Schwartz
et al.
American
of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol 1989;63:847-52. 30. McKay CR, Kawanihi DT, Kotleswski A, Parise K, OdomMaryon T, Gonzalez A, Reid CL, Rahimtoola SH. Improvement in exercise capacity and exercise hemodynamics three months after double-balloon, catheter balloon valvuloplasty treatment of patients with symptomatic mitral stenosis. Circulation 1988;77:1013-21.
Balloon angioplasty aorta in adolescents
March 1992 Heart Journal
Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow up of patients undergoing percutaneous mitral balloon valvotomy. Circulation 198$79:573-g. 32. Safian RD, Berman AD, Diver DJ, McKay LL, Come PC, Riley MF, Warren SE, Cunningham MJ, Wyman M, Weinstein JS, Grossman W, McKay RG. Balloon aortic valvuloplasty in 170 consecutive patients. N Engl J Med 1988;319:125-30. 31.
of native coarctation and young adults
of the
Balloon angioplasty of native coarctation of the aorta was performed in 35 consecutive adolescents and young adults, aged 14 to 37 years (mean 22.6 + 7.1). Twenty-eight (80%) patients had isolated discrete coarctation, six (17.1%) had tubular hypoplasia of the aortic isthmus, and one (2.9%) had hypoplasia of the postcoarctation aorta. The peak systolic pressure gradient decreased from 78.5 -t 23.9 to 15.7 f 11.6 mm Hg (p < O.OOl), and the mean coarctation diameter increased from 4.7 f 2.4 to 13.1 + 2.7 mm (p < 0.001) immediately after angioplasty. Patients with discrete-type coarctation had significantly less residual gradient than patients with long-segment tubular coarctation (12.3 + 10.7 vs 27.2 + 6.6 mm Hg, p < 0.01). On recatheterization and angiography in 26 patients at 12.6 f 1.5 months after dilatation, there was no significant change in gradient (15.5 & 13.3 mm Hg) and diameter (13.1 -t 1.8 mm) from the immediate postangioplasty results. However, two patients had an increase in gradient and three had small aortic aneurysms wlth no change in appearance on restudy after 2 years. After 3 to 67 months’ (mean 32.7 + 19.2) follow-up, all patients showed continued clinical improvement. Hypertension was relieved in 37.5% (12132) and improved in 59.4% (19132). Our experience suggests that balloon angloplasty of native aortic coarctatlon in adolescents and young adults is safe and highly effective with sustained improvement on intermediate-term follow-up. (AM HEART J lgg2;123:674.)
Sanjay Tyagi, MD, DM, Ramesh Arora, MD, DM, Upkar A. Kaul, MD, DM, Kamal K. Sethi, MD, DM, Daljeet S. Gambhir, MD, DM, and Mohd. Khalilullah, MD, DM. New Delhi, India
Since the initial report of balloon angioplasty for coarctation of the aorta in 1982,l several short-2-8 and a few intermediate-termg-17 studies have been carried out to determine the efficacy of this technique. Most of these studies have been in infants and children. There are only a few brief accounts of balloon angioplasty in adolescents and young adults.5, ls20 Reports of surgical correction have shown that hospital mortality, recoarctation, persistent hypertension, and
From Received
the Department for publication
of Cardiology, April
Reprint requests: Sanjay Tyagi, Cardiology, G. B. Pant Hospital, 4/l/34421
674
G. B. Pent
29, 1991;
accepted
Hospital. Aug.
1, 1991.
DM, Associate Professor, Department New Delhi 110 002, India.
of
cerebral hemorrhage are affected by the age at intervention.21-23 In this study, the largest series of patients of this age group, we report our immediate and intermediate-term follow-up results of percutaneous balloon dilatation for relief of native aortic coarctation in adolescents and young adults. METHODS Between July 1985 and December 1990, a total of 35 consecutive patients (29 males and 6 females), ranging in age from 14 to 37 years (mean 22.6 k 7.1), with a diagnosis of native aortic coarctation based on results of clinical examination and two-dimensional and pulsed Doppler echocardiography, underwent cardiac catheterization and aortography. Under local anesthesia, percutaneous retrograde femoral artery catheterization was performed by the
Volume Number
123 3
Seldinger technique. A pigtail/multipurpose catheter was introduced, and pressure across the coarctation was recorded. A 7F pigtail catheter was inserted into the contralateral femoral artery by means of the Seldinger technique to measure the aortic gradient simultaneously across the coarctation. Each patient was given 50 U/kg of heparin (maximum 2500 U) after introduction of the arterial catheter. Aortography was performed by cineangiographyldigital subtraction angiography in the go-degree left anterior oblique and posteroanterior views. The size of the coarctation, the descending thoracic aorta at the level of the diaphragm and at the aortic isthmus between the coarctation and the left subclavian artery, was measured using the catheter diameter as the reference for calculating the magnification factor. The diameter of the balloon selected was equal to or 1 to 2 mm smaller than that of the descending thoracic aorta at the level of the diaphgram but did not exceed five times the diameter of the coarcted segment. A 0.035-inch, flexible-tip, 260 cm, J-guide wire was passed through the angiographic catheter. Over the guide wire, the angiographic catheter was exchanged for a 9F deflated Medi-Tech (Medi-Tech, Inc., Watertown, Mass.) or Mansfield (Mansfield Scientific Inc., Mansfield, Mass.) balloon dilatation catheter. The balloon was positioned across the site of coarctation and inflated with diluted contrast medium. The exact location of the balloon was confirmed by observing the hourglass appearance on fluoroscopy during the initial inflation. At this point the balloon was inflated to progressively higher pressures until either the waist disappeared or the maximum pressure limit of the balloon was reached. In patients with severe coarctation (~3 mm), graded dilatation, that is, initial dilatation with a smaller balloon with progression to a larger one, was used. Three to four inflations at 3 to 5 atm, lasting 5 to 15 seconds each, were performed. After dilatation the deflated balloon catheter was exchanged (over the guide wire) for a pigtail/multipurpose catheter, and aortography was repeated in the same views. Approximately 15 minutes after balloon angioplasty, the pullback pressure was recorded across the coarctation. At no time was the catheter or guide wire manipulated over the area of freshly dilated aortic coarctation. Patients were followed-up clinically. The effect on blood pressure was classified according to the system of Kaufman and Maxwe11.24 Patients were considered “cured” if blood pressure was 140/90 mm Hg or less without antihypertensive medication, “improved” if a reduction in diastolic blood pressure of 15 mm Hg or more was attained, or when they were normotensive (blood pressure
et al.
American
of percutaneous mitral commissurotomy in 200 patients. Am J Cardiol 1989;63:847-52. 30. McKay CR, Kawanihi DT, Kotleswski A, Parise K, OdomMaryon T, Gonzalez A, Reid CL, Rahimtoola SH. Improvement in exercise capacity and exercise hemodynamics three months after double-balloon, catheter balloon valvuloplasty treatment of patients with symptomatic mitral stenosis. Circulation 1988;77:1013-21.
Balloon angioplasty aorta in adolescents
March 1992 Heart Journal
Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow up of patients undergoing percutaneous mitral balloon valvotomy. Circulation 198$79:573-g. 32. Safian RD, Berman AD, Diver DJ, McKay LL, Come PC, Riley MF, Warren SE, Cunningham MJ, Wyman M, Weinstein JS, Grossman W, McKay RG. Balloon aortic valvuloplasty in 170 consecutive patients. N Engl J Med 1988;319:125-30. 31.
of native coarctation and young adults
of the
Balloon angioplasty of native coarctation of the aorta was performed in 35 consecutive adolescents and young adults, aged 14 to 37 years (mean 22.6 + 7.1). Twenty-eight (80%) patients had isolated discrete coarctation, six (17.1%) had tubular hypoplasia of the aortic isthmus, and one (2.9%) had hypoplasia of the postcoarctation aorta. The peak systolic pressure gradient decreased from 78.5 -t 23.9 to 15.7 f 11.6 mm Hg (p < O.OOl), and the mean coarctation diameter increased from 4.7 f 2.4 to 13.1 + 2.7 mm (p < 0.001) immediately after angioplasty. Patients with discrete-type coarctation had significantly less residual gradient than patients with long-segment tubular coarctation (12.3 + 10.7 vs 27.2 + 6.6 mm Hg, p < 0.01). On recatheterization and angiography in 26 patients at 12.6 f 1.5 months after dilatation, there was no significant change in gradient (15.5 & 13.3 mm Hg) and diameter (13.1 -t 1.8 mm) from the immediate postangioplasty results. However, two patients had an increase in gradient and three had small aortic aneurysms wlth no change in appearance on restudy after 2 years. After 3 to 67 months’ (mean 32.7 + 19.2) follow-up, all patients showed continued clinical improvement. Hypertension was relieved in 37.5% (12132) and improved in 59.4% (19132). Our experience suggests that balloon angloplasty of native aortic coarctatlon in adolescents and young adults is safe and highly effective with sustained improvement on intermediate-term follow-up. (AM HEART J lgg2;123:674.)
Sanjay Tyagi, MD, DM, Ramesh Arora, MD, DM, Upkar A. Kaul, MD, DM, Kamal K. Sethi, MD, DM, Daljeet S. Gambhir, MD, DM, and Mohd. Khalilullah, MD, DM. New Delhi, India
Since the initial report of balloon angioplasty for coarctation of the aorta in 1982,l several short-2-8 and a few intermediate-termg-17 studies have been carried out to determine the efficacy of this technique. Most of these studies have been in infants and children. There are only a few brief accounts of balloon angioplasty in adolescents and young adults.5, ls20 Reports of surgical correction have shown that hospital mortality, recoarctation, persistent hypertension, and
From Received
the Department for publication
of Cardiology, April
Reprint requests: Sanjay Tyagi, Cardiology, G. B. Pant Hospital, 4/l/34421
674
G. B. Pent
29, 1991;
accepted
Hospital. Aug.
1, 1991.
DM, Associate Professor, Department New Delhi 110 002, India.
of
cerebral hemorrhage are affected by the age at intervention.21-23 In this study, the largest series of patients of this age group, we report our immediate and intermediate-term follow-up results of percutaneous balloon dilatation for relief of native aortic coarctation in adolescents and young adults. METHODS Between July 1985 and December 1990, a total of 35 consecutive patients (29 males and 6 females), ranging in age from 14 to 37 years (mean 22.6 k 7.1), with a diagnosis of native aortic coarctation based on results of clinical examination and two-dimensional and pulsed Doppler echocardiography, underwent cardiac catheterization and aortography. Under local anesthesia, percutaneous retrograde femoral artery catheterization was performed by the
Volume Number
123 3
Seldinger technique. A pigtail/multipurpose catheter was introduced, and pressure across the coarctation was recorded. A 7F pigtail catheter was inserted into the contralateral femoral artery by means of the Seldinger technique to measure the aortic gradient simultaneously across the coarctation. Each patient was given 50 U/kg of heparin (maximum 2500 U) after introduction of the arterial catheter. Aortography was performed by cineangiographyldigital subtraction angiography in the go-degree left anterior oblique and posteroanterior views. The size of the coarctation, the descending thoracic aorta at the level of the diaphragm and at the aortic isthmus between the coarctation and the left subclavian artery, was measured using the catheter diameter as the reference for calculating the magnification factor. The diameter of the balloon selected was equal to or 1 to 2 mm smaller than that of the descending thoracic aorta at the level of the diaphgram but did not exceed five times the diameter of the coarcted segment. A 0.035-inch, flexible-tip, 260 cm, J-guide wire was passed through the angiographic catheter. Over the guide wire, the angiographic catheter was exchanged for a 9F deflated Medi-Tech (Medi-Tech, Inc., Watertown, Mass.) or Mansfield (Mansfield Scientific Inc., Mansfield, Mass.) balloon dilatation catheter. The balloon was positioned across the site of coarctation and inflated with diluted contrast medium. The exact location of the balloon was confirmed by observing the hourglass appearance on fluoroscopy during the initial inflation. At this point the balloon was inflated to progressively higher pressures until either the waist disappeared or the maximum pressure limit of the balloon was reached. In patients with severe coarctation (~3 mm), graded dilatation, that is, initial dilatation with a smaller balloon with progression to a larger one, was used. Three to four inflations at 3 to 5 atm, lasting 5 to 15 seconds each, were performed. After dilatation the deflated balloon catheter was exchanged (over the guide wire) for a pigtail/multipurpose catheter, and aortography was repeated in the same views. Approximately 15 minutes after balloon angioplasty, the pullback pressure was recorded across the coarctation. At no time was the catheter or guide wire manipulated over the area of freshly dilated aortic coarctation. Patients were followed-up clinically. The effect on blood pressure was classified according to the system of Kaufman and Maxwe11.24 Patients were considered “cured” if blood pressure was 140/90 mm Hg or less without antihypertensive medication, “improved” if a reduction in diastolic blood pressure of 15 mm Hg or more was attained, or when they were normotensive (blood pressure
