Congenital Heart Interventions

Follow-up of hypertension after aortic coarctation stent implantation based on safe and effective re intervention: a retrospective cohort study. Zhang W, Schneider M, Zartner P.J Thorac Dis. 2022 Oct;14(10):3924-3933. doi: 10.21037/jtd-22-1134.PMID: 36389339 Take home points: Hypertension is common with coarctation of the aorta and needs to be evaluated longitudinally. Hypertension decreased after coarctation stent implantation but in-stent restenosis (> 10 mmHg gradient) was accompanied by recurrent hypertension. The younger the age at stent implantation, the less the incidence of hypertension at follow up. However, the younger the age at stent implantation, the more likely (80%) the patient is to require more than one intervention. Hypertension was present in 88% pre-stent (native and recurrent coarctation) and in 28% at last follow-up post stent implantation, suggesting that long term follow-up is required even with a good result. Commentary from Dr. Thomas Zellers (Dallas, USA), section editor of Congenital Heart Disease Interventions and ACHD Journal Watch: Summary: This is a retrospective evaluation of hypertension in 88 consecutive patients with coarctation following stent implantation from the German Pediatric Heart Centre between 2004 and 2012. Long term follow-up (up to 12 years) was available in 82 patients. Stent implantation was indicated for catheter measured gradients > 20 mmHg or angiographic narrowing > 50%. Patients were not eligible for study if they had long segment coarctation or required a palliative stent. Patients were followed at 1, 3, 6 and 12 months and then yearly. BP measurements were performed after 5 minutes of rest and 3 measurements were averaged. Hypertension was defined as systolic BP > 140 mmHg and /or diastolic BP > 90 mmHg or a BP > 95th%’ile for age, height and weight. Anti-Hypertensive medications like betablockers, ACE inhibitors, ARBs, calcium channel blockers and diuretics, or a combination of more than one, were used when hypertension was found. The average follow up was 77 months (6-151 months) with one patient death. Restenosis was common (80%) with 40%, 22% and 17% requiring 1, 2 and 3 reinterventions, respectively. A total of 198 interventions were performed (including the initial 82 stent implants). Complications occurred in 3%, half of which were related to aneurysm formation. Hypertension was present in 88% of patients prior to initial stent implantation and in 28% at last follow-up, all of whom required antihypertensive medications. There was no difference in incidence of hypertension at the time of implant for native vs recurrent coarctation. At follow-up, it was found that the younger the patient at initial implant, the lower in the incidence of hypertension but the more likely the need for at least one additional reintervention. Figure 1. Hypertension recurred with in stent restenosis. Figure 2 (example) Limitations: This is a retrospective study from a single center which involved stent implantation in younger age groups than found in many studies. The number of patients is modest but the follow up is fairly complete. The follow-up information in younger patients in this study could be used to inform how these patients should be followed in the future. What we learned and could use from this study: Stent implantation is safe even in younger patients with a low incidence of complications. Hypertension is common in follow up and may herald re-stenosis and the need for a re-intervention. Even in patients with a good result, hypertension can be found, similar to other studies, and patients require antihypertensive medications. In this study, the incidence of hypertension at last follow up was 28%. The younger the age at implant, the more likely they are to require at least one more reintervention. However, the younger patients had less incidence of hypertension at follow up suggesting that earlier intervention may play a role in reducing the incidence of hypertension at follow-up. Long term follow up is needed in these patients even when they have had a good hemodynamic result. Tables:

Balloon angioplasty and stent implantation within 30 days postcongenital heart surgery (CHS) in children. Quandt D, Callegari A, Niesse O, Meinhold A, Dave H, Knirsch W, Kretschmar O. J Card Surg. 2022 Oct 23. doi: 10.1111/jocs.17057. Online ahead of print. PMID: 36273426 Take Home Points: Balloon angioplasty and stent implantation can be performed safely in immediate post-operative period. Stent implantation more reliably achieves relief of vessel stenosis. Commentary from Dr. Konstantin Averin (Cohen Children’s Heart Center), catheterization section editor of Pediatric Cardiology Journal Watch: Interventional cardiac catheterization in the immediate post-operative period is generally considered high risk.  The traditional teaching has been to delay intervention for 4-6 weeks after the operation to allow for healing and scar formation.  However, there is increasing data to suggest that intervention early after congenital heart surgery has a favorable risk profile if performed selectively.  Quandt et al sought to report on the safety and efficacy of balloon angioplasty (BAP) and stent implantation (SI) within 30 days post-congenital heart surgery (CHS) in children from a single center. Over a 20-year period (01/2001-01/2021) a total of 127 procedures were performed in 104 patients - 31 BAP and 96 SI with no significant differences in baseline demographics.  The median time from CHS to the intervention was 6.5 days but patients who underwent SI were only 4 days removed from CHS compared to 14 for BAP.  SI resulted in greater increase in vessel diameter both in absolute size and relative to adjacent structures.  SI also achieved an increase diameter of >50% more often than BAP (94% v 70%).  The rate of major complications was modest (4.8%) with no intra-procedural mortality.  There was one case in which the authors suspect rupture of a suture line requiring VA-ECMO use with full recovery.  There was no relationship between adverse events and severity of the stenosis. The authors conclude that BAP and SI is feasible and effective following CHS.  SI appears to provide more reliable relief of stenosis compared to BAP and should be favored when treating these critically ill infants.  These insights have the potential to guide clinicians in providing optimal care for children with congenital heart disease during the critical early postoperative period.