J Thorac Cardiovasc Surg 2004;128:488-489
© 2004 The American Association for Thoracic Surgery
Something to expect, diagnose, and treat early
Sameh Elsayed, MD,
Ahmed Kadri Abdulla,
Abed Mowafii,
Shaaban Abdul/Aziz Abulela,
Mohammed Mounir Elsaeid Awadalla, MD
Department of Cardiothoracic Surgery, Mansoura University, Elgomhoria, Mansouria, Egypt
To the Editor:
We read with interest the article entitled "Evolutional aspects of children and adolescents with surgically corrected aortic coarctation: clinical, echocardiographic, and magnetic resonance image analysis of 113 patients."1 We learned that transverse aortic arch hypoplasia should be corrected concomitantly with coarctation.
Nothing about the chest radiograph or cardiothoracic ratio was mentioned. In the authors' echocardiographic analysis, they did not comment about the dimensions or functions of the cardiac chamber, although left ventricular hyperkinesia and increased ventricular mass are found even in normotensive patients long after successful coarctation repair: increased ventricular mass can provoke rhythm disturbances and might cause an imbalance between muscle and coronary vessel growth, with decreased oxygen reserve. Their series is a select group, and not all patients undergoing operations during this 26-year period were included. Therefore, the study is subject to biases and is weak. The definition of recoarctation is to be broadened to include the systolic gradient between the right arm and leg: measured with a sphygmomanometer, Doppler echocardiography, magnetic resonance angiography, and/or angiography of the aortic isthmus and descending aorta, systolic gradients and diameters equal to or greater than 20 mm Hg at rest or a combination of a right arm–leg pressure gradient of more than 50 mm Hg after the bicycle test and more than 40% reduction in cross-sectional diameter of the aorta at the anastomotic site compared with the aorta at the level of the diaphragm.2
The recoarctation percentage after end-to-end anastomosis (14%) is not correct: it should be 12.53% rather than 14%. The patch aortoplasty figure should be 7.69% rather than 7%. However, this did not affect the order of frequency. We do not understand why the aortic ratio median behaved independently of age at coarctation correction or why there was no significant difference between the median ratios of each aortic level within all age groups. Was there any correlation with the recoarctation or with the hypertension?
Factors influencing the process of recoarctation are tubular hypoplasia of the aortic arch, the surgical technique used, infective aortitis, complete resection of ductal tissue, suture material, suture technique, and width of the anastomosis. We do agree with their conclusion that none of the noninvasive methods used alone was sufficient to diagnose aortic recoarctation in every case, and they should be used as complementary methods. We would like to add that magnetic resonance angiography is indicated in all cases of suspected recoarctation. Currie and colleagues in 19854 state that maximal catheter peak gradient equals 10.3 plus Doppler gradient.
What was the indication for surgical intervention? They have seen cases associated with endocardititis or mesentric enteritis preoperatively or postoperatively. What are the methods of spinal protection they used to lessen the possibility of paraplegia, and what is the upper limit in the aortic clamp time?4
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References
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- Smith Maia MMD, Cortês TM, Parga JR, de Ávila LFR, Aiello VD, Barbero-Marcial M, et al. Evolutional aspects of children and adolescents with surgically corrected aortic coarctation. clinical, echocardiographic, and magnetic resonance image analysis of 113 patients. J Thorac Cardiovasc Surg. 2004;127:712-720.[Abstract/Free Full Text]
- Kappetein AP, Zwinderman AH, Bogers AJJC, Rohmer J, Huysmans HA. More than thirty-five years of coarctation repair. an unexpected high relapse rate. J Thorac Cardiovasc Surg. 1994;107:87-95.[Abstract/Free Full Text]
- Brouwer RMHJ, Erasmus ME, Ebels T, Eijgelaar A. Influence of age on survival, late hypertension, and recoarctation in elective aortic coarctation repair including long-term results after elective aortic coarctation repair with a follow-up from 25 to 44 years. J Thorac Cardiovasc Surg. 1994;108:525-531.[Abstract/Free Full Text]
- Currie PJ, Seward GB, Reed GS, Vliestra RE, Brensahan DR, Brensahan JS, Jsmil HG, et al. Continuous wave Doppler echocardiographic assessment of severity of calcific aortic stenosis. a simultaneous Doppler catheter correlative study in 100 adult patients. Circulation. 1985;71(6):1162-1169.[Abstract/Free Full Text]
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