Coarctation Index Predicts Recurrent Aortic Arch Obstruction Following Surgical Repair of Coarctation of the Aorta in Infants.

Recurrent aortic arch obstruction (RAAO) remains a major cause of morbidity following surgical neonatal repair of coarctation of the aorta (CoA). Elucidating predictors of RAAO can identify high-risk patients and guide postoperative management. The Coarctation index (CoA-I), defined as the ratio of the diameter of the narrowest aortic arch segment to the diameter of the descending aorta, has been used to help diagnose RAAO in neonates following the Norwood Procedure. We sought to assess the predictive value of the CoA-I on RAAO after CoA repair in infants with biventricular circulation. Clinical, surgical, and echocardiographic data of infants with biventricular circulation following neonatal CoA repair between 2010 and 2014 were evaluated. RAAO was defined using a composite quantitative outcome variable: a blood pressure gradient >20, a peak aortic arch velocity >3.5 m/s by echocardiogram, or a catheter-measured peak-to-peak gradient >20 within 2 years of surgery. Univariate and multivariate logistic regression analyses were used. Of the 68 subjects included in the analysis, 15 (22%) met criteria for RAAO. In the multivariate model, only CoA-I (OR 35.89, 95% CI 6.08-211.7, p < 0.0001) and use of patch material (OR 9.26, 95% CI 1.57-54.66, p = 0.014) were associated with increased risk of RAAO. The odds of developing RAAO was higher in patients with a CoA-I less than 0.7 (OR 33.8, 95% CI 5.7-199.5, p < 0.001). Postoperative CoA-I may be used to predict RAAO in patients with biventricular circulation after repair of CoA. Patients with a CoA-I less than 0.7 or patch aortoplasty warrant close follow-up.

Percutaneous retrograde recanalization of a chronic total coronary artery occlusion in a 7 year old.

The arterial switch operation for correction of transposition of the great arteries can be complicated by late stenosis or occlusion of the coronary arteries that are re-implanted to the new aorta. We report the case of a young boy who underwent this operation as a neonate and was found to have an occluded anomalous left anterior descending artery (LAD) before age 3. Subsequent bypass surgery was complicated by anastomotic stricture and kinking of the left internal mammary artery graft to the LAD. At age 7, the LAD territory showed reversible ischemia on nuclear perfusion testing and he was referred for percutaneous coronary intervention. A combined approach with pediatric and adult interventional cardiologists resulted in successful retrograde PCI to recanalize the chronic total occlusion of the LAD. Important features of this technique in pediatric patients are discussed.

Usefulness of B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide as biomarkers for heart failure in young children with single ventricle congenital heart disease.

Children with single ventricle (SV) physiology have increased ventricular work and are at risk of heart failure (HF). However, a HF diagnosis is especially difficult, because few objective measures of HF have been validated in this cohort. We have previously shown that plasma B-type natriuretic peptide (BNP) levels are sensitive and specific for detecting HF in a small, heterogeneous SV cohort. The aim of the present study was to define the effect of SV morphology and stage of palliation on the correlation between BNP and HF. We also examined the utility of N-terminal pro-BNP (NT-proBNP), a more stable product of pre-BNP processing, as a biomarker of HF in these patients. A cross-sectional observational study of SV children aged 1 month to 7 years was conducted. The presence of HF was defined as a Ross score > 2. The association of BNP or NT-proBNP with HF was assessed using logistic regression analysis and receiver operating characteristic curves. Of the 71 included children, 22 (31%) had clinical HF. A doubling of BNP was associated with an odds ratio for HF of 2.20 (95% confidence interval 1.36 to 3.55, p = 0.001) with a c-statistic > 75%, yielding a detection threshold of ≥ 45 pg/ml. This threshold was preserved when patients were stratified by the right ventricular morphology or stage of surgical palliation. Similarly, a doubling of NT-proBNP was associated with an odds ratio for HF of 1.92 (95% confidence interval 1.17 to 3.14, p = 0.009). In contrast to BNP, the threshold value of NT-proBNP for predicting HF decreased with the stage of palliation. In conclusion, plasma BNP and NT-proBNP are reliable tests for clinical HF in young children with SV physiology, specifically those with right ventricular morphology, regardless of the stage of palliation.