pediatrics
Coarctation of the Aorta
Treatment of Coarctation of the Aorta
For symptomatic neonates, prostaglandin E1 infusion For hypertension, beta-blockers Surgical correction for neonates, infants, and small children Sometimes balloon angioplasty (sometimes with stent placement) in older children and adolescents Symptomatic neonates are treated promptly. In infants with very mild coarctation and no signs of lower body hypoperfusion, the condition is monitored until definitive repair is done. Symptomatic neonates require early surgical intervention, but preoperative cardiopulmonary stabilization is essential. Stabilization is done with infusion of prostaglandin E1 (beginning at 0.05 to 0.1 mcg/kg/minute) to reopen the constricted ductus arteriosus. Opening the ductus and its aortic ampulla provides some relief of the aortic obstruction. It also allows pulmonary artery blood to bypass the aortic obstruction via right-to-left shunting across the ductus and increases perfusion of the descending aorta, improving systemic perfusion and reversing metabolic acidosis. Diuretics can help treat Heart failure in neonates symptoms. IV In nonemergent situations, patients with hypertension may be treated with beta-blockers; angiotensin-converting enzyme (ACE) inhibitors may adversely affect renal function. After repair of the coarctation, hypertension may persist or develop years after repair and can be treated with beta-blockers, ACE inhibitors,angiotensin IIreceptor blockers, or calcium channel blockers. Supplemental oxygen should be used with caution in neonates because the resulting decrease in pulmonary vascular resistance may increase pulmonary blood flow at the expense of systemic blood flow. The preferred definitive treatment for coarctation remains somewhat controversial. Some centers prefer balloon angioplasty with or without stent placement; others prefer surgical correction and reserve the balloon procedure for recoarctation after surgical correction or for primary treatment of discrete coarctation in older children or adolescents. Both surgical and transcatheter techniques have generally good outcomes. Most studies have found a lower rate of periprocedural complications but a higher risk of restenosis and aneurysm after balloon angioplasty compared to surgical intervention. Surgical options include Resection and end-to-end anastomosis Patch aortoplasty Left subclavian flap aortoplasty In severe coarctation manifesting early in life, the transverse aorta and isthmus are often hypoplastic, and this region of the aorta may need to be surgically enlarged. Choice of surgical technique depends on anatomy and center preference. Surgical mortality rate is<5% for symptomatic infants and<1% for older children. Rarely, paraplegia results from ischemia to the spinal cord during cross-clamping of the aorta during surgery. Balloon angioplasty is highly effective in treating recurrent coarctation after surgery. Prevention is not needed preoperatively and is required only for the first 6 months after repair. 