Beruflich Dokumente
Kultur Dokumente
2. History
Morgagni :
1st description in 1760
Bonnett :
postductal & preductal type in 1903
Crafoord :
1st coarctation repair in 1944
Vorsschulte :
prosthetic onlay graft or vertical incision
and transverse closure in 1957
Waldhausen : subclavian patch aortoplasty in 1966
Coarctation of Aorta
Developmental factor
1. Underdevelopment or hypoplasia of aortic
arch or isthmus
Definition of hypoplasia
* Proximal arch : 60% of ascending aorta
* Distal arch : 50% of ascending aorta
* Isthmus : 40% of ascending aorta
PDA
Coarctation of Aorta
Natural history
1. Incidence
* 5-8% of CHD (5 per 10000 live births)
* Isolated CoA (82% of total CoA) ; male:female = 2:1
CoA + VSD 11%, COA + other cardiac anomalies 7%
* Complex CoA ; no sex difference
2. Survival of pure CoA
* 15% : CHF in neonate or infancy
* 85% : survive late childhood without operation
* 65% : survive 3rd decade of life (2% at 60 years)
3. Bacterial endocarditis : common in 1st 5 decades
4. Aortic rupture : 2~3rd decade
5. Intracranial lesion : subarachnoid hemorrhage(cong. Berry
aneurysm)
Collaterals
in CoA
Coarctation of Aorta
Clinical features & diagnosis
1. Infancy
1) Closure of ductus (7-10 days) produces severe obstruction
2) Ductus arteriosus remains patent - differential cyanosis
3) Associated intracardiac defect - more severe, early onset
4) Degree of collateral circulation
2. Childhood
* Asymptomatic without significant associated lesion
* Hypertension (90%) * Cardiomegaly (33%)
* Rib notching (15%)
3. Adolescence and adult
* Hypertension ; very common * Valvar heart disease
* Heart failure at 30 years of age
4. Associated syndrome
* Turner syndrome (XO) : 2% * Von Recklinghausen’s D
* Noonan’s syndrome or congenital rubella
Coarctation of Aorta
Postoperative hypertension
• Sealy
Altered baroreceptor response with increased e
xcretion of epinephrine or norepinephrine
• Rocchin
Sympathetic nervous system in early phase, an
d renin-angiotensin system in late phase
Coactation of Aorta Repair
Paraplegia
1. Duration of spinal cord ischemia
2. Duration of intercostal artery ischemia
3. Intraoperative proximal hypotension
4. Postoperative hypotension
5. Hyperthermia during operation
6. Anastomosis with tension
7. Acidosis in the perioperative periods
Coactation of Aorta
Special situation & controversies
1. CoA proximal to left subclavian artery
* 1% of all COA
* reverse subclavian flap
* abdominal CoA : 0.5 ~ 2%
2. Mild or moderate coarctation
* degenerative change prone to occur
3. Prevention of paraplegia
* Collateral circulation, hypothermia(< 45min at 33 deg C)
* Descending aortic pressure under 50mmHg after clamp
4. Recurrent coarctation
Increased mortality and morbidity
5. CoA with VSD or other anomalies
Increased mortality and morbidity
Coactation of Aorta
Balloon dilatation
• The role of balloon dilatation is controversial because o
f early restenosis, the need for multiple interventions, p
otential limb ischemia, and the increased risk of aneury
sm formation
• The mechanism for early restenosis in neonates may b
e related to multiple factors including ductal tissue cons
triction or recoil, isthmus hypoplasia, intimal hyperplas
ia as a result of smooth muscle cell proliferation, and m
atrix protein production with arterial remodeling are in
volved in restenosis