135. All Roads Lead to Flow: Open, Hybrid, and Endovascular Repair of Aortic Coarctation in Adolescents and Adults
Cleveland Clinic
Lakewood, OH
United States - Contact Me
Matthew Thompson is a fourth year medical student and aspiring cardiothoracic surgeon studying at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, a 5-year medical degree program with a strong emphasis on academic research. His interest in cardiothoracic surgery began in his first year of medical school, after attending a seminar on the topic given by his current research mentor, Dr. Eric Roselli. Working with Dr. Roselli for the past three years, Matthew’s research has focused on surgical technique for addressing thoracoabdominal aortic aneurysms, outcomes of aneurysmal aortopathy associated with bicuspid aortic valve, and patient factors associated with endocarditis. He is currently completing his research year investigating aortic biomechanical and histological changes in the setting of ascending aortic aneurysm.
Matthew earned a B.S. in biochemistry and B.A. in theatre from Case Western Reserve University, where his research was centered on the development of novel small molecule therapeutics for neurodegenerative disease. He has published multiple manuscripts, book chapters, and abstracts, and has been nationally recognized for his research accomplishments: he received the American Heart Association’s 2020 Student Scholarship in Cardiovascular Surgery, the 2018-2019 Barry Goldwater Scholarship for undergraduate research, the Pfizer Summer Undergraduate Research Fellowship in 2018, as well as numerous institutional grants. He is grateful for the opportunity to be sharing his work at the AATS Annual Meeting and would like to thank Dr. Roselli, as well as the entire Roselli lab team, for their support and mentorship.
Description
Methods: Patients, age >10 years, who underwent primary CoA repair between 1999–2023 were reviewed from a prospectively maintained institutional database. Operative repair trends were evaluated. Longitudinal gradient boosting models were used to predict the probability of postoperative anti-hypertensive use over time. Reoperation and survival were evaluated by Kaplan–Meier methods; median follow-up was 6.8 years with 790 patient-years available.
Results: One-hundred ten patients (age 38+/-16 years; 62% male) underwent CoA repair. Bicuspid aortic valve was present in 48% (N=53), and 38% (N=42) had additional congenital cardiac anomalies. Most patients (90%, N=90/100) had hypertension. Operative techniques were open repair (N=42, 38% [N=25, 60% extra-anatomic bypass]), hybrid repair (N=7, 6% [N=6, 86% frozen elephant trunk]), and endovascular repair (N=61, 56%). Endovascular repair increased in frequency over the study period. Devices used included balloon-expandable stents (bare metal [N=33, 51%] and covered [N=10, 15%]), and self-expanding stent grafts (N=22, 34%). The left subclavian artery was left uncovered in 74% (N=45/60) and revascularized in 21% (N=13/60). Operative mortality was 0.9% (N=1/110), major morbidity including stroke (2.1%, N=2/96) and acute renal failure requiring dialysis (1.0%, N=1/96) were uncommon. Probability of using anti-hypertensive medications fell and stabilized, by two years postoperatively following open repair (Figure 1A), versus an increasing probability of more anti-hypertensive medications beyond two-years following endovascular repair (Figure 1B). Freedom from reintervention at 1, 5, and 10 years following open repair was 98%, 95%, and 95% and following endovascular repair was 91%, 75%, and 64% (Figure 1C). Overall survival at 1, 5, and 10 years was 98%, 98%, and 94%.
Conclusions: A tailored approach to coarctation repair in adolescents and adults with a shift toward endovascular repair when anatomically feasible has yielded excellent outcomes with respect to reintervention and survival. However, the effect on blood pressure control may indicate more durable CoA repair following open interventions.
Authors
Matthew Thompson (1), Jonathan Putnam (2), William Frankel (1), Holliann Willekes (1), Benjamin Kramer (3), Ashley Lowry (4), Patrick Vargo (5), Patcharapong Suntharos (6), Joanna Ghobrial (1), Lars Svensson (1), Eric Roselli (1)
Institutions
(1) Cleveland Clinic, Cleveland, OH, (2) Case Western Reserve University School of Medicine, Cleveland, OH, (3) Cleveland Clinic, United States, (4) Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, OH, (5) Cleveland Clinic, Cleveland, Ohio, (6) Cleveland Clinic Foundation, Cleveland, OH