Should I or Shouldnt I? Should I or Shouldnt I Associated - - PowerPoint PPT Presentation

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Should I or Shouldnt I? Should I or Shouldnt I Associated - - PowerPoint PPT Presentation

Oct 08, 2023 466 likes •882 views

Should I or Shouldnt I? Should I or Shouldnt I Associated Transverse Arch Stent a Coarctation of f Aorta Hypoplasia if its Associated with Transverse Arch Hypoplasia Darren P. Berman, MD Co-Director, Cardiac Catheterization The

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The Heart Center

Should I or Shouldn’t I? Associated Transverse Arch Hypoplasia

Darren P. Berman, MD Co-Director, Cardiac Catheterization The Heart Center Nationwide Children’s Hospital Associate Professor, Pediatrics The Ohio State University Columbus, OH, USA

Should I or Shouldn’t I Stent a Coarctation of f Aorta if it’s Associated with Transverse Arch Hypoplasia

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The Heart Center

  • Consultant
  • Abbott Medical
  • Medtronic
  • Edwards Life Sciences

Disclosures

____________________________________________________________________________________________

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The Heart Center

Should I or Shouldn’t I? Associated Transverse Arch Hypoplasia (T (TAH)

  • Is TAH an important residual lesion?
  • Does TAH improve after relief of Coarctation of Aorta?
  • What are treatment options for TAH?
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The Heart Center

………………..……………………………………………………………………………………………………………………………………..

  • Pathologic study -- 35 aortic arch systems
  • Further define relationship between the ductus arteriosus,

coarctation, and tubular hypoplasia of the aortic arch

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The Heart Center

………………..……………………………………………………………………………………………………………………………………..

  • Normal newborn aortic arch
  • The isthmus is slightly narrower than

either the ascending or descending aorta

Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosis. BHJ, 1979, 41, 268-274.

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The Heart Center

Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosis. BHJ, 1979, 41, 268-274.

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The Heart Center

Coarctation of the Aorta: Following Successful Treatment

  • 30% of patients have important systemic HTN
  • Contributes to cardiovascular morbidity and mortality
  • high incidence of coronary artery disease and stroke
  • Why this high prevalence of HTN?
  • Residual arch obstruction
  • Abnormal aortic arch shape
  • Abnormal vascular properties of the systemic vasculature

O’Sullivan J. Late hypertension in patients with repaired aortic

  • coarctation. Curr Hypertens Rep. 2014;16:421.

Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical

  • correction. Circulation. 1989;80:840–845.
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The Heart Center

Should I or Shouldn’t I? Associa iated Transverse Arch Hypoplasia (T (TAH)

  • Is TAH an important residual lesion?
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The Heart Center

Does TAH contribute to this systemic HTN?

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The Heart Center

………………..……………………………………………………………………………………………………………………………………..

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The Heart Center

………………..……………………………………………………………………………………………………………………………………..

  • Persistent mild TAA hypoplasia
  • In the absence of an arm-leg SBP difference at rest
  • Is associated with late systemic HTN & worse arm-leg SBP gradient

w/exercise

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The Heart Center

Is TAH an important residual lesion?

  • Moderate to severe TAH -- yes
  • Mild TAH
  • Should we be more aggressive?
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The Heart Center

Does TAH improve after relief of CoA of Aorta?

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The Heart Center

  • Retrospective chart review
  • 10/1995 and 4/2015
  • 51 children
  • Median age 11.1 years
  • All had TAH and a CoA stent
  • Explore the clinical impact of the untreated TAH
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The Heart Center

  • Median follow up – 37 months
  • No significant catch-up growth in the transverse arch
  • By echocardiographic imaging and Z-scores
  • A trend to increasing SBP differential between the RUE and LUE
  • 11 mmHg prior to stent --> 16 mmHg in follow-up
  • Medical management can be difficult
  • Approaches to treat this should be considered
  • Surgical arch augmentation
  • Stent implantation
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The Heart Center

What are treatment options for TAH?

  • Surgical arch augmentation
  • Transcatheter stent implantation
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The Heart Center

Case Example

  • 45 yo with history of COA, non-obstructed BAV
  • s/p end to end anastomosis at 4 years of age.
  • Lost to follow up after age 18
  • Referred to ACHD for evaluation of HTN and h/o CoA
  • Medications: Lisinopril 10 mg qd, HCTZ 12.5mg
  • BP: RA 188/96

LA 163/104 RL 165/114

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The Heart Center

3DRA as 1st angiogram

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The Heart Center

Conventional angiogram

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The Heart Center

36mm long Max LD stent on 20mm BIB

Dilation of struts crossing LSCA

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The Heart Center

3DRA post-stent

AAO 113/64 m85 DAO 113/63 m84

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The Heart Center

………………..……………………………………………………………………………………………………………………………………..

  • Retrospective review; 4 centers; from 2000-2010
  • Outcomes for stenting of transverse aortic arch hypoplasia
  • Reduction in peak systolic catheter gradient
  • Dimensions of the stented segment
  • Systolic right arm blood pressure
  • Early and late complications were recorded
  • 21 patients (16 male, 5 female)
  • Median age of 16.5 years (range, 0.25–25.9 years), (2 neonates)
  • Median weight of 55 kg (range, 4.5–103 kg)
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The Heart Center

Results

  • Median transverse arch diameter
  • Increased from 7 to 14 mm after stenting (P < 0.001)
  • Median TAA/DAO at the level of the diaphragm improved
  • 0.43 to 0.9 (P < 0.001)
  • Mean gradient across the hypoplastic TAA decreased
  • 38 mmHg (14–76) to 5 mmHg (0–13) (P < 0.001)
  • No deaths
  • 6 early complications occurred in 5 patients
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The Heart Center

Results: Most recent follow up

  • N= 19/21 patients
  • Median follow-up → 24 months
  • Median systolic blood pressure
  • 153 mmHg (117–180) pre-stent
  • 130 mmHg (105–150) post-stent (P < 0.0002)
  • 13 patients → Antihypertensive medication could be reduced
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The Heart Center

Acute/Early Adverse Events

  • 6 in 5 patients (28.6%)
  • 3 major
  • Stent migration – 2
  • Stroke – 1
  • 3 minor
  • Transient brachial plexus injury – 1
  • Blood transfusion – 1
  • Bacteremia (S. viridians) – 1
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The Heart Center

Adverse Events at last follow up

  • 3 in 2 patients
  • Both neonates
  • Stent fracture + intimial hyperplasia – 1
  • Intimial hyperplasia -- 1
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The Heart Center

Study Conclusions 21 patients; 4 centers

  • Stenting of TAA hypoplasia
  • Technically challenging
  • Good angiographic and haemodynamic results
  • Early improvement in BP control →Appears to be sustained in the medium term
  • Stenting of TAA hypoplasia in neonates
  • More longer-term complications and interventions
  • Longer term follow up is needed
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The Heart Center

Medium- to Long-Term Outcomes of Percutaneous In Intravascular Stent Therapy for TAH

  • Darren P. Berman, MD1; Joanne L. Chisolm, RN1; Sharon L. Cheatham, PhD, ACNP1; Brian A. Boe, MD1; Aimee K.

Armstrong, MD1; Zach Steinberg, MD2; Thomas K. Jones, MD2; Michiel Voskuil, MD3; Gregor J. Krings, MD4; Jyothsna Akam Venkata, MD5; Tom J. Forbes, MD5; John P. Cheatham, MD1

  • 1 Heart Center, Nationwide Children’s Hospital, Columbus, OH
  • 2Seattle Children’s Hospital, Seattle, WA
  • 3Department of Cardiology, University Medical Center Utrecht,

the Netherlands

  • 4Department of Pediatric Cardiology, Wilhelmina Children's

Hospital of the University Medical Center Utrecht, the Netherlands

  • 5Children’s Hospital of Michigan, Detroit, MI
  • Multi-center retrospective review (5 centers)
  • 7/2002 – 12/2017
  • Describe procedural results
  • Assess the medium- to long-term outcomes from stent implantation

for treatment of TAH

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The Heart Center

Results -- Patient Characteristics

  • 146 patients; 48 female
  • 187 stents
  • Median age – 14.4 years (neonate – 63.6 years)
  • Median weight – 58 kg (3 – 149 kg)
  • Anti-hypertensive medication
  • 44% on 1
  • 12% on ≥ 2
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The Heart Center

CoA Type

27% 73%

Native Re-CoA

N=146

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The Heart Center

Previous Repair Type

10 20 30 40 50 60

End-to-end Subclavian flap Patch Other surgery Balloon angioplasty Intravascular stent

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The Heart Center

Initial Stent Characteristics

139 7 79 67

20 40 60 80 100 120 140 160 Bare Covered Open Closed

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The Heart Center

Acute Procedural Results

  • Successful implant in 99%
  • Significant reduction in pressure gradient
  • 25.9±16.5 to 4.0±6.1mmHg (p<0.05)
  • Serious adverse events in 7/146 (4.8%)
  • Aortic tear – 3 (1 death in pt on ECMO)
  • Access site injury – 1
  • Hemodynamic instability -1
  • Stent malposition - 2
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The Heart Center

Arch Vessel Involvement

118 27

Overlapped Arch Vessels

yes no 96 21 1

20 40 60 80 100 120 1 2 3

Number Vessels Covered 118 patients 141 vessels

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The Heart Center

Involved Arch Vessels

92 37 7 13 3

10 20 30 40 50 60 70 80 90 100

LSCA LCCA RSCA/aberrent RSCA innom

  • ther
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The Heart Center

Results

Most Recent Follow-up

  • Follow-up reported in 105 patients – 72%
  • Time to most recent f/u
  • median 7 years (1 mo – 14 yrs)
  • No neurologic events reported
  • no routine brain imaging
  • 60% remain on anti-hypertensive medications
  • 78% on ≤ 1 med
  • 47 patients with re-intervention
  • 25 – stent re-dilation
  • 22 – additional stent implant
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The Heart Center

Stent/Procedure Related Adverse Events

  • N=10 (7%)
  • Stent Fracture (4)
  • Treated with additional stent

3

  • Untreated at this time

1

  • Aortic wall injury (6)
  • Small pseudoaneursym

2

  • Aortic dissection/enlarging pseudoaneursym

1

  • Wire injury during subsequent cath

1

  • Late stent embolization

2

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The Heart Center

Conclusions

  • In pts with CoA, even mild TAH may be an important contributor to

persistent systemic hypertension and its associated morbidities

  • TAH does not show any significant catchup growth after effective

aortic stent relief of juxtaductal/isthmus CoA

  • Stenting the TAA is feasible and effective
  • Open-celled bare metal stents in most cases
  • Medium to long term follow up data are reassuring
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The Heart Center

Conclusions: Should I or Shouldn’t I Stent a Coarctation of Aorta if it’s Associated with Transverse Arch Hypoplasia

  • Cannot ignore TAH in our decision making
  • Decision to stent a CoA associated with TAH → Age dependent
  • Infant and young child
  • Not unreasonable to consider surgical arch augmentation and CoA repair
  • Older child and adults
  • Informed plan with patient and family
  • Need for multiple caths and stents to fix isthmal CoA and reconstruct TAH
  • Yes we can → More long-term robust follow-up is needed
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The Heart Center

Thank you