Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 272--273

Indications for intervention for coarctation of the aorta

Navaneetha Sasikumar1, Atsuko Kato2,  
1 Consultant Pediatric Cardiologist, Department of Cardiothoracic and Vascular Surgery, Government Medical College, Kottayam, Kerala, India
2 Department of Perinatal and Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan

Correspondence Address:
Navaneetha Sasikumar
Consultant Pediatric Cardiologist, Department of Cardiothoracic and Vascular Surgery, Government Medical College, Kottayam, Kerala

How to cite this article:
Sasikumar N, Kato A. Indications for intervention for coarctation of the aorta.Ann Pediatr Card 2020;13:272-273

How to cite this URL:
Sasikumar N, Kato A. Indications for intervention for coarctation of the aorta. Ann Pediatr Card [serial online] 2020 [cited 2022 May 17 ];13:272-273
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Appreciate the gigantic effort behind the updated Indian recommendations.[1] This letter is an attempt to clarify the ambiguity around the treatment of coarctation of the aorta.

Point one recommends that “Patients with coarctation gradient ≥20 mmHg (Class I)” undergo intervention. Whether it is catheterization/Doppler/upper-lower limb blood pressure derived is unclear. Point five says Doppler gradient, so presume 20 is the peak Doppler gradient across coarctation. This is concerning.

Target catheterization gradient for balloon/stent angioplasty is <10–20 mmHg. The average pretreatment catheterization gradient of 2641 balloon dilatations (48 studies) and 1936 stents (42 studies) was 49.0 and 39.2 mmHg, respectively.[2] Hence, it is general practice to go to the catheterization laboratory only when a meaningful difference can be made. The chances of achieving the same going in with an indication of 20 mmHg peak Doppler gradient are grim. The American Heart Association guidelines recommend 20 mmHg catheterization gradient as indication.[3] The European Society of Cardiology guidelines clarify that Doppler is unreliable for severity assessment.[4] Instead, intervention is recommended for upper-lower limb blood pressure gradient >20 mmHg associated with either resting or exercise-induced hypertension or left ventricular hypertrophy.[4]

Many aspects of coarctation interventions remain controversial. Stenting is preferred when size of vessels permits the same. Stent achieves better gradient reductions with lesser complications.[2],[5] For those who are not candidates for stenting, balloon versus surgery is best decided by patient anatomy and age-wise results of individual units for balloon versus surgery. As to indications, there is no ambiguity when there is arm–leg blood pressure gradient more than 20 mmHg or heart failure or left ventricular dysfunction or upper-limb hypertension or left ventricular hypertrophy on quantitative assessment, along with visible significant narrowing on two-dimensional echocardiography.[4],[5] Of the studies considered in Salcher et al.'s meta-analysis, none mentions a standalone Doppler peak gradient of >20 mmHg as indication.[2] Its self-evident that Doppler peak gradients cannot be substituted for catheterization gradients. The former consistently overestimates the gradients from pressure recovery. It is unusual for significant coarctation to present without any of the above-mentioned clinical features. In such instances, we practice and recommend close follow-up. In case of suspicion, the benefits of additional imaging (computed tomography/magnetic resonance imaging) outweigh the attendant risks of an unwarranted intervention in a small child. Imaging helps in severity assessment and to detect collateral flow which could cause spuriously low gradients. This approach would reduce the number of interventions and complications thereof that the patient has to bear with over a lifetime, which should be the goal.

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1Saxena A, Relan J, Agarwal R, Awasthy N, Azad S, Chakrabarty M, et al. Indian guidelines for indications and timing of intervention for common congenital heart diseases: Revised and updated consensus statement of the working group on management of congenital heart diseases. Ann Pediatr Card 2019;12:254-86
2Salcher M, Naci H, Law T J, Kuehne T, Schubert S, Kelm M, et al. balloon dilatation and stenting for aortic coarctation: A systematic review and meta-analysis. Circ Cardiovasc Interv 2016;9:e003153.
3Feltes TF, Bacha E, Beekman RH 3rd, Cheatham JP, Feinstein JA, Gomes AS, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: A scientific statement from the American Heart Association. Circulation 2011;123:2607-52.
4Erbel R, Aboyans V, Boileau C, Bossone E, Bartolomeo RD, Eggebrecht H, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014;35: 2873-926.
5Forbes TJ, Kim DW, Du W, Turner DR, Holzer R, Amin Z, et al. Comparison of surgical, stent, and balloon angioplasty treatment of native coarctation of the aorta: An observational study by the CCISC (Congenital Cardiovascular Interventional Study Consortium). J Am Coll Cardiol 2011;58:2664-74.