Mariano Ledesma

Results of Stenting for Aortic Coarctation

Thisstudy reports the results obtained with stent implanta-tion in young and adult patients with AC.•••Between September 1996 and August 2000, 56stents were implanted in 54 patients with AC (35male, 19 female; age range 8 to 49 years, mean 22 69). AC was defined as a stenosis with a peak-to-peakgradient of

Intraluminal aortoplasty vs. surgical aortic resection in congenitalaortic coarctation

20 mm Hg at rest. Fourteen patients hadassociated malformations: subaortic stenosis (2), ven-tricular septal defect (2), patent ductus arteriosus (1),coronary disease (2), and aortic valve disease (7). Fourpatients had undergone balloon angioplasty 2.5 to 7years before the study. Two had restenosis and 2 hadsmall saccular dilations. One case had surgical end-to-end repair with restenosis. All patients had local-ized AC, but 1 had a long tubular stenosis. Clinicalsuccess was defined as a peak-to-peak pressure gradi-ent of #20 mm Hg after stenting with no majorcomplications. Technical success was defined as suc-cessful stent deployment without complications. Clin-ical and Doppler examinations were performed at 1month and every 6 months. Pressure gradients beforeand after stenting were compared using Student’s t test(paired, 2-tail). A p value of ,0.05 was consideredsignificant.All cases were sedated. Antibiotic prophylaxis wasnot used. After arterial access, all patients received100 U/kg of heparin. Activated clotting time valueswere not measured. Gradient and arch angiographywere assessed. We used 55 Johnson & Johnson stents(41 P-308, 12 P-4014, and 2 P-5014, Warren, NewJersey) and one 60-mm-long Wallstent (Boston Sci-entific Corporation, Natick, Massachusetts). Stentswere selected for the diameter of the proximal aorta.The Wallstent was used for a long stenosis. Predila-tion was performed in only 3 patients. A stiff Amplatzguidewire was used with a 80-cm-long transseptal 9Frsheath (Cook, Bloomington, Indiana) with a P-308stent, or a 11Fr sheath with the P-4014 or P-5014stents. A dilator with a sheath was advanced across theAC. The dilator was removed, leaving the sheath andwire. Afterward, the stent was manually crimped on aballoon with a balloon-to-isthmus ratio of approxi-mately 1.0 to 1.2. Maximum balloon size was 25 mm.The stent was advanced to the stenosis and the sheathwas withdrawn, exposing the stent. The balloon wasinflated to 3 to 6 atm using a 20-ml inflator. Pressuresand angiography were repeated. Heparin was restarted4 hours after sheath removal and infused for 24 hours.Postprocedure heparin infusions were used to mini-mize femoral thrombotic complications, not for stentanticoagulation.Successful deployment was achieved in 53 patients(98%). Fifty-two patients (96%) had clinical success.The 1 failure was due to a residual gradient of 30 mmHg after stenting for restenosis after prior surgicalrepair. Although no high-pressure balloon was avail-able to us, there was no fluoroscopic calcification ofthe AC. This patient underwent a successful reopera-tion. Mean pressure gradient significantly decreased,from 50 6 20 mm Hg (range 11 to 110) to 5 6 8mmHg (range 0 to 30, p ,0.001). In 29 patients there wasno gradient after stent placement (Figure 1). In thepatient with long tubular AC (17 years old, 57 kg), thestenotic site was predilated with an 8-mm balloon toplace a Wallstent (16 3 60 mm length). The stent didnot totally expand, moving to the distal side of the AC.It was thus necessary to place a P-308 stent, whichresulted in expansion of the Wallstent. Fourteenmonths later, a small aneurysm was seen around theWallstent. The aneurysm did not involve the stentends, and may have been due to overdilation of theballoon (Figure 2). Magnetic resonance imagesshowed no growth of the aneurysm 9 months later. Inthe 2 cases in which an aneurysm occurred afterprevious balloon angioplasty, stent implantation wasenough to resolve the problem (Figure 3).One patient experienced vagal bradycardia thatrequired atropine. Two patients had paradoxical hy-pertension immediately after positioning the stent,which was treated with oral bblockers for 3 weeks. In1 case the stent was not delivered because ballooninflation moved the stent distally before the stentexpanded. In this patient, the stent was trapped in thefemoral artery when pulled back to the sheath. It wasremoved by surgery a few days later, and the AC wassurgically corrected.Two cases had stent migration during balloon in-flation. In the first, the stent deployed 2 mm below theAC site. There was complete resolution of the AC asa result of the balloon dilation and nothing further wasdone. This patient developed an aneurysm of the un-stented site. In the second patient, we implanted asecond stent to cover the dilation site after the firststent moved distally. There were no cases where bal-loon rupture caused stent migration.

Percutaneous aortic valvoplasty in congenital aortic valvar stenosis.

BACKGROUND Our objective was to compare results of two therapeutic modalities to treat congenital aortic coarctation: intraluminal aortoplasty without endoluminal stent installation (patients in group A) vs. surgical aortic resection (patients in group B). Trans-coarctation gradient pressure was evaluated prior to and immediately after treatment. Re-coarctation, aneurysm formation, in-hospital morbidity and mortality, and complications related to treatment were also evaluated. METHODS A clinical, randomized, multicenter study was performed in pediatric patients with congenital aortic coarctation. Immediate and mid- to late therapeutic results were evaluated. With regard to statistics, we evaluated event variations by Kaplan-Meier model, nonparametric Wilcoxon test, Mann-Whitney U test, two-tailed Student t and chi-square tests, and Fisher analysis. Significance was considered relevant when p<0.05. RESULTS There were no differences in demographic variables, procedure failure, complications, mortality, or aortic aneurysm between groups A and B, respectively. Intraluminal angioplasty and surgical aortic resection were similarly effective in reducing trans-coarctation pressure gradient, as well as arterial systemic pressure. However, differences were found between groups A and B at follow-up. Group A showed higher re-coarctation (50 vs. 21%). Absence of peripheral arterial pulses in limbs was higher in group A (50 vs. 21%), as well as persistence of arterial hypertension (49 vs. 19%); these differences were significant (p<0.05). On the other hand, complications observed after surgical aortic resection were more serious than post-angioplasty complications, but these differences were not statistically significant. CONCLUSIONS Although re-coarctation and persistency of arterial hypertension were less frequent after surgical aortic resection, complications observed with this procedure are more serious than complications related to angioplasty, although these differences are not statistically significant.

Original articleTypes of Obstructions in Double-Chambered Right Ventricle: Mid-Term Results

OBJECTIVE To evaluate immediate and midterm results with percutaneous aortic valvoplasty. MATERIAL AND METHODS We reviewed the records of 141 patients undergoing percutaneous aortic valvopasty over a period of 13 years. RESULTS The patients were aged from 2 months to 40 years, with a mean of 10.9 +/- 9.9 years. Of the total, 90 (63+/%) were male. The initial systolic peak-to-peak gradient decreased from 163 +/- 52 mmHg to 32 +/- 18 mmHg (p < 0.01) after valvoplasty in all 141 patients, while the proportional reduction ranged from 0 to 100%, with a mean of 72 +/- 27%. The index of the size of the balloon to the diameter of the valvar orifice was 0.88 +/- 0.19 in 128 patients. The follow-up ranged from 6 to 168 months, with a mean 51 +/- 48 months in 70 patients. A significant difference was found in those failing after dilation when the initial evaluation was compared to the final evaluation of patients with follow-up. In those failing, the number of patients rose from 12 (17%) to 21 (30%) (p < 0.01). In contrast, in those in whom we achieved success, there was not such a great difference between the initial and final evaluation: 58 (83%) versus 49 (70%) (p < 0.1). The actuarial freedom curve of patients not needing new percutaneous aortic valvoplasty or surgery, by 182 months, was at 87% and 82% respectively. CONCLUSION We have reviewed the largest series of patients in Latin-America reported thus far after undergoing percutaneous aortic valvoplasty, concentrating on mid term follow-up and limitations. New prospective and multicentric studies are needed from our region.

Types of Obstructions in Double-Chambered Right Ventricle: Mid-Term Results

BACKGROUND The double-chambered right ventricle (DCRV) is increasingly recognized as a distinct obstruction entity. The nature of the obstruction is not well defined. METHODS Patients with DCRV were prospectively studied during the last 4 years according to the following criteria: 1) pressure gradient by echo Doppler and cardiac catheterization within the right ventricle; 2) angiographic demonstration, and 3) surgical confirmation. RESULTS From March 1997 to March 2001, 10 new cases were included. Age ranged from 2 to 14 years (mean 9.5 +/- 4.4 years), weight ranged from 9.9 to 75 kg (mean 23 +/- 13.6 kg), and height from 0.85 to 1.48 m (mean 114 +/- 19 cm). Systolic gradient by echo Doppler ranged from 20 to 135 mmHg (mean 86 +/- 44 mmHg) and by cardiac catheterization, 18 to 130 mmHg (mean 78 +/- 35 mmHg). In terms of angiographic findings, in six patients the right ventriculogram showed an oblique and low obstruction; in four patients the obstruction was high and horizontal. With regard to surgical findings, angiographic findings were confirmed by the surgeon except in one patient, in whom both types of obstruction were present. No mortality was observed. With follow-up 4 to 40 months after surgery (mean 24 +/- 15 months), 8 of 10 patients were evaluated; all corresponded to class I NYHA. Systolic gradient by echo Doppler ranged from 0 to 11 mmHg (mean 4 +/- 6 mmHg). CONCLUSIONS DCRV IS PRODUCED BY THE FOLLOWING THREE TYPES OF MUSCULAR OBSTRUCTIONS: low and oblique obstruction; high and horizontal obstruction, and mixed obstruction. Mid-term surgical results are satisfactory.

Resultados inmediatos y a largo plazo del implante de un nuevo stent coronario de platino (stent Atlas) en pacientes con enfermedad arterial coronaria

BACKGROUND The double-chambered right ventricle (DCRV) is increasingly recognized as a distinct obstruction entity. The nature of the obstruction is not well defined. METHODS Patients with DCRV were prospectively studied during the last 4 years according to the following criteria: 1) pressure gradient by echo Doppler and cardiac catheterization within the right ventricle; 2) angiographic demonstration, and 3) surgical confirmation. RESULTS From March 1997 to March 2001, 10 new cases were included. Age ranged from 2 to 14 years (mean 9.5 +/- 4.4 years), weight ranged from 9.9 to 75 kg (mean 23 +/- 13.6 kg), and height from 0.85 to 1.48 m (mean 114 +/- 19 cm). Systolic gradient by echo Doppler ranged from 20 to 135 mmHg (mean 86 +/- 44 mmHg) and by cardiac catheterization, 18 to 130 mmHg (mean 78 +/- 35 mmHg). In terms of angiographic findings, in six patients the right ventriculogram showed an oblique and low obstruction; in four patients the obstruction was high and horizontal. With regard to surgical findings, angiographic findings were confirmed by the surgeon except in one patient, in whom both types of obstruction were present. No mortality was observed. With follow-up 4 to 40 months after surgery (mean 24 +/- 15 months), 8 of 10 patients were evaluated; all corresponded to class I NYHA. Systolic gradient by echo Doppler ranged from 0 to 11 mmHg (mean 4 +/- 6 mmHg). CONCLUSIONS DCRV IS PRODUCED BY THE FOLLOWING THREE TYPES OF MUSCULAR OBSTRUCTIONS: low and oblique obstruction; high and horizontal obstruction, and mixed obstruction. Mid-term surgical results are satisfactory.

Stent fracture after stent therapy for aortic coarctation.

Background and objectives. We evaluated the technical and clinical results of implantation of the Atlas stent, the hospital stay, and the short and long-term clinical and angiographic outcome. Patients and method. The study included 169 patients (60.1 ± 10.8 year-old), 60.3% of which had acute coronary syndromes and complex lesions. Immediate success was achieved in 98% of cases. The clinical follow-up in 85.7% of the patients at 14.3 ± 6.8 months, revealed that 89% remained free of adverse events and most (94.4%) were functional class I of the CCS. Angiographic followup at 8.4 ± 4.1 months of 40.9% of the cases revealed restenosis in 27.9%. There were 2 cases of subacute thrombosis. Conclusions. The application of the Atlas™ stent in patients with a diverse clinical spectrum demonstrated good immediate and long term results, with a rate of restenosis similar to that of other stents available on the market