S mortem that the coarctate aortic segment could be. Role of Balloon Angioplasty in the Treatment of Aortic Coarctation

Transcription

1 Role of Balloon Angioplasty in the Treatment of Aortic Coarctation P. Syamasundar Rao, MD, and Paramjeet S. Chopra, MD Departments of Pediatrics and Surgery, University of Wisconsin Medical School, Madison, Wisconsin Since the initial report of coarctation balloon angioplasty in 1982, several groups have used this technique for native coarctations in neonates, infants, and children and for postoperative recoarctations. However, recommendations for use of balloon angioplasty as a treatment procedure of choice are clouded by reports of aneurysm development at the site of coarctation. Here we review our experience as well as that published in the literature, including Valvuloplasty and Angioplasty of Congenital Anomalies Registry data, and present evidence in support of balloon angioplasty as a therapeutic procedure of choice for treating native and recurrent postoperative aortic coarctations. Balloon angioplasty of native aortic coarctations in 2 neonates and infants 1 year old or less reduced peak systolic pressure gradient across the coarctation from 4 f 12 mm Hg (mean f standard deviation) to 11 f 8 mm Hg (p <.1); no patient required immediate surgical intervention. The residual gradient at follow-up (mean follow-up, 12 months) in 16 infants was 18 f 16 mm Hg, a significant improvement (p <.1) compared with preangioplasty values. In none of the patients did an aneurysm develop. Recoarctation developed in 5 (31%) of the 16 infants and was successfully treated either by surgical resection (in 2) or by repeat balloon angioplasty (in 3). A comparison of mortality and recurrence rates between the balloon angioplasty and surgical groups was made with the help of data pooled from the literature published since 198. The initial (7% versus 23%) and late (2% versus 25%) mortality and recoarctation (11% versus 18%) rates were higher (p <.25) after surgical intervention than after balloon therapy. When only reports in which patients were operated on after 1979 were included in this type of analysis, the initial and late mortality rates remained higher (p <.1) after operation than after angioplasty, and the recoarctation rates became similar (p >.1). Thirty-two children (>1 year old) underwent balloon angioplasty of native coarctation with a resultant reduction in peak systolic pressure gradient from 48 f 19 mm Hg to 1 f 9 mm Hg (p <.1), which continued to remain low (14 f 11 mm Hg; p <.1) at follow-up catheterization in 24 children 13 months (mean) later. There were no immediate or late deaths. A small aneurysm developed in 1 patient (4%) but did not require intervention. Recoarctation developed in 2 patients (8%), and in both, repeat balloon angioplasty was performed with good results. Hypertension decreased. Comparison with pooled surgical data revealed that initial (% versus 1.6%; p <.25) and late (% versus 8%; p <.1) mortality rates were lower after balloon angioplasty and that rates of recoarctation (6% versus 5.5%) and aneurysm formation (12% versus 13%) were similar (p >.1). Postoperative aortic recoarctation in 1 children was treated by balloon dilation. The coarctation gradient was reduced from 52 f 21 mm Hg to 15 f 7 mm Hg (p <.1), which decreased to 6 f 6 mm Hg (p <.1) at a mean follow-up of 17 months. There were no deaths, recoarctation, or aneurysm formation in this small group of patients. Compared with pooled data of repeat operation from the literature, the balloon angioplasty group had a lower mortality rate, but the recoarctation rates were similar. Although we have compared pooled surgical data with pooled balloon therapy data in all three groups presented, we recognize that there are limitations to the comparison of older surgical studies with current balloon angioplasty experience. Based on our experience and that in the literature, we surmise that coarctation balloon angioplasty is the treatment of choice for symptomatic native coarctation and recoarctation, especially in neonates and infants 1 year old or less. (Ann Thorac Surg 1991;52:621-31) s and colleagues [l] demonstrated in a neonate post S mortem that the coarctate aortic segment could be dilated by balloon angioplasty. Lock and associates [24] extended these observations and showed that surgically excised coarctate aortic segments and experimentally created coarctation in lambs and dogs could be dilated by Accepted for publication Dec 31, 199. Address reprint requests to Dr Rao, Division of Pediatric Cardiology, University of Wisconsin Children s Hospital, 6 Highland Ave, Madison, WI balloon angioplasty. Since then, several short-term and a few intermediate-term results of balloon angioplasty of aortic coarctations not previously operated on ( native coarctations) as well as postoperative recoarctations have been published. However, there is considerable controversy among cardiologists and surgeons in regard to whether the aortic coarctations should be balloon dilated or surgically treated and, if balloon angioplasty is chosen, which coarctations should be dilated. We support the view that balloon angioplasty is an effective therapeutic alternative to surgical treatment of 1991 by The Society of Thoracic Surgeons /91/$3,5

2 622 CONGENITAL HEART RAO AND CHOPRA Ann Thorac Surg 1991:52: m e m C 6.o E Z E c 2 4 m " 2 p'.1 Mean + SEM p<o.ool Pre Post FU Pre Post FU Literature UW - M Fig 1, Peak systolic pressure gradients across aortic coarctation before balloon coarctation angioplasty (Pre), immediately after angioplasty (Post), and at follow-up (FU) in neonates and infants (52 year old) for the literature group and our group (UW - M). Note significant (p <.1) decrease in gradient immediately after angioplasty in both groups. The gradients at follow-up remained low and continued to be significantly lower (p <.1) compared with preangioplasty values. (SEM = standard error of the mean.) aortic coarctation. Data from our experience with balloon angioplasty during the last 5% years in 62 consecutive patients between 3 days and 13 years old for relief of native aortic coarctations (n = 52) and postoperative recoarctations (n = lo), including some patients previously reported [512], and the experience reported in the literature will be used as supportive material. The description of the patients, technique of coarctation percutaneous balloon angioplasty, data gathered, and statistical analysis used have been described previously [5-71 and will not be detailed here except for three important technical aspects of the procedure. First, heparin sodium, 1 Uikg (maximum of 2, U), was administered immediately after the introduction of the arterial catheter. The heparin effect was neither reversed nor continued after balloon angioplasty. Second, the size of the balloon chosen for angioplasty was two times (or more) the size of the coarctate segment but no larger than the size of the descending aorta at the level of the diaphragm as measured from a frozen frame of the video recording. Third, at no time was a catheter or guidewire manipulated over the area of freshly dilated coarctation of the aorta. For the purpose of discussion, the coarctations are divided into three groups: native coarctation, usually associated with other defects, in the neonate and young infant (51 year old); native coarctation in children (>1 year old); and postoperative recoarctations. Native Coarctation in the Neonate and Young Infant Immediate Results In our case material, 2 infants aged 3 days to 12 months (median age, 2.7 months) underwent balloon angioplasty with a resultant reduction in peak systolic pressure gradient across the coarctation from 4 t 12 mm Hg (mean 5 standard deviation) to 11 t 8 mm Hg ( p <.1) (Fig 1). Thirteen (65%) of the 2 infants had associated major cardiac defects. One infant died 2 days after balloon angioplasty and will be discussed later. All the other infants had improvement in symptoms and were discharged home within 24 to 48 hours. The condition of the infants who were in heart failure improved, and their systemic hypertension decreased. The femoral pulses, which had either been absent or markedly reduced and delayed compared with the brachial pulses, became palpable with increased pulse intensity after angioplasty. Review of the literature (excluding our reports and the Valvuloplasty and Angioplasty of Congenital Anomalies [VACA] Registry patients [ 131) revealed that 39 neonates and infants underwent coarctation balloon angioplasty; they were derived from eight reports [ Twenty-two (76%) of the 29 infants for whom data on associated anomalies were available had severe associated defects, including moderate to large ventricular septa1 defect, mitral valve atresia, Shone's anomaly, and subvalvar aortic stenosis. Discrete and not so discrete coarctations were dilated, but long-segment coarctations were excluded for the most part. Adequate pressure data were available for 25 infants ranging between 4 days and 12 months old with a median age of 4 weeks. Balloon angioplasty in these infants reduced the peak systolic pressure gradient across the coarctation from 64 t 34 mm Hg to 23 % 26 mm Hg (p <.1) (see Fig 1). Two of the 39 infants required immediate surgical intervention [14, 161. There were three deaths [14, 16, 181, which will be discussed later. The condition of the remaining infants improved clinically, and they were discharged home. The pressure gradient reduction data in 27 neonates and infants from the VACA Registry [13] were equally impressive. Follow-up Results From our group of 2 neonates and infants who underwent balloon angioplasty, 16 had follow-up catheterization and angiography 12 k 4 months after angioplasty [ll]. The residual gradient was 18 t 16 mm Hg (see Fig l), a significant improvement compared with their preangioplasty gradient of mm Hg ( p <.1). Recoarctation, defined as a gradient greater than 2 mm Hg [ll], developed in 5 (31%) of these patients; 2 underwent surgical repair of residual coarctation early in our experience, and the remaining 3 underwent repeat balloon angioplasty with reduction of gradient from 3, 39, and 46 mm Hg to, 1, and 8 mm Hg, respectively. Follow-up catheterization and angiographic data were available for 8 neonates and infants [17, 19, 21 from among the 39 infants in the literature group. These data were obtained 11 t 4 months after the procedure. The residual gradient at restudy was 22 k 1 mm Hg (see Fig l), a significant improvement compared with the preangioplasty gradient of mm Hg ( p <.5) in these 8 infants. All 39 patients had clinical follow-up, and surgical resection of coarctation was performed in 1 infant because of critical recoarctation [MI. The remaining infants seem to have done well clinically. No follow-up data were reported from the VACA Registry [13]. The high recurrence rate in infants 1 year old or

3 Ann Thorac Surg 1991;52: CONGENITAL HEART RAO AND CHOPRA 623 younger is not too dissimilar to that seen after surgical intervention. In a previous study, our group [8] identified four factors for recurrence of aortic coarctation after balloon angioplasty: age less than 12 months; aortic isthmus less than two thirds the size of the ascending aorta; coarctate aortic segment less than 3.5 mm before angioplasty; and coarctate aortic segment less than 6 mm after dilation. We also observed that the larger the number of risk factors, the higher the chance for recurrence. The majority of the infants in this series had several of the risk factors, and therefore it is not surprising that the recoarctation rate was high. Despite this high recurrence, we believe balloon angioplasty is a worthwhile procedure because repeat intervention to relieve residual or recurrent obstruction can be safely undertaken when the infant is older and not acutely ill. Immediate Complications Of the 2 infants in our study group, one 11-day-old infant died 2 days after balloon angioplasty while awaiting surgical palliation of a complex cyanotic heart defect (double-inlet left ventricle with severe subaortic [bulboventricular foramen] obstruction and hypoplastic transverse aortic arch), a mortality rate of 5%. There were three deaths [14, 16, 181 among the 39 neonates and infants in the literature, giving a mortality rate of 7.7%. One infant did not improve after angioplasty and died during banding of the main pulmonary artery for associated atrioventricular canal defect [14]. Another infant with associated ventricular septa1 defect died after perforation of the aorta caused by manipulation of an angiographic catheter immediately after balloon angioplasty [16]. The third infant died of recurrent ventricular fibrillation on the day of balloon angioplasty [18]; whether or not this was related to transient prolongation of the QTc interval observed after balloon dilation [22] is not known. One 8-day-old infant from the VACA Registry [13] died 3 weeks after angioplasty, giving a 3.7% mortality rate. The cause of death was not reported. A 5-day-old infant required resuscitation immediately after angioplasty and was later referred for surgical ligation of patent ductus arteriosus. Among the 2 neonates and infants in our balloon angioplasty group, 2 neonates had lost their pulse but had good perfusion of the lower extremity. The following morning, the pulse returned to normal. No immediate arterial complications were reported for the 39 neonates and infants collected from the literature [ It is not clear whether the arterial complications were absent or whether the format of the reports did not allow mention of such complications. Description of complications in the VACA Registry patients was not conducive to separating the arterial complications between the infant and children groups. Other complications during and immediately after balloon angioplasty were remarkably minimal. Blood loss necessitating transfusion was reported in several studies. Follow-up Complications There was one late death in our study group, and it was related to severe mitral and aortic stenosis and moderate hypoplasia of the left atrium and left ventricle, a forme fruste hypoplastic left heart syndrome. There was one late death in the infant group from the literature [2], and no late deaths were reported for the VACA Registry patients ~31. The recommendations for use of balloon angioplasty of native aortic coarctations have been clouded by reports [19, 23-27] of development of aneurysms at the site of coarctation dilation. However, to our knowledge, aneurysms have not been reported after balloon angioplasty of native coarctation in the infant group; detailed review of patients reported to have aneurysm development [ 19, 23-27] revealed that none of them were infants less than 1 year old at the time of angioplasty. Also, the VACA Registry [13] did not have any children less than 4 years old in whom aneurysms developed. Although these data are encouraging in regard to lack of aneurysms in the infant group, longer-term follow-up results than are currently available must be scrutinized before declaring freedom from aneurysm development in this age group. Comparison With Operation Twenty-five reports published since 198 (Appendix 1) were examined to assess the results of operation for coarctation in neonates and infants less than 1 year old [ll]. The authors operated on 24 to 191 infants from 1953 to Associated major cardiac defects were present in 1,26 (68%) of 1,846 infants for whom such data were available. Operative mortality rates ranged between % and 5% with an overall mortality rate of 23% (451/1,94) (Table 1). The investigators followed up 18 to 144 infants and observed a 3% to 59% late mortality rate. The average late mortality rate was 25% (349/1,425 infants) during an average follow-up of 11 months to 25 years. Recurrence of coarctation ranged from % to 33% with an average recurrence rate of 18% (211/1,24 infants) (see Table 1). In an attempt to have comparable time periods during which both surgical and balloon interventions were performed, we [ll] examined the results for infants who underwent operation for coarctation between 1979 and Prevalence of associated major heart defects was 74% (151/24 infants), similar ( p >.1) to the prevalence in the balloon angioplasty group (73%; 35/48 infants). The mortality rates and recoarctation rates in these two surgical groups (25 reports published since 198 and five reports on surgical intervention performed between 1979 and 1986) were compared with pooled data from our study plus eight balloon angioplasty reports [ dealing with infants less than 1 year old in Table 1. The mortality rates are higher for operation than for balloon angioplasty, and recoarctation rates are similar, especially when the more recent surgical results are compared with balloon angioplasty results. In conclusion, our data and data in the literature indicate that balloon angioplasty is effective in relieving aortic obstruction in neonates and young infants with an acceptable complication rate. The recoarctation rate is high, but recoarctation can be relieved by repeat balloon angioplasty or surgical intervention when the infant is in stable condition and less acutely ill. Because of these results and

4 624 CONGENITAL HEART RAO AND CHOPRA Ann Thorac Surg 1991; Table 1. Comparison of Mortality and Recoarctation Rates Between Surgical and Balloon Angioplasty Groups of Neonates and lnfants Less thnn 1 Year Old Variable 25 Balloon 5 Coarctation Surgical Reports, Angioplasty Surgical Reports, " p Value p Value ' Initial mortality 451,94 (23%) <.5 4/59 (7%) <.1 3/24 (15%) Late mortality 349,425 (25%) <.5 1/55 (2%) <.5 26/174 (15%) Recoarctation 221/1,24 (18%) <.25 6/55 (11%) >o. 1 14/174 (8%) a Data were pooled from these 25 reports published in the 198s; see Appendix 1. Data were pooled from eight reports in the literature [ plus one case material. Data were pooled from five reports (Appendix 1: [lo, 17,22,24,25]) presenting results of coarctation operations performed between 1979 and Adapted from Rao PS, Thapar MK, Gala1, Wilson AD. Follow-up results of balloon angioplasty of native recoarctation in neonates and infants. Am Heart J 199;12:131M, by permission of Mosby-Year Book, Inc. the reported high mortality and morbidity after surgical repair in neonates and young infants, we recommend balloon angioplasty as the procedure of choice for relief of symptomatic native coarctation in neonates and infants 1 year old or younger. Native Coarctation in Children (>1 Year Old) lmmed iate Results From our case material, 32 children aged 14 months to 13 years (median age, 6.5 years) underwent balloon angioplasty of native coarctation with a resultant reduction in peak systolic pressure gradient across the aortic coarctation from 48 k 19 mm Hg to 1 f 9 mm Hg (p <.1) (Fig 2). No patient required immediate surgical intervention. The femoral pulses became palpable with increased pulse intensity after angioplasty, and hypertension decreased. All patients were discharged home within 24 hours after the procedure. Review of the literature excluding our reports and VACA Registry material revealed that 99 children underwent balloon coarctation angioplasty; they were derived 6.O E ZE L 4 : " 2 p<o.ool p<o.ool Pie Post FU Pre Post FU Literature UW - M Fig 2. Peak systolic pressure gradients across aortic coarctation before balloon coarctation angioplasty (Pre), immediately after angioplasty (Post), and at follow-up (FU) in children (>I year old) for the literature group and our group (UW - M). Note significant (p <.1) decrease in gradient immediately after angioplasty in both groups. The gradients at follow-up remained low and continued to be significantly lower (p <.1) compared with preangioplasty values. (SEM = standard error of the mean.) from nine studies [17, 19, 21, 24, 25, 27-3]. One report [26] presented the results of balloon angioplasty in 33 patients aged 2 months to 29 years, but their description did not indicate the numbers of neonates, children and adults in the study population. Adequate data on predilation and postdilation coarctation gradients were available for 43 of the 99 children. These 43 children ranged in age from 1 year to 18 years (median age, 5.8 years). The gradient across the coarctation was reduced from 52 f 16 mm Hg to 12 k 11 mm Hg ( p <.1) after angioplasty (see Fig 2). Three reports [21, 25, 271 did not provide pressure data for individual patients but did have group data; in each of these studies there was an impressive decrease in peak systolic pressure gradient from a mean of 29, 46, and 51 mm Hg to a mean of 6, 8, and 22 mm Hg, respectively. Of all 99 children, 1 child required surgical resection on the day after balloon dilation [3]. One patient from among the 33 not categorized by age also needed surgical resection 1 month after angioplasty [26]. The remaining patients did well with reduction in hypertension and improvement in symptoms when present [ 17, 19, 24, 27-3]. From the VACA Registry [13], pressure gradient data were available for 97 children. The gradient for the entire group (including neonates and infants) decreased from 48? 19 mm Hg to 12 f 11 mm Hg after balloon angioplasty. Follow-up Results From our study group, 24 children underwent repeat catheterization 13 f 8 months after angioplasty and had a residual gradient of 14 f 11 mm Hg (see Fig 2). The preangioplasty gradient in these 24 patients was 5 & 22 mm Hg (p <.1). Repeat balloon angioplasty was required in 2 children and led to good results in both. The remaining children were asymptomatic with relief of hypertension (138 f 27 mm Hg before angioplasty versus 11 f 15 mm Hg after angioplasty; p <.1) on follow-up. Follow-up catheterization and angiographic data with pressure gradient information on individual patients were available for 26 [17, 19, 24, 31 of 99 patients from the literature group. The follow-up data were obtained 13 f 4 months after angioplasty. The residual gradient at the time of follow-up study in these 26 patients was 13 f 11 mm Hg (see Fig 2), significantly lower ( p <.1) than

5 Ann Thorac Surg 1991;52:62131 CONGENITAL HEART RAO AND CHOPRA 625 Table 2. Prevalence of Recoarctation and Aneurysm Formation at Follow-up After Balloon Angioplasty of Native Coarctation in Children Recoarctation Gradients (mm Hg) No. of Patients Reference Year With Follow-up 2&3 >3 Total Aneurysms Lababidi et a1 [17] Allen et a1 [3] Cooper et a1 [24] Wren et a1 [25] Beekman et a1 [19] Brandt et a1 [27] Morrow et a1 [26] Suarez de Lezo et a1 [21] Rao and Chopra [this report] Total their preangioplasty value of 47 * 15 mm Hg. In the three studies providing only group data and comprising 44 patients [21, 25, 271, the residual gradients were low; mean values were 5.6, 11., and 7.6 mm Hg versus 29, 46, and 51 mm Hg before angioplasty. Adequate clinical follow-up information was available for all 99 patients [17, 19, 21, 24, 25, 27-3]. Repeat intervention for recoarctation was required in 6 children. Elective surgical intervention was performed in 4 to excise the recoarctation [19, 271, and repeat balloon angioplasty was performed in 2 to relieve the residual coarctation [25]. The other children were asymptomatic with reduced hypertension at followup. No follow-up data were available from the VACA Registry [13]. Immediate Complications To our knowledge, no deaths have been reported immediately after balloon coarctation angioplasty in children; this is true for the literature group, the VACA Registry group, and our group. Of the 32 children in our study group, 1 child required thrombectomy, and 1 had a decreased femoral pulse, which improved the following morning. Of the 127 children from the literature group [17, 19, 21, 24, 2.531, 3 required thrombectomy and 5, heparin or streptokinase therapy to improve the arterial pulse on the side of balloon angioplasty. Other complications including balloon rupture at high inflation pressure [6, 71, cerebrovascular accident [ 19, 211, and hypertension with forme fruste postcoarctectomy syndrome [5, 21, 31, though rare, have been reported. Follow-up Complications No late deaths have been reported in children after balloon angioplasty. Data on the incidence of femoral artery occlusion at follow-up are not readily available from the literature. In our study, we [7] systematically looked at femoral artery complications at follow-up. At follow-up catheterization, arterial catheterization was performed on the side opposite that used for angioplasty in two thirds of the patients; the same side was used in the other third. In the former group, iliac arteriography was done with visualization of the femoral artery previously used for angioplasty. Arterial entry in the latter group is considered evidence of arterial patency. Of the 24 children who underwent follow-up study, 2 had femoral arteries that were found to be partially obstructed, but there was good collateral flow. The data on recoarctation in children from the literature and from our study are listed in Table 2. Major recoarctation occurred in only 6 of 18 patients, giving a recurrence rate of approximately 6%, although the recurrence rate is much higher if the gradient cutoff is lowered to 2 mm Hg. Aneurysms at the site of balloon angioplasty have been reported with native coarctations in children, the incidence ranging from 6% to 43% [19, 2>27]. In our material and in our review of the literature, we found aneurysms in 13 of 18 patients, giving a 12% incidence (see Table 2). None of the aneurysms required therapy nor did any aneurysm rupture, although elective resection and repair has been advocated by some authors [24, 271. Comparison With Operation Ten reports published since 198 (Appendix 2) were scrutinized to examine the results of operation for aortic coarctation in children older than 1 year. A total of 1,137 children had surgical intervention from 1957 to 1985; the number of children in each report ranged between 19 and 263. The average operative mortality was 1.6% (18/1,137), although this ranged from % to 5%. The authors followed up 11 to 255 children for a period of 11 months to 25 years and observed a late mortality rate of % to 27%; the mean was 8% (61793 children). The recoarctation rate ranged between.7% and 18% with an average of 5.5% (57/1,37). The mortality and recoarctation rates in the balloon angioplasty and surgical groups are compared in Figure 3. The recoarctation rates are similar, and the mortality rates are slightly higher in the surgical series. Aneurysms occurring after balloon angioplasty [19,

6 626 CONGENITAL HEART RAO AND CHOPRA Ann Thorac Surg 1991;52: a- p <. 2 5 p(.1 6/793 pn /137 I1p 4-5.5% 2-18/1137 /127 - % Ball Surg Ball Surg Ball Surg Initial Mortality Late Mortality Recoarctation Fig 3. Comparison of initial (operative) mortality, late mortality, and recoarctation rates after balloon angioplasty (Ball) and surgical correction (Surg) in children (>1 year old). The data for balloon angioplasty are derived from published literature plus our data. The data for surgical correction are derived from ten reports published in the 198s (see Appendix 2). Note that the initial and late mortality rates are better with balloon angioplasty (p <.25 to <.1) than with surgical intervention, although the recurrence rates are comparable (p >.1) between the two groups ], though of concern, have also been seen after surgical correction of aortic coarctation. Both false aneurysms and true aneurysms have been reported. Development of early false aneurysms appears not to be related to the type of coarctation repair but rather to the surgical technique or infection. Late aneurysms have been well documented to occur with Dacron tube grafts and onlay synthetic patch grafts. Although the exact etiology of these aneurysms is not known, compliance mismatch between the normal aortic wall and the synthetic patch, intimal resection, and translocated ductal tissue on the aortic wall have been postulated as possible causes. Review of seven studies published since 198 (Appendix 3) revealed an incidence of aneurysm formation of 5% to 1% with a mean of 13% (67/51 patients) after synthetic patch angioplasty of aortic coarctation. The true incidence is probably on the order of 24%, as observed by Bromberg and associates [31], who determined the prevalence rate prospectively and with objective, measurable criteria. Sudden deaths secondary to aneurysm rupture have been reported. Elective surgical repair of aneurysms has been carried out with good success. The prevalence of aneurysm formation after balloon angioplasty and Dacron patch angioplasty is similar at 12% and 13%, respectively. Occurrence of aneurysms after subclavian flap angioplasty is also well documented, although the prevalence rate is not yet determined. It must be remembered, however, that aneurysms are seen mostly with patch angioplasty and not as frequently with resection and end-to-end anastomosis. Other complications such as paraplegia and paradoxical hypertension are seen with variable frequency after surgical repair but are either rare or, if present, very mild and inconsequential after balloon angioplasty. The rate of femoral artery occlusion may be higher with balloon angioplasty than with surgical therapy. Vascular function and growth of the left upper limb after subclavian flap aortoplasty repair of coarctation [32, 331 have been studied. The vascular function appears to be preserved, whereas definitive reduction in the length and muscle mass of the upper arm [32] and forearm [33] has been observed. Thus, this review of comparison of surgical versus balloon therapy of aortic coarctation suggests that balloon angioplasty is no worse than surgical intervention when mortality and major complication rates are compared. Longer hospital stay and the attendant increased costs, need of intubation and general anesthesia, and residual scar are additional disadvantages with surgical intervention. Postoperative Recoarctation lmmediate Results Our own experience with recurrent coarctation including that reported previously [12] is limited to 1 patients. Recoarctation developed 6 months to 7 years (26 * 25 months) after surgical repair of coarctation. Previous operations included end-to-end anastomosis after resection of coarctation in 5; patch angioplasty in 4 (Dacron, 2; subclavian flap, 2); and repair of interrupted aortic arch in 1. Surgical repair of coarctation was performed in the neonatal period in 7 patients and at 2, 1, and 18 months of age in 3. At the time of balloon angioplasty, they were 6 months to 7 years old (median age, 22 months). The peak-to-peak systolic pressure gradient across the recoarctate area decreased from 52 * 21 mm Hg to 15 * 7 mm Hg (p <.1) after angioplasty. As a result of angioplasty, the coarctate aortic segment increased from 3.4 * 1.4 mm Hg to mm Hg ( p <.1). There are several reports in the literature of balloon angioplasty for recoarctation [9, 14, 16, 17, 3, 34-41], Immediate results (excluding single case reports) were tabulated and are comparable with our results (Table 3). Thus, review of data from the literature and from our experience indicates that balloon angioplasty can be successfully performed and the aortic obstruction relieved in the vast majority of patients. Balloon angioplasty produces significant pressure gradient relief irrespective of the type of previous operation for coarctation. Data from the VACA Registry [41] suggest the pressure gradient relief is inversely proportional to the age at angioplasty, although there was considerable overlap between the groups. Follow-up Results Seven children from our study group had follow-up catheterization and angiography 8 to 2 months ( months) after balloon angioplasty. Clinical and Doppler echocardiographic follow-up data were obtained in 9 patients 8 to 23 months ( months) after angioplasty. Residual gradient across the dilated postsurgical recoarctation was calculated by combining the catheterizationderived peak-to-peak pressure gradient in 7 children with arm and leg cuff systolic pressure difference in the other 2 children. The residual gradient in these 9 children was 6 2

7 Ann Thorac Surg 1991;52: CONGENITAL HEART RAO AND CHOPRA 627 Table 3. lmmediate Results of Balloon Angioplasty of Postoperative Recoarctation Interval No. of No. of Between Gradient Patients Patients Types of Operation Before and With Undergoing Previous and BA After BA Residual Reference Year BA Ageb (mo) Operations (mo) (mm Hg) Coarctation Complications Lock et a1 [I41 Kan et a1 [35] Lababidi et a1 [I71 Allen et a1 [3] Hess et a1 [36] Lorber et a1 (371 Saul et a1 [38] Cooper et a1 [39] Hellenbrand et ald (VACA Registry) [41] Rao and Chopra [this report] t 17 (1 5264) 113 f 64 (1-24) 121 f 53 (36-192) 97 t 12 (7-24) 8.2 (mean) ( ) 422 (3-9) (3-264) (2-24) 84 (mean) (1-312) (6-84) EE, 3 SF, 2 EE, 3 TG, 2 PA, 1 IA, 1 EE, 3 PA, 4 EE, 5 SF, 2 TG, 1 EE, 3 SF, 1 ST, 1 SF, 5 EE, 14 SF, 7 PA, 3 NP, 3 EE, 21 SF, 13 PA, 5 MO, 5 EE, 84 SF, 48 PA, 4 NP, 12 TG, 4 UK, 12 EE, 5 SF, 2 PA, 2 IA, 1 95 f 59 (1-198) (36132) 4f2 (3-9) 24 (median) (S18) 49 f 54 (1.5-18) 65 (mean) (1.5-42) 26 t 25 (6-84) f t 9 39 t 21 8f6 51 t (mean) 12 (mean) 59 t f t f f t 2 13 t f t 7 2 (4%) 1(14%) 1(14%) 2 (25%) 2 (4%) 5 (19%) 41 (22%) 2 (2%) Operation done within 1 week of BA, 2 patients Death due to ventricular fibrillation, 1 patient None reported Severe hypertension, after BA, 1 patient Balloon rupture, 3 patients Femoral artery thrombosis, 1 patient; hypotension, 1 Blood loss, 6 patients; femoral artery occlusion, 5; procedures, 3 failed Femoral artery occlusion, 4 patients; aneurysm, 1 patient; deaths, 2 Deaths, 5 patients; femoral artery occlusion, 17; hypertension, 4; neurological event, 3; fair to poor result, 41; balloon rupture, 19 Blood loss, 2 a Single case reports were not included. Data are shown as the mean? the standard deviation with range in parentheses. Residual coarctation was defined as a peak to peak gradient higher than 2 mm Hg. Only mean values without the standard deviation were available. BA = balloon angioplasty; EE = end-to-end anastomosis; IA = interrupted aortic arch repair; MO = multiple operations; NP = Norwood procedure; PA = patch angioplasty (Dacron, Gore-Tex, or pericardial patch); SF = subclavian flap; ST = subclavian artery-thoracic aorta anastomosis, end-to-side; TG = tube graft; UK = unknown; VACA = valvuloplasty and angioplasty of congenital anomalies. Adapted from Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. Am Heart J 199;12:1315-2, by permission of Mosby-Year Book, Inc. 6 mm Hg with a range of to 18 mm Hg. The gradients averaged 52 L 2 mm Hg before angioplasty and 16 & 8 mm Hg immediately after angioplasty; thus there was a further decrease ( p <.1) in gradient at follow-up. No aneurysms were seen in the area of previously dilated recoarctation. The literature has a limited number of studies with a limited number of patients for whom follow-up data were recorded. The available studies are listed in Table 4. Of the 53 patients for whom follow-up data were available, 11 (21%) had major residual gradient or restenosis at follow-up. Aneurysms were found in 5 patients (9%) at follow-up. Follow-up information on a larger number of patients for a longer duration may be necessary before

8 628 CONGENITAL HEART RAO AND CHOPRA Ann Thorac Surg 1991; Table 4. Follow-up Results of Balloon Angioplasty of Postoperative Recoarctation No. of Duration of Follow-up Patients Follow-up Gradient Reference Year Followed Up (mo) (mm Hg) Aneurysm Restenosisb Comment Lock et a1 [14] ? 2.9 1(33%) Lababidi et a1 [17] Allen et a1 [3] Lorber et a1 [37] Saul et a1 [38] Cooper et a1 [39] Rao and Chopra [this report] Total (.2M.O) 722 (4-11) 12? 12 (2-3) 12? 8 (2-24) 17? 6 (8-23) 2 (4%) 3 (14%,)E 5 (9%) When available, data are shown as the mean t the standard deviation with range in parentheses. higher than 2 mrn Hg. This includes one aneurysm that developed immediately after BA. BA = balloon angioplasty. 1(17%) 4 (8%) 2 (4%) 3 (14%) 11 (21%) Duration of follow-up not given Femoral artery occlusion at follow-up, 1 patient Repeat BA, 2 patients Repeat BA, 2 patients (duration of follow-up not given) Repeat BA, 3 patients Femoral artery occlusion, 1 patient Restenosis was defined as a peak to peak gradient Adapted from Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. Am Heart J 199;12:1315-2, by permission of Mosby-Year Book, Inc. surgeons can be certain of the long-term favorable effects of balloon angioplasty of postoperative recoarctation. Complications In the present small series, the complications were modest. In the VACA Registry [41] involving 2 patients, five deaths (2.5%) were reported after balloon angioplasty. This death rate is higher than that seen with native coarctations (.7%, 11141) in the VACA Registry [13], although this difference did not attain significance (.5 < p <.1). Other major complications reported by the registry [41] include balloon rupture (9.5%), femoral artery complications (8.5%), postcoarctectomy syndrome (2%), and neurological event (1.5%). Development of aneurysms at follow-up is another complication that needs to be addressed. The incidence of this complication appears to be 9% (see Table 4), similar to that seen after balloon angioplasty of native coarctation [9]. It has been thought that circumferential scar tissue at the recoarctation site after previous surgical repair might prevent formation of aneurysms and, if formed, prevent their rupture [36, Such a hypothesis may not be tenable, at least in some patients; in the VACA Registry [41], it was observed that there was little scar tissue surrounding the previous surgical repair site in a patient with aortic rupture after balloon angioplasty. Comparison With Operation The operative mortality rate for recoarctation after initial surgical repair of aortic coarctation is high and ranges between 3% and 33% (Appendix 4). The mortality rate after balloon angioplasty of aortic recoarctations varies between % and 2.5% [14, 4, 411 which compares favorably with the operative mortality after a second operation. Recoarctation rates after the second operation for postsurgical recoarctation are also high, ranging between 6% and 3%, and these recoarctation rates appear comparable with those reported for balloon angioplasty for postoperative recoarctation (21%, 11/53; see Table 4) [14, 17, 3, 37-39]. However, there are limitations to comparing the surgical data with balloon angioplasty data because of the small number of balloon angioplasty patients available for follow-up, the shorter duration of follow-up, and the possible inaccuracy of comparing older surgical studies with current balloon angioplasty studies. Nonetheless, there are advantages to balloon therapy, ie, avoidance of intubation, anesthesia, repeat thoracotomy, possible bleeding while isolating the recoarctate segment, and stay in the intensive care unit. Shorter duration of hospitalization and less expense are additional advantages of balloon angioplasty. Conclusion Immediate results of balloon angioplasty of native aortic coarctation and postoperative aortic recoarctation appear encouraging. Follow-up results are available on only a small number of patients and after only a short follow-up. The magnitude of the problem of aneurysms at follow-up is unknown. However, mortality and morbidity appear to be better for balloon angioplasty than for surgical treatment. Based on our experience and this review, we

9 Ann Thorac Surg 1991; CONGENITAL HEART RAO AND CHOPRA 629 COARCTATION BALLOON ANGIOI'LASTY recommend balloon angioplasty as a procedure of choice in the treatment of native coarctation and postoperative recoarctation with critical hypertension, congestive heart failure, or both. The technique is particularly valuable in neonates and infants 1 year old or younger. Final and definitive recommehdation for application of balloon angioplasty of native coarctation in children and recoarctation should probably await longer-term follow-up of a larger number of patients. We acknowledge the contributions made by past and present colleagues in pediatric cardiology and cardiovascular surgery including Drs M. Brais,. Galal, F. Kutayli, J. M. Levy, M. I<. Mardini, H. N. Najjar, L. Solymar, M. K. Thapar, and A. D. Wilson. This work is supported in part by a grant from Oscar Rennebohm Foundation, Inc, Madison, WI. References Sos T, Sniderman KW, Rettek-Sos B, Strupp A, Alonso DR. Percutaneous transluminal dilatation of coarctation of thoracic aorta post mortem. Lancet 1979;2:97-1. Lock JE, Niemi T, Burke BA, Einzig S, Castaneda-Zuniga WR. Transcutaneous angioplasty of experimental aortic coarctation. Circulation 1982;66: Lock JE, Castaneda-Zuniga WR, Bass JL, Foker JE, Amplatz K, Anderson RW. Balloon dilatation of excised aortic coarctations. Radiology 1982;143: Castaneda-Zuniga WR, Lock JE, Vlodaver Z, et al. Transluminal dilatation of coarctation of the abdominal aorta: an experimental study in dogs. Radiology 1982;143: Rao PS. Transcatheter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation. Br Heart J 1986;56:2568. Rao PS. Balloon angioplasty for coarctation of the aorta in infancy. J Pediatr 1987;11:71S. Rao PS, Najjar HN, Mardini MK, Solymar L, Thapar MK. Balloon angioplasty for coarctation of the aorta: immediate and long-term results. Am Heart J 1988;115: Rao PS, Thapar MK, Kutayli F, Carey P. Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation. J Am Coll Cardiol 1989;13: Rao PS. Balloon angioplasty of aortic coarctation: a review. Clin Cardiol 1989;12: Rao PS, Carey P. Remodeling of the aorta following successful balloon coarctation angioplasty. J Am Coll Cardiol 1989; 14: Rao PS, Thapar MK, Galal, Wilson AD. Follow-up results of balloon angioplasty of native coarctation in neonates and infants. Am Heart J 199;12:131(r-4. Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. Am Heart J 199;12: Tynan M, Finley JP, Fontes V, et al. Balloon angioplasty for the treatment of native coarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol 199;65:79-2. Lock JE, Bass JL, Amplatz K, Fuhrman BP, Castaneda-Zuniga W. Balloon dilation angioplasty of aortic coarctations in infants and children. Circulation 1983;68: Sperling DR, Dorsey TJ, Rowen M, Gazzaniga AB. Percutaneous transluminal angioplasty of congenital coarctation of the aorta. Am J Cardiol 1983;51: Finley JP, Beaulieu RG, Nanton MA, Roy DL. Balloon catheter dilatation of coarctation of the aorta in young infants. Br Heart J 1983;5: Lababidi ZA, Daskalopoulos DA, Stoeckle H Jr. Transluminal balloon coarctation angioplasty: experience with 27 patients. Am J Cardiol 1984;54: Suarez de Lezo J, Fernandez R, Sancho M, et al. Percutaneous transluminal angioplasty for aortic isthmic coarctation in infancy. Am J Cardiol 1984;54: Beekman RH, Rocchini AP, Dick M 11, et al. Percutaneous balloon angioplasty for native coarctation of the aorta. J Am Coll Cardiol 1987;1: Alyousef S, Khan A, Nihill M, Lababidi Z, Mullins C. Perkutane transvenose angegrade Ballonangioplastie bei Aortenisthmusstenose. Herz 1988;13: Suarez de Lezo J, Sancho M, Pan M, Romero M, Olivera C, Luque M. Angiographic follow-up after balloon angioplasty for coarctation of the aorta. J Am Coll Cardiol1989;13: Martin GR, Stanger P. Transient prolongation of the QTc interval after balloon valvuloplasty and angioplasty in children. Am J Cardiol 1986;58: Marvin WJ, Mahoney LT, Rose EF. Pathologic sequelae of balloon dilation angioplasty for unoperated coarctation of the aorta in children [Abstract]. J Am Coll Cardiol 1986;7:117A. 24. Cooper RS, Ritter SB, Rothe WB, Chen CK, Griepp R, Golinko RJ. Angioplasty for coarctation of the aorta: longterm results. Circulation 1987;75: Wren C, Peart I, Bain H, Hunter S. Balloon dilatation of unoperated aortic coarctation: immediate results and oneyear follow-up. Br Heart J 1987;58: Morrow WR, Vick GW 111, Nihill MR, et al. Balloon dilatation of unoperated coarctation of the aorta: short- and intermediate-term results. J Am Coll Cardiol 1988;11: Brandt B 111, Marvin WJ Jr, Rose EF, Mahoney LT. Surgical treatment of coarctation of the aorta after balloon angioplasty. J Thorac Cardiovasc Surg 1987;94: Brodsky SJ. Percutaneous balloon angioplasty: treatment for congenital coarctation of the aorta and congenital valvar pulmonic stenosis. Am J Dis Child 1984;138: Cooper RS, Ritter SB, Golinko RJ. Balloon dilation angioplasty: nonsurgical management of coarctation of the aorta. Circulation 1984;7: Allen HD, Marx GR, Ovitt TW, Goldberg SJ. Balloon dilatation angioplasty for coarctation of the aorta. Am J Cardiol 1986;57: Bromberg BI, Beekman RH, Rocchini AP, et al. Aortic aneurysm after patch aortoplasty repair of coarctation: a prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989;14: Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late effects on the left upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg 1983;85: Shenberger IS, Prophet SA, Waldhausen JA, Davidson WR Jr, Sinoway LI. Left subclavian flap aortoplasty for coarctation of the aorta: effects of forearm vascular function and growth. J Am Coll Cardiol 1989;14: Singer MI, Rowen M, Dorsey TJ. Transluminal aortic balloon angioplasty for coarctation of the aorta in the newborn. Am Heart J 1982;13: Kan JS, White RI Jr, Mitchell SE, Farmiett EJ, Donahoo JS, Gardner TJ. Treatment of restenosis of coarctation by percutaneous transluminal angoplasty. Circulation 1983;68: Hess J, Mooyaart EL, Busch HJ, Bergstra A, Landsman MI. Percutaneous transluminal balloon angoplasty in restenosis of coarctation of the aorta. Br Heart J 1986;55:45941.

10 63 CONGENITAL HEART RAO AND CHOPRA Ann Thorac Surg 1991;52: Lorber A, Ettedgui JA, Baker EJ, Jones ODH, Reidy J, Tynan M. Balloon aortoplasty for recoarctation following the subclavian flap operation. Int J Cardiol 1986;1: Saul JP, Keane JF, Fellows KE, Lock JE. Balloon dilation angioplasty of postoperative aortic obstructions. Am J Cardiol 1987;59: Cooper SG, Sullivan ID, Wren C. Treatment of recoarctation: balloon dilation angioplasty. J Am Coll Cardiol 1989;14: 41S9. 4. Lo RNS, Leung MP, Yau KK, Cheung DLC. Transvenous antegrade balloon angioplasty for recoarctation of the aorta in an infant. Am Heart J 1989; Hellenbrand WE, Allen HD, Golinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol 199;65: Lock JE. Now that we can dilate, should we? Am J Cardiol 1984;54: Huhta JC. Angioplasty for recoarctation. J Am Coll Cardiol 1989;14:42Gl. Appendix 1. Results of Operation for Native Aortic Coarctation in Neonates and Infants: 25 Reports Published in the 198s Beerman LB, Neches WH, Patnode RE, Fricker FJ, Mathews RA, Park SC. Coarctation of the aorta in children: late results after surgery. Am J Dis Child 198;134:4646. Fyler DC, Buckley LP, Hellenbrand WE, et al. Report of the New England Regional Infant Cardiac Program. Pediatrics 198;65(SuppI):37%461. Williams WG, Shindo G, Trusler GA, Dische MR, Olley PM. Results of repair of coarctation of the aorta during infancy. J Thorac Cardiovasc Surg 198;79:6M3. Kamau P, Miles V, Toews W, et al. Surgical repair of coarctation of the aorta in infants less than six months of age including the question of pulmonary artery banding. J Thorac Cardiovasc Surg 1981;81: Hesslein PS, McNamara DG, Morriss MJH, Hallman GL, Cooley DA. Comparison of resection versus patch aortoplasty for repair of coarctation in infants and children. Circulation 1981;64: Leanage R, Taylor JFN, de Leva1 MR, Stark J, Macartney FJ. Surgical management of coarctation of aorta with ventricular septa1 defect: multivariate analysis. Br Heart J 1981;46: Lerberg DB, Hardesty RL, Siewers RD, Zuberbuhler JR, Bahnson HT. Coarctation of the aorta in infants and children: 25 years of experience. Ann Thorac Surg 1982;33: Bergdahl LAL, Blackstone EH, Kirklin JW, Pacific AD, Bargeron LM Jr. Determinants of early success in repair of aortic coarctation in infants. J Thorac Cardiovasc Surg 1982; 83: 73U2. Harlan JL, Doty DB, Brandt B 111, Ehrenhaft JL. Coarctation of the aorta in infants. J Thorac Cardiovasc Surg 1984;88: Moulton AL, Brenner JI, Roberts G, et al. Subclavian flap repair of coarctation of the aorta in neonates. Realization of growth potential. J Thorac Cardiovasc Surg 1984;8722&35. Penkoske PA, Williams WG, Olley PM, et al. Subclavian arterioplasty. Repair of coarctation of the aorta in the first year of life. J Thorac Cardiovasc Surg 1984; Cobanoglu A, Teply JF, Grunkemeier GL, Sunderland CO, Starr A. Coarctation of the aorta in patients younger than three months. A critique of the subclavian flap operation. J Thorac Cardiovasc Surg 1985;89:12%35. Kopf GS, Hellenbrand W, Kleinman C, Lister G, Talner N, Laks H. Repair of aortic coarctation in the first three months of life: immediate and long-term results. Ann Thorac Surg 1986;41: Beekman RH, Rocchini AP, Behrendt DM, et al. Long-term outcome after repair of coarctation in infancy: subclavian angioplasty does not reduce the need for reoperation. J Am Coll Cardiol 1986;8: Ziemer G, Jonas RA, Perry SB, Freed MD, Castaneda AR. Surgery for coarctation of the aorta in the neonate. Circulation 1986;74(Suppl 1): Sanchez GR, Balsara RK, Dunn JM, Mehta AV, ORiordan AC. Recurrent obstruction after subclavian flap repair of coarctation of the aorta in infants. Can it be predicted or prevented? J Thorac Cardiovasc Surg 1986;91:73&? Goldman S, Hernandez J, Pappas G. Results of surgical treatment of coarctation of the aorta in the critically ill neonate. Including the influence of pulmonary artery banding. J Thorac Cardiovasc Surg 1986;91: Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, Scheld HH. Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation. J Thorac Cardiovasc Surg 1986;92: Yee ES, Soifer SJ, Turley K, Verrier ED, Fishman NH, Ebert PA. Infant coarctation: a spectrum in clinical presentation and treatment. Ann Thorac Surg 1986;42: Kirklin JW, Barratt-Boyes BG. Coarctation of the aorta and aortic arch interruptions. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery: morphology, diagnostic criteria, natural history, techniques, results and indications. New York John Wiley, 1986: Koller M, Rothlin M, Senning A. Coarctation of the aorta: review of 362 operated patients. Long-term follow-up and assessment of prognostic variables. Eur Heart J 1987;8: Mellgren G, Friberg LG, Eriksson BO, Sabel K, Mellander M. Neonatal surgery for coarctation of the aorta: the Gothenburg experience. Scand J Thorac Cardiovasc Surg 1987;21: Fenchel G, Steil E, Seybold-Epting W, Seboldt H, Apitz J, Hoffmeister H. Repair of symptomatic aortic coarctation in the first three months of life: early and late results after resection and end-to-end anastomosis and subclavian flap angioplasty. J Cardiovasc Surg (Torino) 1988;29: Vouhe PR, Trinquet F, Lecompte Y, et al. Aortic coarctation with hypoplastic aortic arch. Results of extended end-to-end aortic arch anastomosis. J Thorac Cardiovasc Surg 1988;96: Yamaguchi M, Tachibana H, Hosokawa Y, Ohashi H, Oshima Y. Early and late results of surgical treatment of coarctation of the aorta in the first three months of life. J Cardiovasc Surg (Torino) 1989; Appendix 2. Results of Operation for Native Aortic Coarctation in Children: 1 Reports Published in the 198s 1. Beerman LB, Neches WH, Patnode RE, Fricker FJ, Mathews RA, Park SC. Coarctation of the aorta in children: late results after surgery. Am J Dis Child 198;134: Hesslein PS, McNamara DG, Morriss MJH, Hallman GL, Cooley DA. Comparison of resection versus patch aortoplasty for repair of coarctation in infants and children. Circulation 1981;64: Lerberg DB, Hardesty RL, Siewers RD, Zuberbuhler JR,

11 Ann Thorac Surg 1991;52: CONGENITAL HEART RAO AND CHOPRA Bahnson HT. Coarctation of the aorta in infants and children: 25 years of experience. Ann Thorac Surg 1982;33: Bergdahl L, Bjork VO, Jonasson R. Surgical correction of coarctation of the aorta: influence of age on late results. J Thorac Cardiovasc Surg 1983;85:5324. Clarkson PM, Nicholson MR, Barratt-Boyes BG, Neutze JM, Whitlock RM. Results after repair of coarctation of the aorta beyond infancy: a 1 to 28 year follow-up with particular reference to late systemic hypertension. Am J Cardiol 1983; 51: Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, Scheld HH. Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation. J Thorac Cardiovasc Surg 1986;92: Kirklin JW, Barratt-Boyes BG. Coarctation of the aorta and aortic arch interruptions. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery: morphology, diagnostic criteria, natural history, techniques, results and indications. New York: John Wiley, 1986:1358. Koller M, Rothlin M, Senning A. Coarctation of the aorta: review of 362 operated patients. Long-term follow-up and assessment of prognostic variables. Eur Heart J 1987;8:67-9. Presbitero P, Demarie D, Villani M, et al. Long-term results (15-3 years) of surgical repair of aortic coarctation. Br Heart J 1987; Behl PR, Sante P, Blesovsky A. Surgical treatment of isolated coarctation of the aorta: 18 years experience. Thorax 1987;42: Appendix 3. Aneurysms After Patch Angioplasty for Aortic Coarctation Bergdahl L, Ljungqvist A. Long-term results after repair of coarctation of the aorta by patch grafting. J Thorac Cardiovasc Surg 198;8: Clarkson PM, Brandt PWT, Barratt-Boyes BG, Rutherford JD, Kerr AR, Neutze JM. Prosthetic repair of coarctation of the aorta with particular reference to Dacron onlay patch grafts and late aneurysm formation. Am J Cardiol 1985;56:3424. Del Nido PJ, Williams WG, Wilson GJ, et al. Synthetic patch angioplasty for repair of coarctation of the aorta: experience with aneurysm formation. Circulation 1986;74(Suppl 1):324. Hehrlein FW, Mulch J, Rautenburg HW, Schlepper M, Scheld HH. Incidence and pathogenesis of late aneurysms after patch graft aortoplasty for coarctation. J Thorac Cardiovasc Surg 1986;92: Rheuban K, Gutgesell HP, Carpenter MA, et al. Aortic aneurysms after patch angioplasty for aortic isthmic coarctation in childhood. Am J Cardiol 1986;58:17%3. 6. Ala-Kalju K, Heikkinen L. Aneurysms after patch graft aortoplasty for coarctation of the aorta: long-term results of surgical management. Ann Thorac Surg 1989;47:85M. 7. Bromberg BI, Beekman RH, Rocchini AP, et al. Aortic aneurysm after patch aortoplasty repair of coarctation: a prospective analysis of prevalence, screening tests and risks. J Am Coll Cardiol 1989:14: Appendix 4. Results of Operation for Postoperative Recoarctation 1. Cerilli J, Lauridsen P. Reoperation for coarctation of the aorta. Acta Chir Scand 1965;129: Ibarra-Perez C, Castaneda AR, Varco RL, Lillehei CW. Recoarctation of the aorta: nineteen-year clinical experience. Am J Cardiol 1969;23: Castaneda A, Norwood W. Residual coarctation of the aorta: surgical experience. In: Castaneda A, Norwood W, eds. First clinical conference on congenital heart disease. New York: Grune & Stratton, 1979: Beekman RH, Rocchini AP, Behrendt DM, Rosenthal A. Reoperation for coarctation of the aorta. Am J Cardiol 1981; 48: Pollack P, Freed MD, Castaneda AR, Norwood WI. Reoperation for isthmic coarctation of the aorta: follow-up of 26 patients. Am J Cardiol 1983;51: Kirklin JW, Barratt-Boyes BG. Coarctation of the aorta and aortic arch interruptions. In: Kirklin JW, Barratt-Boyes, eds. Cardiac surgery: rnorphologv, diagnostic criteria, natural - 1 v, v history, techniques, results and indications. New York: John Wiley, 1986: Campbell DB, Bartholomew M, Waldhausen JA. The case for subclavian flap repair (Editorial]. J Am Coll Cardiol 1986;8: Beekman RH, Rocchini AP, Behrendt DM, et al. Long-term outcome after repair of coarctation in infancy: subclavian angioplasty does not reduce the need for reoperation. J Am Coll Cardiol 1986;8: Hopkins RA, Kostic I, Armiru U, et al. Correction of coarctation of the aorta in neonates and young infants: an individualized surgical approach. Eur J Cardiovasc Surg 1988;2: Cooper SG, Sullivan ID, Wren C. Treatment of recoarctation: balloon dilation angioplasty. J Am Coll Cardiol 1989;14: EDITOR S NOTE This report presents an interesting counterpoint to the surgical papers in this supplement, but the role of balloon angioplasty in the management of native coarctation remains controversial. It is noteworthy that the incidence of aneurysm after balloon aortoplasty is minimal in the infant group. In the group of patients greater than 1 year of age, the incidence is similar to that seen after Dacron patch aortoplasty-a procedure abandoned by most surgeons who found the incidence of this complication unacceptable. Furthermore, it is a risk that progressively increased with longer follow-up in that surgical experience. Whether a similar pattern will be seen in the balloon group will need close evaluation. Anthony L. Moulton, MD Brown UniversityiMiriam Hospital 164 Summit Ave Providence, RI 296