Omar Galal

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.

One- to Ten-Year Follow-Up Results of Balloon Angioplasty of Native Coarctation of the Aorta in Adolescents and Adults

OBJECTIVES We attempted to evaluate the role of balloon angioplasty in the treatment of discrete coarctation of the aorta in adolescents and adults, with special emphasis on long-term results. BACKGROUND Controversy persists over the use of balloon dilation for the treatment of native coarctation of the aorta. METHODS Between July 1986 and January 1997, 43 consecutive adolescent and adult patients with discrete coarctation of the aorta underwent balloon angioplasty. One- to 10-year follow-up data of 37 patients, including results of cardiac catheterization and magnetic resonance imaging (MRI), form the basis of this study. RESULTS No early or late deaths occurred. Balloon angioplasty produced a reduction in the peak to peak coarctation gradient from a mean +/- SD of 69 +/- 24 mm Hg (95% confidence interval [CI] 61 to 76) to 12 +/- 8 mm Hg (95% CI 10 to 14.8) (p < 0.001). Follow-up catheterization 12 months later (37 patients) revealed a residual gradient of 6.7 +/- 6 mm Hg (95% CI 4.6 to 8.9); 3 (7%) of 43 patients had suboptimal results with development of recoarctation, defined as peak gradient >20 mm Hg, with successful repeat angioplasty. A small aneurysm developed at the site of dilation in 3 (7%) of the 43 patients. MRI follow-up data 1 to 10.8 years (mean 5.2 +/- 2.7) after angioplasty (37 patients) revealed no new aneurysm or appreciable change in the size of the preexisting aneurysm in the three patients. The blood pressure had normalized without medication in 27 (73%) of 37 patients at follow-up examination. CONCLUSIONS Balloon angioplasty is safe and effective and should be considered a viable alternative to operation for treatment of discrete coarctation of the aorta in adolescents and adults.

Balloon coarctation angioplasty in adolescents and adults : early and intermediate results

Twenty-three adolescent and adult patients with native coarctation of the aorta underwent balloon dilatation. Dissection of the aorta developed in one patient. Data were collected on the remaining 22 patients. They ranged in age from 15 to 55 years (mean 23 +/- 9.2 years). Invasive measurement of the peak systolic gradient (PSG) and biplane angiography were performed before and immediately after angioplasty and at follow-up 4 to 48 months (mean 15 months) later. PSG before dilatation was 37 to 100 mm Hg (mean 66.9 +/- 19.9 mm Hg) and decreased to 0 to 30 mm Hg (mean 9.1 +/- 11 mm Hg) immediately after dilatation (p less than 0.001). Restenosis occurred in two patients 6 months after dilatation, and one patient had an incomplete dilatation. These three patients underwent successful redilatation and remained improved 12 to 19 months later. There was no significant change in gradient at repeat catheterization in the remaining 20 patients. PSG was 0 to 20 mm Hg (mean 5.8 +/- 7.2 mm Hg). Angiography showed that a small aneurysm developed in one patient immediately after dilatation and in another 6 months later. Eleven patients were restudied more than once, and no change in gradient or size of the aneurysm was noted at mean follow-up 25 months after dilatation. This study demonstrated that balloon angioplasty is an effective method of treating adolescent and adult patient with native coarctation of the aorta. However, because of the uncertain natural history of aneurysm after dilatation, this procedure should be considered investigational until much longer follow-up times are available.

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.

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)

Transcatheter closure of the patent ductus arteriosus : comparison between the Rashkind occluder device and the anterograde Gianturco coils technique

Thirty-five patients (mean age 43.7 months, mean weight 13 kg) underwent anterograde patent ductus arteriosus (PDA) occlusion with Gianturco coils (coil group). These patients were compared with 35 age- and weight-matched patients who underwent closure of their PDA with the Rashkind umbrella device (device group). The mean PDA diameter at its narrowest point was 2.8 mm in the coil group and 2.7 mm in the device group. There was immediate closure angiographically in 20 (57%) of 35 in the coil group compared with 9 (26%) of 35 for the device group. Color flow mapping before discharge revealed complete closure in 30 (86%) of 35 in the coil group compared with 18 (51%) of 35 in the device group (chi square = 9.5455, p < 0.005). Mean fluoroscopy time was 18.5 minutes (median 13.5 minutes) and 14.7 minutes (median 13 minutes) for the coil and device, respectively. Four coils and one device embolized down the pulmonary artery; all were successfully retrieved in the catheterization lab. Coil closure of the small to moderate PDA is safe and effective. It is more effective in achieving immediate closure than the Rashkind device. More clinical trials with the coil technique are warranted to establish the long-term results of this technique.

Percutaneous mitral valvotomy with the Inoue balloon catheter in children and adults: immediate results and early follow-up.

Percutaneous mitral balloon valvotomy (PMV) using the Inoue balloon catheter was attempted in 60 consecutive patients with severe symptomatic mitral stenosis. There were 10 children (mean age 13 years) and 50 adults (mean age 31 years). Forty patients were females and 20 were males; 53 were in sinus rhythm. The procedure was technically successfully performed in 57 (95%) patients. There were no deaths or thromboembolic complications. Balloon valvotomy was done using a 22 to 30 mm diameter catheter with the echo/Doppler guided stepwise mitral dilatation technique. After PMV the mean left atrial pressure decreased from 23.0 +/- 5.0 to 14.0 +/- 4.0 mm Hg (p less than 0.001). The mean mitral valve gradient (MVG) decreased from 15.0 +/- 4.0 to 6.0 +/- 2.0 mm Hg (p less than 0.001). The mitral valve area (Gorlin formula) increased from 0.7 +/- 0.2 to 1.6 +/- 0.4 cm2 (p less than 0.001). The mitral valve area as determined by echocardiography increased from 0.8 +/- 0.1 to 1.9 +/- 0.3 cm2 (p less than 0.001). Mild mitral regurgitation (MR) developed in six patients (11%) and increased by one grade in another five patients (9%). No patient developed severe mitral regurgitation. Mitral valve area at mean follow-up of 4.8 months remained unchanged at 1.9 +/- 0.3 cm2. We conclude that PMV, using the Inoue balloon catheter, is safe and effective in the treatment of severe mitral stenosis in children and adults, without inducing significant mitral regurgitation.

Magnetic resonance imaging compared with angiography in the evaluation of intermediate-term result of coarctation balloon angioplasty

Between July 1986 and December 1990, 24 consecutive adult patients with native coarctation of the aorta underwent balloon dilatation. Their ages ranged from 15 to 55 (mean 25) years. Dissection of the aorta developed in one patient. The remaining 23 patients were restudied by catheterization and magnetic resonance imaging (MRI) 8 to 60 (mean 21) months after dilatation. Both studies were performed between 1 and 180 (mean 40) days of each other. The diameter of the aorta at the site of previous coarctation was measured on angiogram and MRI by two independent observers. The data were compared by means of linear regression analysis. The gradient across the previous coarctation site ranged from 0 to 20 (mean 7 +/- 7.3) mm Hg. The diameter of the aorta at the site of previous coarctation measured on angiogram was 13.7 +/- 3.7 mm and on MRI it measured 13.5 +/- 3.7 mm, with excellent correlation (r = 0.96, SEE = 0.92, p < 0.001). Two patients had small aneurysms 2 cm in diameter demonstrated by angiography and MRI, and two patients developed restenosis, diagnosed correctly by both cardiac catheterization and MRI. This study demonstrates that MRI provides excellent visualization of the anatomy of the aorta and is a good noninvasive method for follow-up of patients undergoing balloon coarctation angioplasty.

Feasibility and effectiveness of repeated balloon dilatation of restenosed congenital obstructions after previous balloon valvuloplasty/angioplasty

Balloon dilatation of congenital stenotic lesions of the heart and great vessels has been used for more than a decade. Varying incidence of residual obstruction or recurrence, hereafter referred to as restenosis, has been observed at follow-up. The purpose of this study was to evaluate the feasibility and effectiveness of repeated balloon dilatation of restenosed lesions after previous balloon dilatation for pulmonic (PS) and aortic (AS) stenosis and native aortic coarctation (AC). Neonates, infants, and children (n = 178) underwent balloon valvoplasty/angioplasty with reduction (p < 0.001) or peak-to-peak systolic pressure gradients from 91 +/- 41 (mean +/- SD) mm Hg to 25 +/- 19 mm Hg, from 70 +/- 20 mm Hg to 26 +/- 12 mm Hg, and from 48 +/- 17 mm Hg, to 11 +/- 9 mm Hg in patients with PS, AS, and AC, respectively. Repeated catheterization or echo-Doppler studies or both were performed from 3 months to 5 years after initial balloon dilatation. Residual gradients at follow-up were 26 +/- 26 mm Hg, 34 +/- 20 mm Hg, and 16 +/- 15 mm Hg, respectively, for PS, AS, and AC and remained significantly lower (p < 0.01) compared with gradients before the balloon dilatation. However, when results of individual patients were scrutinized, 9 (11%) of 80 patients with PS, 6 (23%) of 26 patients with AS, and 16 (27%) of 60 patients with AC had restenosis, on the basis of standard criteria. Repeated balloon dilatation was performed with reduction (p < 0.05 to < 0.001) of peak-to-peak gradients from 89 +/- 40 mm Hg to 38 +/- 20 mm Hg in 9 patients with PS, from 77 mm Hg to 13 mm Hg and 66 mm Hg to 6 mm Hg, respectively, in 2 patients with AS, and from 38 +/- 11 mm Hg to 10 +/- 6 mm Hg in 12 patients with AC. Echo-Doppler studies, 2 to 6.5 years after repeated balloon dilatation, indicated excellent results, with residual peak instantaneous Doppler gradients of 24 +/- 13 mm Hg in PS, 43 +/- 20 mm Hg in AS, and 11 +/- 6 mm Hg in AC groups, respectively. This improvement is irrespective of the cause of restenosis after initial balloon valvuloplasty/angioplasty. From this experience, we conclude that repeated balloon dilatation is feasible and effective in relieving restenosis after initial balloon valvuloplasty/angioplasty.

Regulation of sympathetic activity in children with various congenital heart diseases.

ABSTRACT: We studied the α and β-adrenoceptor activity and catecholamine and cAMP levels in 112 children and infants admitted to the hospital for diagnostic or interventional catheterization of tetralogy of Fallot, ventricular septal defects with or without hypertension, pulmonary stenosis, coarctation of the aorta, and various complex cyanotic congenital cardiac diseases and compared them with 14 children undergoing transcatheter occlusion of patent ductus arteriosus with insignificant left-to-right-shunts. The mean total platelet α-adrenoceptor density of the study population was elevated by 73%. Both the increases in acyanotic (p < 0.05) and cyanotic (p < 0.005) patients as well as the difference between the two groups (p < 0.01) were significant. Based on the congenital disease classification, the elevation in receptor density was also significant in all groups of patients, except coarctation of the aorta. On the other hand, the mean lymphocyte β-adrenoceptor density was attenuated by 27%, showing significant difference between the acyanotic and the patent ductus arteriosus groups, but none between acyanotic and cyanotic or cyanotic and the patent ductus arteriosus groups. Among the congenital groups, only the left-to-right shunts and the pulmonary stenosis group showed significant (p < 0.05) decrease in β-adrenoceptor density, whereas the affinity of all the groups toward [125I]iodocyanopindolol was hardly influenced. The plasma levels of all three catecholamines, norepinephrine, epinephrine, and dopamine, were elevated, but cAMP remained unchanged. It seems that the sympathetic nervous system responds to changes triggered by some congenital heart diseases by stimulating α-adrenoceptors, which may be further increased by cyanosis and an attenuation of β-adrenoceptors associated with an increase in plasma catecholamine levels.