up catheterization revealed patency of the femoral artery in 44 (86%) of 51 patients. Femoral artery occlusion, complete in three (6%) and partial in four (8%), was observed, but all had excellent collateral flow. Blood pressure, echocardiography-Doppler ultrasound and repeat angiographic or magnetic resonance imaging data 5 to 9 years after angioplasty revealed no new aneurysms and minimal (2%) late recoarctation. CONCLUSIONS On the basis of these data, it is concluded that balloon angioplasty is safe and effective in the treatment of native aortic coarctation; significant incidence of recoarctation is seen in neonates and infants; repeat balloon angioplasty for recoarctation is feasible and effective; and the time has come to consider balloon angioplasty as a therapeutic procedure of choice for the treatment of native aortic coarctation.

Long-Term Follow-Up Results of Balloon Angioplasty of Postoperative Aortic Recoarctation

Immediate- and short-term follow-up results of balloon dilatation of aortic recoarctation following surgery have been well documented, but there is sparse data on long-term follow-up. During a 10-year period ending in August 1995, 33 children, aged 2 months to 14 years old, underwent balloon angioplasty of aortic recoarctation. Prior surgery included resection and end-to-end anastomosis (n = 9), subclavian flap (n = 16) or prosthetic (Dacron or Gore-Tex) patch (n = 5) angioplasty, and repair of an interrupted aortic arch (n = 3). Recoarctation developed 1 month to 14 years (mean +/- SD 29 +/- 44 months) after surgery. The indications for angioplasty were peak-to-peak systolic gradients > 20 mm Hg and systemic hypertension and/or congestive heart failure. After balloon angioplasty, the peak-to-peak systolic pressure gradient across the coarctation decreased from 48 +/- 22 to 13 +/- 15 mm Hg (p <0.01), and the size of the coarcted segment increased from 3.3 +/- 1.4 to 6.5 +/- 2.3 mm (p <0.01). Follow-up angiography and/or magnetic resonance imaging were performed in 20 children 17 +/- 12 months after angioplasty. No aneurysms were observed and improvement in the diameter of the coarcted aortic segment (9 +/- 3 mm) persisted. One- to 10-year (median 5) clinical follow-up was available in 32 children. During follow-up, 2 children required surgery to repair a long tubular isthmic narrowing. The residual gradients, determined by arm-leg systolic blood pressure difference, were 5 +/- 8 mm Hg. No patient was symptomatic and only 1 patient (3%) was hypertensive, controlled with antihypertensive medications. We conclude that balloon angioplasty of aortic recoarctation following all types of surgical repair is feasible, safe, and effective with good long-term results. We recommend balloon angioplasty as the procedure of choice in the management of postsurgical recoarctation with hypertension and/or congestive heart failure.

Follow-up results of balloon aortic valvuloplasty in children with special reference to causes of late aortic insufficiency☆☆☆★

The purpose of this study was to report on 3- to 9-year follow-up data after balloon aortic valvuloplasty in children and to investigate causes of aortic insufficiency at late follow-up. Although the immediate and short-term results of balloon aortic valvuloplasty have been well documented, little information is available on long-term follow-up results. During a 7.3-year period ending December 1992, 26 young patients, aged 6 weeks to 20 years, underwent balloon aortic valvuloplasty with resultant reduction of peak-to-peak aortic valvar gradient from 71 +/- 20 (mean +/- SD) to 25 +/- 12 mm Hg (p < 0.001). None required immediate surgical intervention. At intermediate-term follow-up, 6 (23%) of 26 had restenosis develop and underwent surgical (4 patients) or repeat balloon valvuloplasty (2 patients). Clinical and echo-Doppler data 3 to 9 years (median 6 years) after balloon valvuloplasty revealed residual peak instantaneous Doppler gradients of 26 +/- 13 mm Hg (p < 0.001), without restenosis beyond what was observed at intermediate-term follow-up. Aortic insufficiency progressed in seven patients. However, none required intervention. Actuarial intervention-free rates at 1, 2, 5, and 9 years were 80%, 76%, 76%, and 76%, respectively. Logistic regression analysis suggested that the degree of Doppler-quantitated aortic insufficiency 1 day after valvuloplasty predicts persistent aortic insufficiency at late follow-up. These data indicate that immediately successful balloon aortic valvuloplasty in children yields a residual gradient of < or = 36 mm Hg at a median of 6 years of follow-up in most patients and an intervention-free rate at 9 years of 76%. Restenosis occurs but can be treated with a repeat intervention with good results. Aortic insufficiency remains stable and does not appear to require intervention, at least during the first decade after balloon dilatation.

Surgical versus balloon therapy for aortic coarctation in infants ≤ 3 months old☆

OBJECTIVES This study compared the efficacy and safety of balloon angioplasty with surgical correction of native aortic coarctation in infants < or = 3 months old. BACKGROUND There is a controversy with regard to the role of balloon angioplasty in the treatment of aortic coarctation, especially in young infants. METHODS Data from 29 infants < or = 3 months old undergoing therapy for aortic coarctation during the decade ending 1992 were analyzed. Fourteen infants underwent surgery, and 15 had balloon angioplasty. The sole criterion for allotment to the balloon group was the availability of an interventional cardiologist at the time of presentation of the infant. RESULTS The surgical and balloon groups were comparable (p > 0.1) with regard to age (27 +/- 35 [mean +/- SD] vs. 29 +/- 27 days), weight (3.5 +/- 0.9 vs. 3.8 +/- 1.0 kg) and prevalence (7 of 14 vs. 8 of 15) and type of associated defects. Operative (1 of 14 vs. 1 of 15) and late (3 of 13 vs. 3 of 14) mortality, immediate gradient relief (36 +/- 25 to 10 +/- 9 mm Hg vs. 41 +/- 14 to 6 +/- 6 mm Hg) and follow-up gradient (27 +/- 27 vs. 24 +/- 19 mm Hg) were similar (p > 0.1). Infants with a gradient > 20 mm Hg at follow-up (6 of 13 vs. 7 of 14) and need for reintervention (6 of 13 vs. 7 of 14) were also similar (p > 0.1) in both groups. Duration of hospital stay during the first intervention was higher (p < 0.05) in the surgical (32 +/- 37 days) than the balloon (7 +/- 6 days) group. Similarly, duration of endotracheal intubation and mechanical ventilation was longer (p < 0.05) in the surgical (12 +/- 16 days) than the balloon (2 +/- 3 days) group. Complications after surgical intervention (0.86 events/patient) were higher (p < 0.01) than those seen after balloon angioplasty (0.27 events/patient). However, the lack of significant differences observed for mortality rates and residual gradients may be due to low statistical power to detect differences (16% to 49%), implying that this may be due to either actual lack of statistical difference or small sample size. CONCLUSIONS The data indicate that the degree of relief from aortic coarctation and the frequency with which reintervention is needed are similar in both groups. However, the morbidity and complication rates are lower with balloon than with surgical therapy. These data suggest that balloon angioplasty may be an acceptable alternative to surgical correction in the treatment of symptomatic aortic coarctation in infants < or = 3 months old.

Follow-up results of balloon angioplasty of native coarctation in neonates and infants

The purpose of this study is to present intermediate-term results of balloon angioplasty of native aortic coarctation in neonates and infants less than 1 year of age. During a 60-month-period that ended in January 1990, 19 infants ages 3 days to 12 months (median, 2.5 months), underwent balloon angioplasty of native coarctation with resultant reduction in peak-to-peak systolic pressure gradient from 39 +/- 12 mm Hg (mean +/- SD) to 11 +/- 7 mm Hg (p less than 0.001) and increase in coarctation segment size from 2.2 +/- 0.8 mm to 4.7 +/- 1.0 mm. None required immediate surgical intervention. Thirteen of the 19 (68%) had severe associated cardiac defects. There was one death (5%) 2 days after balloon angioplasty, and it was related to associated cardiac defect. One infant was lost to follow-up. It is too soon to restudy one infant. The remaining 16 infants had clinical (36 +/- 18 months) and catheterization (12 +/- 4 months) follow-up data. The residual coarctation gradient (22 +/- 15 mm Hg) and coarcted segment size (4.4 +/- 1.6 mm) remain improved (p less than 0.01) when compared with pre-balloon angioplasty values. Five of the 16 (31%) infants (four were neonates at the time of balloon angioplasty) had evidence for recoarctation (defined as gradient greater than 20 mm Hg) and underwent surgical resection (two) or repeat balloon angioplasty (three), all with success. None developed aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of buttoned double-disc device in the management of atrial septal defects

Abstract Sixteen patients seen over a 9-month period ending in August 1990 were offered transcatheter closure of their ASD with a custom-made “buttoned” double-disc device. The study was approved by the Institutional Review Board and informed consent was obtained in each case. The device consists of an occluder, a counteroccluder, and a loading wire and is delivered to the ASD site via an 8F sheath. Parents of two children elected surgical closure. In five children the stretched diameter of the ASD was too large (>20 mm) and transcatheter closure was not attempted. These seven children underwent elective surgical closure without incident. In one child the defect measured 5 mm and the Qp:Qs was 1.4:1 and therefore ASD closure was not recommended. In the remaining eight children transcatheter closure was attempted. In two of the children the occluder pulled through the ASD and was successfully retrieved and the children later underwent uneventful elective surgical closure. The device was implanted across the ASD in six children. In one child the device dislodged from the ASD site within minutes after implantation and the child was sent to emergency surgery, where the device was removed and the ASD was closed. In the remaining five patients, aged 7 months to 45 years (weight 3.6 to 50 kg), with a Qp:Qs range of 1.3 to 2.3 and a stretched diameter of 10 to 19 mm, the ASD closure was successful with 25 to 40 mm size devices. Repeat echo-Doppler studies 2 weeks and 3 months after the procedure in all patients and 6 months later in two children did not reveal any residual shunt. It is concluded that (1) the custom-made “buttoned” double-disc device can be implanted across the ASD safely and effectively via an 8F sheath, thus making transcatheter ASD closure feasible even in very young infants; (2) measurement of stretched diameter of the ASD in the catheterization laboratory is a useful guide for selection of an appropriate-sized device; and (3) additional clinical trials are warranted to confirm the efficacy and safety of the device.

Echocardiographic predictors of success of catheter closure of atrial septal defect with the buttoned device

Transcatheter occlusion of ostium secundum atrial septal defects (ASD) with the buttoned device has been shown to be feasible, effective, and safe. The final decision to implant the device is largely based on the balloon sizing of the ASD during cardiac catheterization. Only subjective criteria of ASD size and the septal rims on echocardiography have been used before catheterization, balloon sizing, and transcatheter occlusion. The purpose of this study was to determine whether objective echo criteria could be developed to predict successful occlusion of the ASD. During a 46-month period ending August 1992, 29 children with secundum ASD were evaluated for transcatheter occlusion. The device was successfully implanted in 15 (group A); in the remaining 14 children, this procedure could not be performed (group B). Preocclusion echos were analyzed by independent investigators who had no knowledge of outcome of the procedure. Echo parameters studied included size of ASD, length of atrial septum (LAS), and size of the superior and inferior rims in precordial and subcostal views and maximum jet width by color flow mapping. From these measurements several ratios were derived, and the data were compared. A smaller (p < 0.05) ASD was present in the group of patients with successful implantation of the device; LAS was similar (p > 0.1) in both groups. A lower (p < 0.05) ratio of ASD to LAS and a higher (p < 0.05) ratio of the superior and inferior septal rims to ASD were associated with the group of patients with successful implantation of the device.(ABSTRACT TRUNCATED AT 250 WORDS)

Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children

The purpose of this article is to present immediate and follow-up results of balloon angioplasty of aortic recoarctations following previous surgery in infants and children. During a 45-month period that ended in June 1989, nine infants and children, ages 6 months to 7 years, underwent balloon angioplasty of recoarctation with resultant reduction in peak-to-peak systolic pressure gradient from 52 +/- 20 mm Hg (mean +/- SD) to 16 +/- 8 mm Hg (p less than 0.001) and increase in coarctation segment size from 3.4 +/- 1.4 mm to 6.1 +/- 1.6 mm (p less than 0.01). None required surgical intervention. There were no significant complications. Follow-up catheterization (16 +/- 7 months) data in six children and follow-up clinical (17 +/- 6 months) data in all children were available for review. Both the residual coarctation pressure gradient (6 +/- 6 mm Hg) and coarctation segment size (8.2 +/- 2.4 mm) remain improved (p less than 0.001) when compared with pre-balloon angioplasty values and the pressure gradient fell further (p less than 0.01) when compared with that measured immediately after balloon angioplasty. None developed restenosis, although one child required surgical relief of severe narrowing of isthmus of the aortic arch. None developed aneurysms. On the basis of this experience and that reported in the literature and because of high morbidity and mortality rates associated with repeat surgery for postoperative recoarctation, we recommend balloon angioplasty as the procedure of choice for relief of postoperative recoarctation with significant hypertension.

Intermediate-term follow-up results of balloon aortic valvuloplasty in infants and children with special reference to causes of restenosis

Sixteen infants and children with valvular aortic stenosis underwent percutaneous balloon aortic valvuloplasty over a 36-month period ending August 1988. The mean systolic pressure gradient across the aortic valve decreased from 72 +/- 21 (mean +/- standard deviation) to 28 +/- 13 mm Hg (p less than 0.001) immediately after valvuloplasty; the degree of aortic insufficiency did not significantly increase. Follow-up catheterization (in 10 patients) and Doppler data (in all 16 patients) were available 3 to 32 months (mean 12 months) after valvuloplasty and revealed a residual aortic valvular gradient of 37 +/- 23 mm Hg, which continues to be significantly lower (p less than 0.001) than that before valvuloplasty. There was no increase in aortic insufficiency. On the basis of follow-up data, the 16 children were divided into 2 groups: group I with good results (gradients less than or equal to 49 mm Hg), 12 patients; and group II with poor results (gradients greater than or equal to 50 mm Hg), 4 patients. All 4 patients in group II required repeat balloon valvuloplasty or surgical valvotomy; none from group I required these procedures. Seventeen general, anatomic, physiologic and technical variables were examined by a multivariate logistic regression analysis to identify factors associated with restenosis; these risk factors were: age less than or equal to 3 years; and immediate aortic valvular gradient after valvuloplasty greater than or equal to 30 mm Hg. The immediate and intermediate-term follow-up results of balloon aortic valvuloplasty are encouraging. Recognition of the risk factors may help identify potential candidates for recurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Normal fetal foramen flap and transatrial Doppler velocity pattern.

To define the normal size of the foramen ovale and the transatrial Doppler velocity pattern in the fetus, we examined foramen ovale size, foramen flap angle, and motion in 48 consecutive normal human fetal ultrasound studies. The maximal foramen diameter was similar in size to aortic root diameter at all gestational ages, differing by no more than 1.0 mm in any study. Attachment angle at the junction of the foramen with the rim of the foramen varied from 30 degrees to 50 degrees; at least a 30-degree angle was present at some point in the cardiac cycle in all studies. A redundant flap, defined as flap reaching greater than one half of the way across to the left atrial free wall, was observed in only three (6%) fetuses. Seventeen patients had transatrial Doppler velocities recorded with sample volume placed in the trough of the foramen flap on the left atrial side of the foramen ovale. A triphasic pattern was evident in systole with predominantly right-to-left flow in all fetuses. A biphasic pattern was present in diastole with bidirectional flow in all fetuses; this is toward the left atrium in early diastole and toward the right atrium in late diastole. Maximal right-to-left velocity ranged from 15 to 40 cm/sec (mean, 23 cm/sec) and was always less than or equal to mitral A wave velocity. Maximal left-to-right velocity ranged from 5 to 20 cm/sec (mean, 13 cm/sec). These data indicate that normal foramen ovale size is similar to aortic diameter, and foramen flap angle should reach 30 degrees or greater.(ABSTRACT TRUNCATED AT 250 WORDS)