Transcatheter interventions can be used to delay surgery until patients are larger, older and more likely to have a more durable, long-term surgical repair.
A new study published in Pediatric Cardiology found transcatheter intervention, including stent placement, is a feasible alternative to surgery for aortic coarctation in infants, with an acceptable adverse event profile.
Coarctation of the aorta (CoA) is a common form of congenital heart disease, accounting for an estimated 5% to 8% of congenital heart defects.
Surgery remains the preferred treatment option in infants less than a year old. However, age and weight at time of surgery have been shown to be risk factors for both re-coarctation
and mortality. Stent implantation increasingly has become the treatment of choice in children who can accommodate a stent.
Before this study, little data existed on long-term outcomes of patients less than a year old treated with a transcatheter approach.
Lead author on the study “Late Outcomes of Transcatheter Coarctation Intervention in Infants with Biventricular Anatomy” was Joshua D. Kurtz, M.D., pediatric cardiologist at Norton Children’s Heart Institute, affiliated with the UofL School of Medicine.
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Looking at cases with a mean follow-up interval of 5.4 years, Dr. Kurtz and his co-authors concluded transcatheter interventions “can be used to delay surgery until a time when patients are larger, older and more likely to have a more durable, long-term surgical repair.”
Results show stent is feasible in some when balloon is insufficient
This chart review study looked at outcomes of catheter intervention for aortic coarctation in infants at Seattle Children’s Hospital in Washington. Infants were excluded from the study if they had single ventricle physiology or a nontypical location for the coarctation.
The results showed “catheter-based treatment of CoA in infants is beneficial with an acceptable risk profile,” the authors wrote. In some patients when balloon angioplasty does not obtain sufficient results, stent implantation is feasible. As expected, stent dilation was common. Surgical revision occurred in over half of the stent patients.
A total of 34 patients were included in the analysis, with a mean age of 4 months and weight of 5.3 kilograms. Sixteen underwent stent placement; the others received balloon angioplasty. Twelve patients underwent the procedure due to ventricular dysfunction. The rest were for high resting gradient.
As a result of the procedure, the entire cohort showed an increase in coarctation diameter from 2.4 to 4.5, a mean ratio of post-intervention coarctation diameter to pre-intervention coarctation diameter of 2.1, while gradient decreased from 32.0 to 9.2 mmHg, on average. On follow-up, 12 (35%) of the patients were on anti-hypertensive medications.
The stent group had a mean reduction in gradient of 27.6 mmHg and a mean ratio of pre- and post-treatment coarctation diameters of 2.8. The balloon angioplasty group had a mean reduction in gradient of 19.1 mmHg and ratio of pre- and post-treatment coarctation diameters of 1.7.
Of the 16 stented patients, 13 required at least one re-intervention, at an average of 1.7 years from the index procedure, compared with five of 18 patients undergoing balloon angioplasty. The stent group also was more likely to require future surgical intervention: nine patients in the stent group versus three in the balloon angioplasty group.
Overall, patients in the stent group underwent a total of 30 re-interventions: 17 stent re-dilations, four additional stent placements and nine surgeries. There was no mortality due to the procedure and one serious procedural adverse event. There was also one late mortality in a stent patient, two months after the index procedure. The death was related to left-sided atrioventricular valve disease, with failure of a mechanical valve leading to pulmonary hypertension with no further options for intervention on the valve.
“The need for early re-intervention is cited as the main reason limiting the role of transcatheter interventions as the treatment of choice in this population,” the authors wrote. “In older children, adolescents and adults, CoA stenting has been shown to be an effective therapy with low rates of re-intervention and adverse events. It is more common for balloon angioplasty alone to be the treatment of choice in recurrent re-coarctation in infants.”