COARCTATION OF THE AORTA - A 25 YEARS EXPERIENCE

1. COARCTATION OF THE AORTA - A 25 YEARS EXPERIENCE Dan Fagarasanu Andrei Iosifescu Vlad Iliescu Dan Mihalcescu Traian Anca Cardiovascular Surgery Unit �C.C.Iliescu Institute for Cardiovascular Disease Bucharest, Romania

2. 1976- 2000 :510 OPERATIONS FOR COARCTATION OF THE ISTHMIC AORTA Age= 12 +/- 9 yrs. Extreme ages: 6 months - 50 yrs. Sex ratio : ?/? 302/208 0.59/0.41 consecutive operations retrospective study operations performed by 12 different surgeons

3. AGE AT OPERATION

4. MORHOLOGIC FORMS �TRUE CoAo� (Diaphragm type) 434 87% =>LUMINAL STENOSIS 368 (84,8%) =>LUMINAL ATRESIA 66 (15,2%) TUBULAR HYPOPLASIA +/-Diaph. 76 13% ANEURYSMS 34 6,6% AORTIC ANEURYSMS 16 INTERCOSTAL ANEURYSM 18

5. ASSOCIATED ANOMALIES Patent Ductus 88 17.3% Aortic lesions 61 12% VSD 37 7.3% Mitral valve anomalies 12 2.4% Subaortic stenosis 11 2.2% ASD 9 1.8% Endocarditis/endarteritis 6 1.2%

6. TECHNIQUES PATCH ISTHMOPLASTY 368 PERICARDIAL PATCH (Modified Vosschulte) 248 SYNTTHETIC PATCH (Vosschulte - Dacron/PTFE) 120 RESECTION+INTERPOSITION (Cooley) 60 RESECTION+ete ANASTOMOSIS (Crafoord) 38 BYPASSES (Ao-Ao, Scl-Ao) 32

7. FRESH PERICARDIAL PATCH ISTHMOPLASTY Modified Vosschulte technique Original technique (D.Fagarasanu, 1975) initially developed because of lack of an apropriate material Technique: longitudinal aortotomy +limited resection of the diaphragm + suture of ~ oval shaped patch Advantages: less dissection self material with apropriate tissular resistance less bleeding (easy to suture) available, cheap resistance to infection

8. EARLY RESULTS:COMPLICATIONS Hemorrhagic complications 19 3.7% Residual gradient => early reop. 6 1.2% Paraplegia 2 0.4% Wound infection 10 1.9%

9. HOSPITAL MORTALITY HM 6 / 510 1.2% Concentrated at the extreme ages <2 yrs. 2/26 7.6% 3-40 yrs. 1/467 0.2% >40 yrs. 3/17 17.6% Causes: Heart failure in small children (1 with concomit.Banding) Adults with complicated CoAo (2 aneurysms repair, 1 concomitent AVR for endocarditis)

10. LATE RESULTS 82% follow up; 1 control/year Reop. for recurrent stenosis 21 4.1% after patch plasty 10/368 2.7% after non-patch procedures 11/142 7.7% Late aneurysms 11 2.2% after pericardial patch plasty 3/248 1.2% after Dacron/PTFE patch 5/120 4.1% after non-patch procedures 3/142 2.1% Residual arterial hypertension 65/444 14,5%

11. DISCUSSION: LATE ANEURYSMS AFTER PATCH AORTOPLASTIES Literature is controversial : % late aneurysms after synthetic patches: 0%�25% some indicate it as first choice >1yr. (Mavroudis, 2000) other think it should be abandoned (Borst, 1993) Pathogenic hypothesis extensive resection of the diapragm (DeSanto, 1987) different wall stress profile after synthetic patch (McGiffin,1992) Late aneurysms can be avoided by limited resection of the diaphragm using patches with a better stress profile ? pericardium>PTFE>Dacron

12. CONCLUSIONS The isolated CoAo in children >1yr. was surgicaly treated with a H.M. <1%; Patch aortoplasty proved an efficient method for relief of aortic coarctation, with a lower rate of late restenosis than other procedures; The use of fresh pericardium as a patch proved fully satisfactory; late aneurysms were found in only 1.2% of the pts.; limited resection of the diapragm and a better stress profile of pericardium, may have a contribution to it;