Chirurgische Behandlung der isolierten Aortenisthmusstenose: Risiken und Komplikationen im Langzeitverlauf
by Marilena Christin Quitzau
Date of Examination:2024-02-14
Date of issue:2024-02-09
Advisor:Prof. Dr. Theodoros Tirilomis
Referee:PD Dr. Michael Steinmetz
Referee:Prof. Dr. Margarete Schön
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EnglishAortic coarctation is the fifth most common congenital heart defect in Germany. Pathophysiologically, it is a narrowing at the distal end of the aortic arch, which results in reduced perfusion in the lower half of the body. Depending on the severity of the stenosis, this can lead to an acutely life-threatening situation for the affected newborns. The current treatment of choice is surgical removal of the stenosis, usually using an extended end-to-end anastomosis and within the first year of life. Even after successful surgery, patients with coarctation of the aorta have an increased risk of mortality compared to the normal population, which is caused by increased cardiovascular morbidity. The causes of this are currently the subject of numerous studies. The most important risk factor for cardiovascular events is arterial hypertension that persists postoperatively or develops over time in these patients. The present retrospective work evaluated the long-term results of 132 patients with isolated aortic stenosis who received surgical treatment for the aortic stenosis for the first time in the thoracic-cardiac-vascular surgery department at the University Medical Center Göttingen from the beginning of 1995 to the end of 2014. Over a period of up to 23.6 years postoperatively, all available examination findings and data were analyzed with regard to the long-term outcome and possible complications in the long-term postoperative course. A total of 1040.8 patient-years were recorded, with a mean follow-up of 9.5 ± 6.2 years. The mean age of patients at follow-up was 11.8 ± 9.7 years. The primary surgical procedure was an extended end-to-end anastomosis in 80% and a simple end-to-end anastomosis in 18%. The mortality rate was 1.5%. The overall perioperative complication rate (major and minor) was 38%, with serious complications such as nerve palsy, chylothorax, pneumonia, or spinal cord syndrome being rare at approximately 1.5%. The operation achieved a significant reduction in the arm-leg blood pressure gradient from 26 ± 21 to 2 ± 11 mmHg and the maximum flow velocity in the descending aorta from 3.09 ± 1.12 to 2.03 ± 0.58 m/s . The proportion of patients with good left ventricular pump function increased from 49% preoperatively to 85% postoperatively. ISTA reintervention occurred in 11% of patients – all affected patients had been operated on as infants. Other cardiac interventions were also performed in 18% of patients, of which aortic valve interventions accounted for 55%. These were recorded significantly more frequently in patients with bicuspid aortic valves than in patients with tricuspid aortic valves. In the long-term follow-up interval, there was a significant proportion of patients (42%) who had already taken antihypertensive medication or had hypertensive blood pressure values in the outpatient blood pressure measurements. Antihypertensive medication was required in 14% of children and adolescents over four years of age. The need for antihypertensive medication in the long-term postoperative course was significantly increased in children who were operated on over 18 months of age compared to younger children. Data analysis shows good results and an overall low complication rate of current surgical treatment of aortic coarctation. The successful elimination of the stenosis leads to a normalization of the hemodynamic conditions with an effective reduction of the blood pressure gradient and the flow velocity. Nevertheless, cardiovascular problems continue to determine the long-term course of patients successfully operated on for isolated aortic stenosis. While restenosis only occurred in patients operated on under one year of age, there was a positive influence of the early age at surgery on the development of systemic hypertension. Close follow-up care is absolutely necessary for all patients in order to be able to best treat complications such as restenosis, other cardiac complications or systemic arterial hypertension through early diagnosis. Consistent blood pressure measurement on all four extremities in combination with regular long-term blood pressure measurements is an indispensable element in blood pressure diagnostics. The comparison of diagnostic methods for detecting restenosis shows that the arm-leg blood pressure gradient is inadequate as the sole diagnostic criterion. A combined assessment using further diagnostics such as echocardiography and MRI is strongly recommended. Follow-up care should also continue into adulthood and under standardized conditions in order to enable intra- and inter-individual comparisons of the examination findings over time. The view of aortic coarctation as a generalized vasculopathy is essential in order to understand the pathophysiological processes in the development of long-term complications. Future studies that explore the connection between vascular changes in the prestenotic vascular bed and aortic coarctation could provide new insights for an even more precise understanding of the disease and possibly reveal new therapeutic approaches. With good primary surgical results, avoiding long-term complications is now the predominant goal in the treatment of patients with aortic coarctation.
Keywords: Aortic Coarctation; Postoperative arterial hypertension; extended end-to-end anastomosis; long-term results; cardiovascular morbidity