(47Kb)Sreeram N, de Giovanni JV, Boehm W. Palliative
balloon dilation of native coarctation of the aorta in a preterm infant.
Images Paediatr Cardiol 2005;25:1-4
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(47Kb) |
Sreeram N, de Giovanni JV, Boehm W. Palliative
balloon dilation of native coarctation of the aorta in a preterm infant.
Images Paediatr Cardiol 2005;25:1-4
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University Hospital of Cologne, Germany. |
| Angioplasty, Balloon | Aortic Coarctation/diagnosis/*therapy | Child |
| Recurrence |
Introduction
Balloon dilation of native coarctation in neonates and infants has
been considered to be of unproven benefit, in view of the high recurrence
rate.1 We report successful palliation by balloon dilation of
native coarctation in a 1.0 kg preterm neonate with severe left ventricualr
cardiomyopathy.
Patient
The patient was a 29 week gestation preterm female infant with a birth
weight of 940 grams. Coarctation of the aorta was diagnosed at routine
neonatal ultrasound screening. Sufficient anterograde flow across the coarctation
was present, and no intravenous prostaglandin was administered. At weekly
echocardiographic follow-up, the patient was seen to develop progressive
left ventricular dilation and cardiomyopathy (LVEDD 23mm; fractional shortening
21%), with relatively low gradient across the coarctation (25 mm Hg) on
Doppler sonography. As the duct had already closed spontaneously in the
first postnatal week, intravenous prostaglandin E infusion to maintain
patency of the duct for several weeks was not considered. At 3 weeks of
age (weight 1000 grams), balloon angioplasty was undertaken to relieve
the coarctation, and allow the patient to grow further prior to definitive
surgical repair.
Via a cutdown of the right axillary artery a 3F sheath was introduced
into the aorta. Angiography performed with a 3F Judkins catheter confirmed
severe coarctation (fig. 1).
The post-dilation gradient was 14 mm Hg (53 vs 39 mm Hg). The entry site in the axillary artery was maaged by simple compression, followed by suture closure of the skin. Measurable improvement in left ventricular function was observed within 7 days of balloon angioplasty. At 4 weeks of follow-up (age 7 weeks, weight 1240 grams) recurrence of coarctation was observed. Repeat balloon angioplasty was performed in an identical fashion, via the right axillary artery, with similar results. Despite a mild residual gradient, left ventricular function improved following redilation, and marked somatic growth was observed. At 13 weeks of age (weight 2.1 kg) elective surgical repair with resection of the coarctation segment and end-to-end anastomosis was successfully performed. The postoperative course was uneventful. Follow-up examination at 3 months confirms a good repair. The patient is on no medications, and has a normal resting blood pressure for age.
Discussion
In preterm neonates with coarctation, intravenous prostaglandin therapy
for several weeks, until the patient has achieved a suitable weight for
definitive surgical repair, should always be considered. As the patient
was thought to have mild coarctation, with sufficient anterograde flow,
this therapy option was not carried out. Within the first 7 days the duct
had closed spontaneously, and thereafter left ventricular failure was progressive.
Although balloon dilation of neonatal coarctation is associated with a
high recurrence rate,1,2 and cannot therefore be considered
to be definitive therapy, palliative balloon dilation has a role in the
management of preterm and severely sick neonates with impaired ventricular
function. The right axillary artery approach is relatively straightforward,
and the artery does not require suture repair even after surgical cutdown
(on 2 occasions in our patient). Successful dilation followed by improvement
of ventricular function and further gain in weight allowed definitive surgical
repair to be safely postponed.
References
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