Troy A. Johnston

Procedural Results and Acute Complications in Stenting Native and Recurrent Coarctation of the Aorta in Patients Over 4 Years of Age: A Multi-Institutional Study

Background: We report a multi‐institutional experience with intravascular stenting (IS) for treatment of coarctation of the aorta. Methods and Results: Data was collected retrospectively by review of medical records from 17 institutions. The data was broken down to prior to 2002 and after 2002 for further analysis. A total of 565 procedures were performed with a median age of 15 years (mean = 18.1 years). Successful reduction in the post stent gradient (<20 mm Hg) or increase in post stent coarctation to descending aorta (DAo) ratio of >0.8 was achieved in 97.9% of procedures. There was significant improvement (P < 0.01) in pre versus post stent coarctation dimensions (7.4 mm ± 3.0 mm vs. 14.3 ± 3.2mm), systolic gradient (31.6 mm Hg ± 16.0 mm Hg vs. 2.7 mm Hg ± 4.2 mm Hg) and ratio of the coarctation segment to the DAo (0.43 ± 0.17 vs. 0.85 ± 0.15). Acute complications were encountered in 81/565 (14.3%) procedures. There were two procedure related deaths. Aortic wall complications included: aneurysm formation (n = 6), intimal tears (n = 8), and dissections (n = 9). The risk of aortic dissection increased significantly in patients over the age of 40 years. Technical complications included stent migration (n = 28), and balloon rupture (n = 13). Peripheral vascular complications included cerebral vascular accidents (CVA) (n = 4), peripheral emboli (n = 1), and significant access arterial injury (n = 13). Older age was significantly associated with occurrence of CVAs. A significant decrease in the technical complication rate from 16.3% to 6.1% (P < 0.001) was observed in procedures performed after January 2002. Conclusions: Stent placement for coarctation of aorta is an effective treatment option, though it remains a technically challenging procedure. Technical and aortic complications have decreased over the past 3 years due to, in part, improvement in balloon and stent design. Improvement in our ability to assess aortic wall compliance is essential prior to placement of ISs in older patients with coarctation of the aorta.

Intermediate follow‐up following intravascular stenting for treatment of coarctation of the aorta

Background: We report a multiinstitutional study on intermediate‐term outcome of intravascular stenting for treatment of coarctation of the aorta using integrated arch imaging (IAI) techniques. Methods and Results: Medical records of 578 patients from 17 institutions were reviewed. A total of 588 procedures were performed between May 1989 and Aug 2005. About 27% (160/588) procedures were followed up by further IAI of their aorta (MRI/CT/repeat cardiac catheterization) after initial stent procedures. Abnormal imaging studies included: the presence of dissection or aneurysm formation, stent fracture, or the presence of reobstruction within the stent (instent restenosis or significant intimal build‐up within the stent). Forty‐one abnormal imaging studies were reported in the intermediate follow‐up at median 12 months (0.5–92 months). Smaller postintervention of the aorta (CoA) diameter and an increased persistent systolic pressure gradient were associated with encountering abnormal follow‐up imaging studies. Aortic wall abnormalities included dissections (n = 5) and aneurysm (n = 13). The risk of encountering aortic wall abnormalities increased with larger percent increase in CoA diameter poststent implant, increasing balloon/coarc ratio, and performing prestent angioplasty. Stent restenosis was observed in 5/6 parts encountering stent fracture and neointimal buildup (n = 16). Small CoA diameter poststent implant and increased poststent residual pressure gradient increased the likelihood of encountering instent restenosis at intermediate follow‐up. Conclusions: Abnormalities were observed at intermediate follow‐up following IS placement for treatment of native and recurrent coarctation of the aorta. Not exceeding a balloon:coarctation ratio of 3.5 and avoidance of prestent angioplasty decreased the likelihood of encountering an abnormal follow‐up imaging study in patients undergoing intravascular stent placement for the treatment of coarctation of the aorta. We recommend IAI for all patients undergoing IS placement for treatment of CoA.

Endovascular stents for treatment of coarctation of the aorta: Acute results and follow-up experience

Balloon angioplasty as treatment for coarctation of the aorta is increasingly performed. Endovascular stents have been proposed as a means of improving the efficacy and safety of the procedure. In this report, we describe one institutions immediate results and clinical follow‐up after implantation of endovascular stents. Retrospective analysis for endovascular stent placement for coarctation of the aorta between 1993 and 2002 was made. The immediate hemodynamic results and clinical follow‐up were reviewed. Thirty‐two patients underwent attempted stent placement for coarctation. Twenty‐three patients had postoperative recurrent coarctation and nine had native coarctation. The systolic gradient decreased from 31 to 1.8 mm Hg (P = 0.001) and the diameter was increased 8.1 to 13.5 mm (P–0.001). Mean follow‐up was 1.5 years. The mean follow‐up gradient as assessed by sphygomomanometry was 13.1 mm Hg. Eight patients underwent 10 successful further dilations. Complications included one stent migration and one aortic dissection. The use of stents as an adjunct to balloon angioplasty in selected patients with coarctation can be performed with low complication rates and provides excellent immediate relief of obstruction with promising follow‐up. Further dilation of these stents is possible. Long‐term follow‐up is warranted. Catheter Cardiovasc Interv 2004;62:499–505.

Front Teeth-to-Carina Distance in Children Undergoing Cardiac Catheterization

Background:Knowledge of normal front teeth–to–carina distance (FT-C) might prevent accidental bronchial intubation. The aim of the current study was to measure FT-C and to examine whether the Morgan formula for oral intubation depth, i.e., endotracheal tube (ETT) position at front teeth (cm) = 0.10 × height (cm) + 5, gives appropriate guidance when intubating children of different ages. Methods:FT-C was measured in 170 infants and children, aged 1 day to 19 yr, undergoing cardiac catheterization. FT-C was obtained as the sum of the ETT length at the upper front teeth/dental ridge and the distance from the ETT tip to the carina. The latter measure was taken from an anterior–posterior chest x-ray. Results:There was close linear correlation between FT-C and height: FT-C (cm) = 0.12 × height (cm) + 5.2, R2 = 0.98. The linear correlation coefficients (R2) for FT-C versus weight and age were 0.78 and 0.91, respectively. If the Morgan formula had been used for intubation, the ETT tip would have been at 90 ± 4% of FT-C. No patient would have been bronchially intubated, but the ETT tip would have been less than 0.5 cm from the carina in 13 infants. Conclusions:FT-C can be well predicted from the height/length of the child. The Morgan formula provides good guidance for intubation in children but can result in a distal ETT tip position in small infants. Careful auscultation is necessary to ensure correct tube position.

Coronary compression by an epicardial pacing lead within the pericardium

A 9-year-old boy who had required implantation of an epicardial ventricular pacemaker as a neonate for significant bradycardia presented with chest pain during exercise. At the time of pacemaker implantation, additional lead slack was advanced into the pericardial space to accommodate linear growth (Fig. 1). As part of his evaluation, exercise stress testing was performed. There were significant ST segment changes evident on the electrocardiogram. The following day, he underwent coronary angiography, which demonstrated that the epicardial pacing lead was compressing the left anterior descending coronary artery (Fig. 2). Because of concern of coronary artery impingement, he was scheduled for surgi-

Balloon angioplasty for Blalock-Taussig shunt failure in the early postoperative period.

Blalock‐Taussig shunt failure is an infrequent but devastating, and often life‐threatening, postoperative complication. Percutaneous balloon angioplasty (BA) of a stenotic modified Blalock‐Taussig shunt (mBTS) has been successfully used in the setting of progressive shunt failure months to years after shunt creation. Only a few case reports exist where BA was used in the early postoperative period. We report a case series of urgent balloon angioplasty for acute early postoperative mBTS failure. Five patients were performed with BA. BA was performed within the first 24 hr following mBTS placement in three patients. Mean total procedure time was 57 min (range, 34–77 min) and mean total fluoroscopic time was 13.8 min (range, 6.4–24.1 min). Immediate success, defined as increased angiographic diameter, was accomplished in 4/5 procedures. One patient died during the procedure. Two patients survived to Glenn procedure. One patient underwent redo mBTS and one died the day after the BA. In selected patients, BA can relieve acute thrombosis of mBTS. The risk for reintervention and death is high.

Amplatzer septal occluder closure of secundum atrial septal defects in the presence of persistent left superior vena cava to coronary sinus

Secundum atrial septal defects (ASDs) are routinely closed using transcatheter devices. In patients with left superior vena cava (LSVC) draining to the coronary sinus (CS), the device must not obstruct CS drainage. We report five cases of successful ASD device closure without obstructing flow from the LSVC or dilated CS.

Long‐term outcomes and re‐interventions following balloon aortic valvuloplasty in pediatric patients with congenital aortic stenosis: A single‐center study

To describe long‐term risk of mortality, aortic insufficiency (AI), and re‐intervention following balloon aortic valvuloplasty (BAV) in pediatric patients and to identify risk factors for re‐intervention.

A phantom case of coarctation of the aorta.

A 9-month–old infant girl was referred for management of transverse aortic arch hypoplasia in the setting of a right arch with mirror-image branching of the brachiocephalic vessels and an aberrant left subclavian artery originating from the descending aorta. Because she was asymptomatic and without left ventricular hypertrophy on echocardiogram, no interventions were undertaken. At multiple subsequent clinic visits through 4 years of age, extremity pulses and blood pressures continued to be normal and equal despite persistent arch hypoplasia and Doppler evidence of arch obstruction on serial echocardiograms. At 4.5 years of age, her left radial pulse was noted to be relatively weaker for the first time, but 4-extremity blood pressures remained equal. An echocardiogram with Doppler revealed a continuous systolic-diastolic forward flow waveform in the abdominal aorta. One year later, her left radial pulse remained relatively weak, and her right leg systolic blood pressure was 30 mm Hg lower than that in her upper extremities. These findings prompted magnetic resonance angiography, which revealed a complex form of right aortic arch with moderate transverse aortic arch hypoplasia measuring 6 mm in diameter, narrowing to 4 mm at the isthmus. Distal to the coarctation, the proximal descending aorta was 11 mm in diameter. Both common carotid arteries arose proximal to the hypoplastic transverse aortic arch. There were no significant aortic-intercostal collateral arteries (Figure 1 and online-only Data Supplement Movie I). Figure 1. Three-dimensional (3D) reconstruction of …