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Coarctation in the first year of life. Patterns of postoperative effect
Insights
Surgical repair of aortic coarctation in infants offers high survival rates. Postoperative Doppler studies reveal dynamic pressure gradient changes, highlighting the need for stress testing to fully assess outcomes.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Medical Diagnostics
Background:
- Aortic coarctation is a critical congenital heart defect often presenting with congestive heart failure in infants.
- Surgical intervention is necessary for infants with severe aortic coarctation and heart failure.
- Assessing the long-term efficacy of surgical repair in this population is crucial.
Purpose of the Study:
- To evaluate the surgical outcomes and long-term hemodynamic effects of aortic coarctation repair in infants.
- To assess the utility of noninvasive Doppler pressure measurements and stress testing in monitoring postoperative results.
Main Methods:
- Retrospective analysis of 31 infants operated on for aortic coarctation and congestive heart failure between 1975 and 1982.
- Surgical procedures included resection and end-to-end anastomosis (RETE), subclavian flap aortoplasty (SFA), and patch aortoplasty (PA).
- Noninvasive assessment using serial Doppler arm-to-leg pressure measurements at rest and during stress testing.
Main Results:
- High operative survival rate of 97% (30 out of 31 infants).
- Postoperative Doppler studies identified four patterns of pressure gradients: spontaneous resolution, persistence, progressive increase, and absence of gradient.
- Stress testing effectively unmasked residual gradients not evident at rest; no significant differences were observed between surgical techniques.
Conclusions:
- Surgical repair of infantile aortic coarctation is associated with expected survival.
- Postoperative hemodynamic response is dynamic, with varying patterns of residual or recurrent coarctation.
- Doppler techniques combined with stress testing provide valuable physiological evaluation for infantile aortic coarctation.
Abstract:
From 1975 to 1982, 31 infants were operated upon in the first year of life for aortic coarctation and congestive heart failure. Operations performed were resection and end-to-end anastomosis (RETE) in 14, subclavian flap aortoplasty (SFA) in six, patch aortoplasty (PA) in five, and other procedures in six. Thirty of the thirty-one (97%) survived the operation. To assess the effect of operation, 26 infants were studied noninvasively with Doppler arm-to-leg pressure measurements at rest and with stress. Preoperatively, the median arm-to-leg gradient at rest was 77 mm Hg. Serial postoperative Doppler studies demonstrated progressive changes in arm-to-leg pressure gradients: 69% had residual arm-to-leg gradients that spontaneously resolved, 13% had residual gradients that persisted, 13% had progressive increase in gradient, and one child had neither early nor late gradient. Stress testing often unmasked gradients not present in the resting state. No differences were noted among the three surgical groups: RETE, SFA, and PA. From our experience, we have made four conclusions with regard to repair of coarctation of the aorta in infants. First, surgical survival is expected. Second, the effect of the operation is dynamic, with four patterns defined: (1) complete relief of coarctation, (2) transient residual coarctation, (3) persistent residual coarctation, and (4) recurrent coarctation. Third, optimal surgical therapy seems to be an eclectic approach. Fourth, physiological evaluation of coarctation in infants can be obtained by Doppler techniques in conjunction with stress testing.