Should I or Shouldnt I? Should I or Shouldnt I Associated - PowerPoint PPT Presentation

Should I or Shouldn’t I? Should I or Shouldn’t I Associated Transverse Arch Stent a Coarctation of f Aorta Hypoplasia if it’s Associated with Transverse Arch Hypoplasia Darren P. Berman, MD Co-Director, Cardiac Catheterization The Heart Center Nationwide Children’s Hospital Associate Professor, Pediatrics The Ohio State University Columbus, OH, USA The Heart Center

Disclosures ____________________________________________________________________________________________ • Consultant • Abbott Medical • Medtronic • Edwards Life Sciences The Heart Center

Should I or Shouldn’t I? Associated Transverse Arch Hypoplasia (T (TAH) • Is TAH an important residual lesion? • Does TAH improve after relief of Coarctation of Aorta? • What are treatment options for TAH? The Heart Center

• Pathologic study -- 35 aortic arch systems • Further define relationship between the ductus arteriosus, coarctation, and tubular hypoplasia of the aortic arch ………………..…………………………………………………………………………………………………………………………………….. The Heart Center

• Normal newborn aortic arch • The isthmus is slightly narrower than either the ascending or descending aorta Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosis. BHJ, 1979, 41, 268-274 . ………………..…………………………………………………………………………………………………………………………………….. The Heart Center

Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosis. BHJ, 1979, 41, 268-274 . The Heart Center

Coarctation of the Aorta: Following Successful Treatment • 30% of patients have important systemic HTN • Contributes to cardiovascular morbidity and mortality • high incidence of coronary artery disease and stroke • Why this high prevalence of HTN? • Residual arch obstruction • Abnormal aortic arch shape • Abnormal vascular properties of the systemic vasculature Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of O’Sullivan J. Late hypertension in patients with repaired aortic the aorta. Long-term follow-up and prediction of outcome after surgical coarctation. Curr Hypertens Rep. 2014;16:421. correction. Circulation. 1989;80:840 – 845. The Heart Center

Should I or Shouldn’t I? Associa iated Transverse Arch Hypoplasia (T (TAH) • Is TAH an important residual lesion? The Heart Center

Does TAH contribute to this systemic HTN? The Heart Center

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• Persistent mild TAA hypoplasia • In the absence of an arm-leg SBP difference at rest • Is associated with late systemic HTN & worse arm-leg SBP gradient w/exercise ………………..…………………………………………………………………………………………………………………………………….. The Heart Center

Is TAH an important residual lesion? • Moderate to severe TAH -- yes • Mild TAH • Should we be more aggressive? The Heart Center

Does TAH improve after relief of CoA of Aorta? The Heart Center

• Retrospective chart review • 10/1995 and 4/2015 • 51 children • Median age 11.1 years • All had TAH and a CoA stent • Explore the clinical impact of the untreated TAH The Heart Center

• Median follow up – 37 months • No significant catch-up growth in the transverse arch • By echocardiographic imaging and Z-scores • A trend to increasing SBP differential between the RUE and LUE • 11 mmHg prior to stent --> 16 mmHg in follow-up • Medical management can be difficult • Approaches to treat this should be considered • Surgical arch augmentation • Stent implantation The Heart Center

What are treatment options for TAH? • Surgical arch augmentation • Transcatheter stent implantation The Heart Center

Case Example • 45 yo with history of COA, non-obstructed BAV • s/p end to end anastomosis at 4 years of age. • Lost to follow up after age 18 • Referred to ACHD for evaluation of HTN and h/o CoA • Medications: Lisinopril 10 mg qd, HCTZ 12.5mg • BP: RA 188/96 LA 163/104 RL 165/114 The Heart Center

3DRA as 1 st angiogram The Heart Center

Conventional angiogram The Heart Center

36mm long Max LD stent on 20mm BIB Dilation of struts crossing LSCA The Heart Center

3DRA post-stent AAO 113/64 m85 DAO 113/63 m84 The Heart Center

• Retrospective review; 4 centers; from 2000-2010 • Outcomes for stenting of transverse aortic arch hypoplasia • Reduction in peak systolic catheter gradient • Dimensions of the stented segment • Systolic right arm blood pressure • Early and late complications were recorded • 21 patients (16 male, 5 female) • Median age of 16.5 years (range, 0.25 – 25.9 years), (2 neonates) • Median weight of 55 kg (range, 4.5 – 103 kg) ………………..…………………………………………………………………………………………………………………………………….. The Heart Center

Results • Median transverse arch diameter • Increased from 7 to 14 mm after stenting (P < 0.001) • Median TAA/DAO at the level of the diaphragm improved • 0.43 to 0.9 (P < 0.001) • Mean gradient across the hypoplastic TAA decreased • 38 mmHg (14 – 76) to 5 mmHg (0 – 13) (P < 0.001) • No deaths • 6 early complications occurred in 5 patients The Heart Center

Results: Most recent follow up • N= 19/21 patients • Median follow-up → 24 months • Median systolic blood pressure • 153 mmHg (117 – 180) pre-stent • 130 mmHg (105 – 150) post-stent (P < 0.0002) • 13 patients → Antihypertensive medication could be reduced The Heart Center

Acute/Early Adverse Events • 6 in 5 patients (28.6%) • 3 major • Stent migration – 2 • Stroke – 1 • 3 minor • Transient brachial plexus injury – 1 • Blood transfusion – 1 • Bacteremia (S. viridians) – 1 The Heart Center

Adverse Events at last follow up • 3 in 2 patients • Both neonates • Stent fracture + intimial hyperplasia – 1 • Intimial hyperplasia -- 1 The Heart Center

Study Conclusions 21 patients; 4 centers • Stenting of TAA hypoplasia • Technically challenging • Good angiographic and haemodynamic results • Early improvement in BP control → Appears to be sustained in the medium term • Stenting of TAA hypoplasia in neonates • More longer-term complications and interventions • Longer term follow up is needed The Heart Center

Medium- to Long-Term Outcomes of Percutaneous In Intravascular Stent Therapy for TAH • Darren P. Berman, MD 1 ; Joanne L. Chisolm, RN 1 ; Sharon L. Cheatham, PhD, ACNP 1 ; Brian A. Boe, MD 1 ; Aimee K. Armstrong, MD 1 ; Zach Steinberg, MD 2 ; Thomas K. Jones, MD 2 ; Michiel Voskuil, MD 3 ; Gregor J. Krings, MD 4 ; Jyothsna Akam Venkata, MD 5 ; Tom J. Forbes, MD 5 ; John P. Cheatham, MD 1 • Multi-center retrospective review (5 centers) • 1 Heart Center, Nationwide Children’s Hospital, Columbus, OH • 7/2002 – 12/2017 • 2 Seattle Children’s Hospital, Seattle, WA • Describe procedural results • 3 Department of Cardiology, University Medical Center Utrecht, • Assess the medium- to long-term outcomes from stent implantation the Netherlands for treatment of TAH • 4 Department of Pediatric Cardiology, Wilhelmina Children's Hospital of the University Medical Center Utrecht, the Netherlands • 5 Children’s Hospital of Michigan, Detroit, MI The Heart Center

Results -- Patient Characteristics • 146 patients; 48 female • 187 stents • Median age – 14.4 years (neonate – 63.6 years) • Median weight – 58 kg (3 – 149 kg) • Anti-hypertensive medication • 44% on 1 • 12% on ≥ 2 The Heart Center

CoA Type N=146 27% 73% Native Re-CoA The Heart Center

Previous Repair Type Intravascular stent Balloon angioplasty Other surgery Patch Subclavian flap End-to-end 0 10 20 30 40 50 60 The Heart Center

Initial Stent Characteristics 160 140 139 120 100 80 79 67 60 40 20 7 0 Bare Covered Open Closed The Heart Center

Acute Procedural Results • Successful implant in 99% • Significant reduction in pressure gradient • 25.9±16.5 to 4.0±6.1mmHg (p<0.05) • Serious adverse events in 7/146 (4.8%) • Aortic tear – 3 (1 death in pt on ECMO) • Access site injury – 1 • Hemodynamic instability -1 • Stent malposition - 2 The Heart Center

Arch Vessel Involvement Number Vessels Covered Overlapped Arch Vessels 120 100 96 27 118 patients 80 141 vessels 60 118 40 yes no 20 21 1 0 1 2 3 The Heart Center

Involved Arch Vessels 3 other 13 innom 7 RSCA/aberrent RSCA 37 LCCA 92 LSCA 0 10 20 30 40 50 60 70 80 90 100 The Heart Center