Coarctation: A Review of 80 Children and Adolescents James E. Cheatham, Jr, MD, Oklahoma G. Rainey Williams, MD, Oklahoma Webb M. Thompson, MD, Oklahoma Eugene F. Luckstead, MD, Oklahoma
City, Oklahoma
City, Oklahoma City, Oklahoma City, Oklahoma
Jerry D. Razook, MD, Oklahoma
City, Oklahoma
Ronald C. Elkins, MD, Oklahoma
City, Oklahoma
Surgical correction of coarctation of the thoracic aorta was first accomplished in 1944 by Crafoord and Nylin [I]. In two important areas, the optimal timing for elective repair and the operative technique to be used, general agreement has not been reached. The optimal age for elective repair was recently reported to be between 5 and 15 years of age by Sehested [2]. Pennington et al [3] state that because of residual hypertension, repair is mandatory before age 11 and preferred before age 6. The technical problems associated with repair in small children or infants plus the chance of recurrence or persistence must be weighed against the increased incidence of cardiovascular abnormalities, particularly hypertension, in those patients who undergo repair later. The technique most commonly used is resection with primary end-to-end anastomosis as originally described by Gross [4]. Waldhausen and Nohrwald [5] recommend a subclavian patch angioplasty whereas Vosschulte [6] and Rue1 et al [ 71 advocate a patch graft angioplasty. Interposition grafts are also used in adolescents and adults. To add to the available data concerning these problems, we reviewed all patients who underwent repair for coarctation at Oklahoma Children’s Memorial Hospital between July 1968 and November 1978. Material and Methods The charts of 80 consecutive patients who underwent surgery for coarctation of the thoracic aorta during this period were reviewed. Fifty-one (64 per cent) were male From the Divisions of Thoracic Surgery and Pediatric Cardiology, Children’s Memorial Hospital and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. Reprint requests should be addressed to Ronald C. Elkins, MD, Oklahoma City, Oklahoma 73125. Presented at the 31st Annual Meeting of the Southwestern Stirgical Congress, Las Vegas, Nevada, April 23-26, 1979.
Volume 138, December 1979
and 29 (36 per cent) female. The age range was 1 week to 19 years (average 4.5). Thirty-two patients (40 per cent) were less than 2 years of age (group I), whereas 48 (60 per cent) were 2 years of age and older (group II) (Table I). There were 23 patients (29 per cent) who weighed less than 5 kg. Patients with an interrupted aortic arch were not included in this study. Group I. Of the 32 patients less than 2 years of age who comprise group I, 24 presented with signs and symptoms of congestive heart failure. Twenty-nine (91 per cent) presented with upper extremity hypertension (systolic blood pressure greater than 100 mm Hg) (Table II). Twenty-six had evidence of ventricular hypertrophy on electrocardiography and 31 had an abnormal chest x-ray. Twenty-five patients‘(78 per cent) in this group had an associated cardiac defect (Table III). The most common associated anomaly was patent ductus arteriosus, which was present in 13 patients (41 per cent). Ventricular septal defect was present in 12 patients (38 per cent), atria1 septal defect in 4, aortic valve disease in 2, mitral valve disease in 2, t,ransposition of the great vessels in 1, and endocardial fibroelastosis in 3 patients. Five patients (16 per cent) were cyanotic at the time of operative intervention. Group II. Forty-seven patients (98 per cent) over 2 years of age had absent or diminished femoral pulses associated with upper extremity hypertension. A cardiac murmur was present in all patients. Seven patients complained of easy fatigability, whereas five had claudication of the legs. Four patients had signs and symptoms of congestive heart failure (Table II). Three patients had Turner’s syndrome and one had Poland’s syndrome. Associated cardiac defects were present in 10 patients (21 per cent) (Table III). Aortic valvular disease was present in four patients, patent ductus arteriosus in four, and ventricular septal defect and atria1 septal defect in one patient each. One patient in this group had undergone previous resection and end-to-end anastomosis for coarctation at another hospital. Twenty-three patients (47 per cent) had abnormal electrocardiograms with evidence of ventricular hypertrophy. Twenty-eight patients (58 per cent) had cardiomegaly on chest x-ray examination. Two
689
Cheatham et al
TABLE I
Patient Profile
TABLE II Group I (
City, Oklahoma
City, Oklahoma City, Oklahoma City, Oklahoma
Jerry D. Razook, MD, Oklahoma
City, Oklahoma
Ronald C. Elkins, MD, Oklahoma
City, Oklahoma
Surgical correction of coarctation of the thoracic aorta was first accomplished in 1944 by Crafoord and Nylin [I]. In two important areas, the optimal timing for elective repair and the operative technique to be used, general agreement has not been reached. The optimal age for elective repair was recently reported to be between 5 and 15 years of age by Sehested [2]. Pennington et al [3] state that because of residual hypertension, repair is mandatory before age 11 and preferred before age 6. The technical problems associated with repair in small children or infants plus the chance of recurrence or persistence must be weighed against the increased incidence of cardiovascular abnormalities, particularly hypertension, in those patients who undergo repair later. The technique most commonly used is resection with primary end-to-end anastomosis as originally described by Gross [4]. Waldhausen and Nohrwald [5] recommend a subclavian patch angioplasty whereas Vosschulte [6] and Rue1 et al [ 71 advocate a patch graft angioplasty. Interposition grafts are also used in adolescents and adults. To add to the available data concerning these problems, we reviewed all patients who underwent repair for coarctation at Oklahoma Children’s Memorial Hospital between July 1968 and November 1978. Material and Methods The charts of 80 consecutive patients who underwent surgery for coarctation of the thoracic aorta during this period were reviewed. Fifty-one (64 per cent) were male From the Divisions of Thoracic Surgery and Pediatric Cardiology, Children’s Memorial Hospital and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. Reprint requests should be addressed to Ronald C. Elkins, MD, Oklahoma City, Oklahoma 73125. Presented at the 31st Annual Meeting of the Southwestern Stirgical Congress, Las Vegas, Nevada, April 23-26, 1979.
Volume 138, December 1979
and 29 (36 per cent) female. The age range was 1 week to 19 years (average 4.5). Thirty-two patients (40 per cent) were less than 2 years of age (group I), whereas 48 (60 per cent) were 2 years of age and older (group II) (Table I). There were 23 patients (29 per cent) who weighed less than 5 kg. Patients with an interrupted aortic arch were not included in this study. Group I. Of the 32 patients less than 2 years of age who comprise group I, 24 presented with signs and symptoms of congestive heart failure. Twenty-nine (91 per cent) presented with upper extremity hypertension (systolic blood pressure greater than 100 mm Hg) (Table II). Twenty-six had evidence of ventricular hypertrophy on electrocardiography and 31 had an abnormal chest x-ray. Twenty-five patients‘(78 per cent) in this group had an associated cardiac defect (Table III). The most common associated anomaly was patent ductus arteriosus, which was present in 13 patients (41 per cent). Ventricular septal defect was present in 12 patients (38 per cent), atria1 septal defect in 4, aortic valve disease in 2, mitral valve disease in 2, t,ransposition of the great vessels in 1, and endocardial fibroelastosis in 3 patients. Five patients (16 per cent) were cyanotic at the time of operative intervention. Group II. Forty-seven patients (98 per cent) over 2 years of age had absent or diminished femoral pulses associated with upper extremity hypertension. A cardiac murmur was present in all patients. Seven patients complained of easy fatigability, whereas five had claudication of the legs. Four patients had signs and symptoms of congestive heart failure (Table II). Three patients had Turner’s syndrome and one had Poland’s syndrome. Associated cardiac defects were present in 10 patients (21 per cent) (Table III). Aortic valvular disease was present in four patients, patent ductus arteriosus in four, and ventricular septal defect and atria1 septal defect in one patient each. One patient in this group had undergone previous resection and end-to-end anastomosis for coarctation at another hospital. Twenty-three patients (47 per cent) had abnormal electrocardiograms with evidence of ventricular hypertrophy. Twenty-eight patients (58 per cent) had cardiomegaly on chest x-ray examination. Two
689
Cheatham et al
TABLE I
Patient Profile
TABLE II Group I (
