[Management of aortic coarctation at the adult age]

Abstract

Classical treatment of coarctation of the aorta consists of resection and suture through a left thoracotomy. However, over the last 20 years, balloon angioplasty, recently associated with stenting, has progressively supplanted surgery in the adult both in native forms and in recoarctions. Usually, the diameters of the balloon and stent are chosen to be the same as that of the aortic isthmus or proximal aortic arch without exceeding that of the aorta at the diaphragm. Moreover, the tendency now is to recommend stenting in cases of severe, tubular and long stenosis associated with proximal hypoplasia and in cases of residual gradients after dilatation. The complications of percutaneous techniques are the risk of restenosis (11-15%), aneurysm formation (5%), and a very small risk of dissection. However, it is recognised that stenting is associated with fewer complications than dilatation alone or surgery. After correction, the main problem is that of hypertension, often associated with persistence of a pressure gradient at the isthmus. Coarctation is often associated with a congenital bicuspid aortic valve in nearly 50% of cases and the valvular condition may progress to stenosis or incompetence requiring corrective surgery. In these cases, a dilatation of the aorta must also be suspected which may progress to an aneurysm. In addition, pregnancy is often complicated by maternal hypertension. The consequences are a high risk of abortion and, for the child, a prematurity, poor growth, and a small risk of recurrence of the cardiac disease. Pregnant women should be followed up in a multidisciplinary fashion and, when possible, problems of residual stenosis, aneurysm and hypertension should be controlled and corrected before the woman wishes to be pregnant. In practice, medium and long term follow up should be undertaken by specialist teams and comprise clinical examination, blood pressure investigations on effort and by ambulatory recording, Doppler ultrasonography of the aortic arch and aortic valve and MRI which has become the reference examination for the aortic arch. After the initial investigations, these tests should be repeated every 2 or 5 years in adults or sooner depending on the results of the initial work-up.