Ventricular Septal Defect (VSD)
Coarctation of the Aorta
What is coarctation of the Aorta?
Coarctation of the Aorta (CoA) is a narrowing of the main artery (Aorta) which carries oxygenated blood away from the heart to the body. The narrowing decreases the blood flow to the body and makes the left side of the heart work harder to pump blood out of the smaller than normal opening. Coarctations are usually a congenital defect (the child is born with it). The usual location for the narrowing is between the beginning of the left subclavian artery and the beginning of the ductus arteriosus on the transverse portion of the aortic arch. Coarctations can be characterized by an elongated and diffuse narrowing of the aorta or by a localized indention located at a certain point or by a localized indentation along the length of the aorta.
Diffuse Narrowing Localized Coarctation
What happens when a coarctation of the aorta occurs?
Because 100% of the blood leaving the heart leaves by way of the aortic arch a narrowing at any part of the artery causes resistance to the blood flow through the vessel. With the increased resistance the blood pressure before the coarctation rises, and the blood pressure past the coarctation decreases. Any decrease in the blood pressure to the lower body can cause damage to vital organs (kidneys, liver, bowel, etc.). To compensate for this discrepancy in pressures the heart works harder to pump higher pressures to the lower body. Because the heart is working harder than normal to pump blood out to the head and body the left ventricle may “tire” causing blood to back up into the lung. This is known as congestive heart failure.
How is coarctation of the aorta diagnosed?
Normally coarctation of the aorta in an infant is diagnosed during the first few weeks of life, usually when the ductus arteriosus starts to close. On exam these babies will have a lower BP, cool extremities, weak peripheral pulses, decreased urine output, coarse lung sounds, and the usually have a marked discrepancy between the blood pressure in the upper extremities and the lower extremities.
Sometimes coarctation of the aorta may not be diagnosed until the child is older. These patients are usually diagnosed during routine physical exams for athletics or school. These children are usually recommended for further diagnostic evaluation by cardiac Catheterization. Surgical treatment or stent placement in the cardiac cath lab is usually recommended once the diagnosis has been made to prevent further left sided dysfunction.
How is coarctation of the aorta treated?
A few coarctations if not severe can be treated with close follow-up and medications to control the heart failure and hypertension. If an infant with a coarctation presents with persistent low blood pressure, acidosis, and/or aneuria (decreased urine output) repair of the defect should be scheduled without delay. Infants who present with a coarctation but are not hemodynamically unstable are usually monitored by a cardiologist. The defect will be repaired electively at a later date if symptoms of left heart failure become apparent.
Surgical treatments for symptomatic coarctations include 2 main techniques:
- Resection and direct end-to-end anastomosis
- Subclavian flap repair
The preferred surgical treatment for CoA is the resection of the narrowed area of the aorta and end-to- end anastomosis. With this technique an incision on the chest (thoracotomy) is performed usually on the left side. The narrowed area of the aorta is isolated and resected. The two exposed ends of the aorta are then mobilized, pulled together and sewn. The procedure to resect the narrowed area requires that the aorta be clamped for a short period of time.
The second treatment used for repair of a CoA utilizes the patients own subclavian artery. In this procedure the left subclavian artery is cut distal to the body and mobilized. The artery is opened up and folded back over the narrowed area of the arch (which has been opened). Once the flap is in place it is sewn creating a top dome enlarging the diameter of the barrel of the aorta. The blood flow to the left arm that was supplied by the left subclavian artery returns to normal post-op with collateral vessels.
Can there be other heart defects or anomalies associated with coarctation?
Coarctations can occur alone or in conjuction with other cardiac anomalies. Septal defects, especially defects in the ventricular septum, can occur with coarctations. Abnormalities of the aortic valve such as bicuspid aortic valve are also common with CoArc.
Aortic coarctation is more common in some genetic conditions such as Turner’s syndrome and Digeorge syndrome.
Will my baby have a normal heart after the surgery to repair the CoArc?
The goal in repairing any coarctation is complete repair of the lesion and long-term success. Incidence for recurrence of a severe coarctation in the neonatal period is high. Usually however the new coarctation, depending on the age it appears, may be able to be ballooned or even stented open with a trip to the cardiac catheterization lab eliminating the need for a re-operation. The older a patient is when a coarctation is diagnosed, the less likely it is for the CoArc to reoccur after repair.
What are some of the complications associated with repair of the coarctation?
Bleeding- Usually minimal, but the aorta does carry all the blood in the body from the heart.
Infection- We give antibiotics, but this still is a risk with any incision into the body.
Paralysis (spinal cord ischemia)- Possible because of interrupted blood flow while clamps are on aorta during repair.
Recurrent Laryngeal Nerve injury- Possible with ligation of the ductus arteriosus during the repair of the coarctation.
Chylothorax- During repair invisible lymph ducts may get cut and leak.
Death- rare, but may occur if baby is very sick or has a related heart disease.
Contact Information:
John Mark Morales MD, FACS, FAAP
Chief of Cardiothoracic, Director of Perfusion Services
Certified by the American Board of Surgery, American Board of Thoracic SurgeryMark Bielefeld, MD
Driscoll Children's Hospital Chief of Staff
Certified by the American Board of Surgery, American Board of Thoracic SurgeryThoracic surgeons are available for questions and consultations: (361) 854-0201. For appointments, assistance, and physician references in Corpus Christi call: (361) 854-0201 or 800-DCH-LOVE
Fax : 361-855-7572
E-MAIL : jmarkmorales@aol.com
For further information on any surgical procedures you can contact Carol Kaplan, RN, Surgical Nurse Liaison at (361) 694-5150. Consultation and surgery for inpatients is provided in concert with neonatology and pediatric cardiology departments. Complete evaluation and management for infants, children, adolescents and adults with congenital or acquired cardiac, vascular or thoracic anomalies.
Cardiothoracic Associates
3533 S. Alameda, Suite 202
Corpus Christi, Texas 78411
Phone: (361) 694-5150
Fax: (361) 855-7572
Hours: 9am to 6pm
Fri 9am to 5pm
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Corpus Christi, Texas
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