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Turk Arch Pediatr
Turk Arch Pediatr
Turkish Archives of Pediatrics
2757-6256
Turkish Pediatrics Association

10.5152/TurkArchPediatr.2024.24050
tap-59-5-480
Original Article
Evaluation of Children with Aortic Coarctation: A Single-Center Experience
Türkmen Hasan 1http://orcid.org/0000-0001-5501-6905

Uysal Fahrettin 1http://orcid.org/0000-0002-7747-4859

Genç Abdüsselam 1http://orcid.org/0000-0002-7181-8585

Bostan Özlem M. 1http://orcid.org/0000-0001-7707-2174

Şenkaya Siğnak Işık 2http://orcid.org/0000-0001-8813-4481

1 Department of Pediatric Cardiology, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
2 Department of Pediatric Cardiovascular Surgery, Faculty of Medicine, Bursa Uludag University, Bursa, Türkiye
Corresponding Author:Hasan Türkmen ક hasanturkmen28@gmail.com
Cite this article as: Türkmen H, Uysal F, Genç A, Bostan ÖM, Şenkaya Siğnak I. Evaluation of children with aortic coarctation: A single center experience. Turk Arch Pediatr. 2024;59(5):480-487 .

9 2024
01 9 2024
59 5 480487
25 2 2024
26 7 2024
2024 authors
2024
authors
https://creativecommons.org/licenses/by-nc/4.0/ Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

Objective:

Coarctation of the aorta (CoA) accounts for 3.5% of all congenital heart diseases in children. The clinical manifestations range from heart failure to asymptomatic hypertension. Treatment options include surgical repair, balloon angioplasty, and stenting. We aimed to investigate the long-term results of surgery and balloon angioplasty to identify the possible risk factors for recoarctation and predictors associated with early success in treatment modalities.

Materials and Methods:

The data of 138 children who underwent examinations at a tertiary center between 2015 and 2020 with the diagnosis of CoA were evaluated. The basic demographic characteristics, clinical and echocardiographic findings, results, and treatment methods of the patients were evaluated retrospectively.

Results: The

mean follow-up period was 75.1 months (range of 1-223). As initial treatment, 75 patients (60.5%) underwent balloon angioplasty, 44 (35.5%) underwent surgery, and 5 (4%) underwent stenting. The early success rate of balloon angioplasty and surgery was 72.5% and 79.5%, respectively. Recoarctation occurred in 47.6% of patients following the first therapy. The median reintervention-free survival time was 138 months for all patients and was significantly higher in the surgery group (P = .025). The recoarctation rate was slightly lower in the surgery group than in those who underwent balloon angioplasty, but it was not statistically significant. None of the clinical and echocardiographic findings were found to be associated with recoarctation or early success.

Conclusion:

The rate of recoarctation is still high in long-term follow-up after aortic coarctation treatment, and clinical and echocardiographic findings are insufficient to predict the chance of early success and the risk of recoarctation.

Keywords

Aortic coarctation
balloon angioplasty
early success
recoarctation
surgery
This study received no funding.
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pmcWhat is already known on this topic ?

Despite advanced interventional and surgical techniques, long-term recoarctation and reintervention rates after aortic coarctation treatment are high, and the risk factors for recoarctation reported in the literature are contradictory.

What this study adds on this topic ?

Our study showed that clinical and echocardiographic findings are insufficient to predict the chances of early success in the treatment of aortic coarctation or the risk of recoarctation after treatment.

Introduction

Coarctation of the aorta (CoA) is a narrowing of the descending aorta and accounts for 3.5% of all congenital heart diseases in children.1 The clinical manifestations of CoA range from infantile heart failure to asymptomatic hypertension in older children or adults. Treatment options for native or recurrent CoA include surgical repair, percutaneous balloon angioplasty, and stenting.2 Although effective coarctation repair in childhood is predicted to result in high-quality survival, there may be long-term consequences, including systemic arterial hypertension, recurrence of coarctation, aortic aneurysm/dissection, atherosclerosis, and cerebral hemorrhage, which require lifelong follow-up.3-6 Additionally, the rate of recoarctation due to insufficient growth of the surgical anastomosis site, narrowing due to fibrosis or residual ductal tissue, or insufficient anastomosis is quite high and often requires re-intervention in the following period.7 Operation techniques have also been improved, with aortic coarctation repair being performed at an increasingly younger age, and re-intervention-free survival has become the most important factor determining the success of the surgery. While the early success rate of balloon angioplasty treatment, which has been applied to all age groups for the last 40 years, is comparable to that of surgery, recoarctation rates due to insufficient rupture of the aortic intima layer are considerably high. The aims of our study are to determine the early success rates of balloon angioplasty and surgery, to compare the long-term results of these treatment modalities, and to identify the possible factors that may predict the chance of early success or the risk of recoarctation.

Materials and Methods

Patient Characteristics

This is a retrospective cohort study evaluating patients diagnosed with aortic CoA who underwent examinations at a tertiary center between January 2015 and December 2020. Ethics committee approval was received from the Ethics Committee of Bursa Uludag University (approval no: 2022-16/39, approval date: 08.11.2022). Informed consent was obtained from the patients. Demographic data at their first admission to the hospital, including clinical, echocardiographic, and angiographic evaluation reports, were obtained from hospital records and analyzed retrospectively. Systemic hypertension was defined as systolic blood pressure at admission ≥95th percentile for age and height.8 Children with major cardiac anomalies (hypoplastic left heart syndrome, tetralogy of Fallot, double outlet right ventricle, etc.) were excluded from the study. Minor cardiac anomalies were divided into 2 groups according to the presence or absence of an accompanying bicuspid aortic valve (BAV). Left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD) Z scores according to height and weight, peak systolic flow gradient in the coarctation region, and a diastolic flow pattern (diastolic tail) in the Doppler examination were noted. Left ventricular ejection fraction measurements below 60% were defined as systolic dysfunction, while LVEDD Z scores above +2 were defined as left ventricular dilatation.

Diagnosis of CoA

Transthoracic echocardiography was performed on all patients as the first step in diagnosis. Cardiac catheterization was used as a second-line diagnostic procedure before computed tomography or magnetic resonance in patients for whom echocardiographic evaluation was inadequate or for whom therapeutic intervention was planned after echocardiography due to the benefits of pressure measurement and intervention.

Treatment

The presence of anatomical coarctation on echocardiographic and angiographic examinations, as well as a systolic pressure gradient of ≥20 mmHg between the upper and lower extremities, were indications for treatment. Due to the limited availability of congenital cardiovascular surgeons in our center and the high volume of cases, we prioritize balloon angioplasty as the initial treatment for discrete native CoA. This approach ensures timely treatment without any delays. Surgery was performed in cases that were not anatomically suitable for balloon dilation, such as tubular narrowing or arcus hypoplasia, as well as in cases with recoarctation after balloon angioplasty. Balloon angioplasty was performed in all cases with recoarctation after surgery.

Balloon Angioplasty Procedure

During the balloon angioplasty procedure, patients were sedated with intravenous midazolam and ketamine. The femoral artery was used for percutaneous vascular access in all cases. During catheterization, coarctation angiography was performed before and after the procedure and recorded in the anterior-posterior (AP) and left lateral projections. Systolic-diastolic and mean arterial pressures were measured in the ascending and descending aorta before and after the procedure. The diameter of the PTA (percutaneous transluminal angioplasty) balloon used for dilation did not exceed the diameter of the descending aorta at the diaphragm level. The balloon was inflated 2 or 3 times under fluoroscopy until the stenosis disappeared, provided the manufacturer’s pressure limit was not exceeded and the inflation lasted less than 10 seconds. After the procedure, intravenous heparin (100 units/kg) was administered to all patients. Early success was defined as a pressure gradient of 20 mmHg or less in the coarctation region after balloon angioplasty.

Surgical Technique

All of the surgeries in our center were performed by a single experienced surgeon. A left thoracotomy or median sternotomy approach was chosen according to the degree of hypoplasia of the aortic arch in the preoperative echocardiographic examination. Resection of the coarcted segment and end-to-end anastomosis was the surgical technique selected for the majority of patients. When tubular hypoplasia was present, an extended resection and end-to-end anastomosis were performed. Other techniques, such as subclavian flap aortoplasty, patch aortoplasty, and arch reconstruction, were rarely used.

Follow-up

Patients were examined on day 1 and day 15 and at 1 month, 6 months, 1 year, and annually after balloon angioplasty or surgery. Recoarctation was defined as a systolic gradient of more than 20 mmHg on echocardiographic examination. In patients who developed recoarctation after the first treatment, possible risk factors such as sex, age, weight at presentation, coarctation pattern on echocardiographic examination, pressure gradient, the presence of BAV, and the first treatment method chosen (balloon angioplasty or surgery) were analyzed.

Statistical Analysis

Patients’ data were analyzed using The Statistical Package for the Social Sciences version 25.0 for Windows (IBM Corp., Armonk, NY, USA) and described as frequencies, medians with ranges (minimum-maximum), and means with standard deviations as appropriate. Where there were missing data, the number of non-missing values was reported for that variable. The Shapiro–Wilk test was performed to test for data normality. The Student’s t-test was used to compare continuous variables that conformed to the normal distribution, whereas the Mann–Whitney U-test was used to compare continuous variables that did not conform to the normal distribution. Differences between categorical variables were analyzed using Pearson’s chi-squared test (with Yates’ continuity correction and Fisher’s exact test if necessary). Time-dependent variables were examined using Kaplan–Meier analysis. Cox proportional hazards models were used to examine all variables as possible predictors of reintervention. The variables significant at the 0.25 level on univariate analysis were analyzed in the multivariable model. A P-value less than .05 was considered significant.

Results

Patient Characteristics

Data on 138 patients (85 males) with a diagnosis of CoA were analyzed. The follow-up period ranged from 1 to 223 months. Their ages ranged from 0 to 16 years (30.03 ± 47.89 months). Cardiac murmur noticed by a physician, fatigue, and respiratory distress were the most common reasons for admission, respectively. A genetic syndrome was present in 5.7% (n = 8) of patients, and a family history of congenital heart disease was present in 3.6% (n = 5). In the physical examination at the first admission, 34.8% (n = 48) of patients had non-palpable lower extremity pulses, and 29.7% (n = 41) had systemic hypertension. The characteristics of the patients are shown in Table 1.

Echocardiography

Based on the echocardiographic examination, 55.8% (n = 77) of patients had a BAV with CoA. The left ventricular ejection fraction ranged from 35% to 80%, and 15.2% (n = 21) of the patients showed systolic dysfunction. Left ventricular dilatation was also found in 23 individuals (16.7%). The pressure gradient in the coarctation region ranged from 17 mmHg to 100 mmHg, and a diastolic flow pattern was seen in 71.7% (n = 94) of the patients. The results of the echocardiographic examination are shown in Table 2.

Initial interventions and reinterventions in patients with CoA are presented in Figure 1. Fourteen of 138 patients diagnosed with CoA were followed without treatment because of a low pressure gradient on catheter angiography or because they refused treatment. As initial treatment, 75 patients (60.5%) underwent balloon angioplasty, 44 (35.5%) underwent surgery, and 5 (4%) underwent stenting. Resection and end-to-end anastomosis was the method chosen for 90.9% of patients whose initial treatment was surgery (40 of 44) and was used in 91% of total surgeries (71 of 78). There was no statistically significant difference between the median ages of patients who underwent balloon angioplasty and surgery (4 months (range 0-198) vs 3 months (range 0-201), P = .44).

Balloon Angioplasty

Balloon angioplasty was applied to 75 patients as initial treatment. The pressure measurements of 6 patients could not be obtained after the procedure, and when the data of 69 patients were analyzed, early success was seen in 72.5% (n = 50). The impact of patients’ demographic characteristics and echocardiographic findings on early balloon angioplasty success are shown in Table 3. Age, weight, sex, accompanying BAV, ejection fraction, pressure gradient in the coarctation region, and the diastolic flow pattern in the Doppler echocardiographic examination had no significant effect. After balloon angioplasty, femoral artery thrombosis requiring heparin treatment was observed in 1 patient, local hematoma was observed in 1 patient, and bleeding requiring transfusion occurred in 1 patient. In a 4-year-old patient who was operated at another center and presented with recoarctation, aortic perforation occurred after balloon angioplasty, and urgent surgical repair was performed. A female patient with BAV had a saccular aneurysm in the coarctation area 12 years after balloon angioplasty and was referred to another center for stenting.

Surgery

Of the 44 patients who had surgery as their first treatment, 39 (79.5%) had early success. Age, weight, sex, accompanying BAV, LVEF, pressure gradient in the coarctation region, and the diastolic flow pattern in the Doppler echocardiographic examination had no significant effect on early success of surgery (Table 3). A 2-year-old patient who underwent surgery for coarctation accompanied by ventricular septal defect and severe pulmonary hypertension died 2 weeks after surgery due to sepsis and multiorgan failure.

Recoarctation

Recoarctation occurred in 59 of 124 (47.6%) individuals following the first therapy. The recurrence time ranged from 0.5 to 192 months. The recoarctation rate was slightly lower in patients who underwent surgery than in those who underwent balloon angioplasty, but it was not statistically significant (38.6% vs 56%, P = .10). Table 4 presents details on the treatments and recurrence rates. During our follow-up, no recoarctation was seen in the stented patients. Age at presentation, weight, sex, accompanying BAV, the pressure gradient in the coarctation region, and the diastolic flow pattern in the Doppler echocardiographic examination were analyzed to determine possible risk factors for recoarctation (Table 5). None of these factors were found to be associated with recoarctation, both when all patients were evaluated together and separately according to treatment methods. The reintervention-free survival rates in the first and fifth years after the first therapy were 74.2% and 63.2% in all patients, 63.6% and 54.9% in those who underwent balloon angioplasty, and 87.6% and 77.9% in those who underwent surgery, respectively. The median reintervention-free survival time was 138 months for all patients, 124 months for balloon angioplasty, and 163 months for surgery, which was significantly higher in surgical patients (P = .025) (Figure 2). Cox proportional hazards regression analysis showed that when the first treatment method is surgery, there is 0.36 (P = .02) times risk than when the first treatment method is balloon, and none of the possible risk factors had an impact on reintervention-free survival (Table 6).

Discussion

Coarctation is a discrete or tubular narrowing of the descending aorta at the insertion site of the ductus arteriosus and can present at any age. Although it is typically termed “juxtaductal,” it can also be located in the transverse or abdominal aorta. While bicuspid aortic valve is the most prevalent congenital heart defect associated with coarctation (occurring in ~60% of cases), aortic arch hypoplasia, ventricular septal defect, and mitral valve anomalies are also common.9 Patients may present with symptoms and signs ranging from a murmur heard on routine examination or incidentally detected hypertension to severe heart failure. The difference in blood pressure between the upper and lower extremities and weak femoral pulses should suggest the diagnosis of coarctation. Echocardiography, magnetic resonance imaging (MRI), or computed tomography (CT) are used to diagnose discrete or tubular narrowing. Today, with advanced imaging and 3D reconstruction methods, catheter angiography is mostly used for treatment only.

Treatment indications for pediatric aortic coarctation are similar to those in adults, with a transcatheter systolic pressure gradient >20 mmHg or <20 mmHg accompanied by systemic hypertension, severe left ventricular dysfunction, and low cardiac output.10,11 Surgery, balloon angioplasty, or stenting are the current treatment options. Surgical repair was applied to 44 of our patients, balloon angioplasty to 75, and stenting to 5 of them.

Balloon angioplasty has been utilized since the 1980s and is based on the controlled tearing of the intima and media layers of the aortic wall in the coarctation zone. Balloon angioplasty for aortic coarctation has an early success rate of 73.9% to 96%, and it has become increasingly popular due to its low complication rate.12,13 The early success rate in our study was 72.5%, and demographic data and echocardiographic findings had no significant effect on this success. McCrindle et al14 reported that a higher systolic pressure gradient in the coarctation region and older age were associated with a lower early success rate, but there was no significant difference between native coarctation or recoarctation. Lee et al15 studied patients who underwent balloon angioplasty for native coarctation and found no difference between age groups in terms of early success rate, while the rate of recoarctation was significantly lower in children older than 3 months. Ovaert et al16 reported an early success rate of balloon angioplasty of 90% in children with native coarctation, and the reintervention-free survival rate was also quite high (90% in the first year and 87% in the fifth year). While a lower systolic pressure gradient between the ascending and descending aorta and a higher ratio of balloon diameter to diaphragmatic aorta diameter were related to early success, age and body weight were not.16 Because we reviewed not only native coarctation but also recoarctation patients with a history of past surgery or balloon angioplasty, the effect of aortic arch measures on early balloon success was not examined in our study. Complications occurred in 4% of patients who underwent balloon angioplasty, which is consistent with the literature. Only 1 patient had a major complication (aortic perforation), and no procedure-related mortality was observed.

Today, in most centers, the first treatment option for aortic coarctation, especially in infants, is surgery. Surgical repair of aortic coarctation has been practiced since the 1940s, and extended resection and end-to-end anastomosis are the most commonly used and successful methods. At our center, our first treatment option for children under 1 year of age is balloon angioplasty if the anatomy is suitable. For this reason, the number of cases whose first treatment was surgery was quite low in our study (n = 44). The occurrence of death during CoA-intervention surgery is infrequent, with a mortality rate of less than 5%.17,18 Early success was 79.5%, and there was only 1 patient (2%) who died after 2 weeks due to hospital infection and sepsis.

The rates of reinterventions for recoarctation have been reported to be between 17.9% and 63.6% in patients who underwent balloon angioplasty and between 6.6% and 34% in patients who underwent surgery.19-22 In our study, the rate of recoarctation after the first treatment was 47.6% (56% in those who underwent balloon angioplasty, 38.6% in those who underwent surgery), and the rate of reintervention was 35% (45.3% in those who underwent balloon angioplasty, 22.7% in those who underwent surgery). Although extended resection and end-to-end anastomosis have been used more frequently in the last 5 years, the use of resection and end-to-end anastomosis in the past may be the cause of the high rate of recoarctation. There are conflicting reports in the literature comparing the long-term results of balloon angioplasty and surgical repair. Wallhout et al12 found no statistically significant difference in recoarctation and reintervention rates between the 2 treatment modalities. In a randomized controlled trial conducted by Cowley et al,23 no difference was observed between the 2 methods in terms of reintervention. However, it has also been reported that recoarctation and reintervention rates were lower in patients of similar age who underwent surgical repair compared to those who underwent balloon angioplasty.24,25 Hu et al26 found no difference between the mid- and long-term recoarctation rates of both techniques in their meta-analysis, although the short-term recoarctation rate was higher in those who underwent balloon angioplasty.

Although many risk factors related to recoarctation have been reported, there is no consensus among the studies. A hypoplastic aortic arch, lower weight, arm-leg pressure gradient at discharge, and age are the most commonly reported risk factors for postoperative recoarctation.17,27-30 Burch et al31 found the rate of recoarctation to be significantly higher in females but showed that body weight was not a risk factor. According to Ramachandran et al,32 age, weight, and aortic arch diameter were not risk factors for reintervention; a smaller isthmus diameter was the only risk factor reported. A recent study demonstrated that sex, accompanying hypoplastic aortic arch, and a bicuspid aortic valve were not associated with recoarctation, and the surgical technique was the only risk factor.18 In our study, age, sex, body weight, echocardiographic pressure gradient, diastolic flow pattern, and the presence of a bicuspid aortic valve were not found to be possible risk factors for recoarctation. In the study of McElhinney et al,29 which involved patients with neonatal and infant aortic coarctation who underwent surgical repair, the median reintervention-free time was significantly lower than in our study (5 months vs 163 months), while the reintervention-free survival rates in the first and fifth years were similar to ours (88% and 82%, respectively). In the study of Sandoval et al,19 which included infants 3-12 months of age who underwent balloon angioplasty, the reintervention-free survival rates in the first and fifth years were higher than ours (89% and 83%, respectively).

Limitations

The retrospective aspect of this study is the major limitation, despite the large patient population and age dispersion. Aortic coarctation accompanied by complex congenital heart disease, which may affect hemodynamic measurements, procedural success, and recoarctation rates, was also not included in this study.

Conclusion

Early success rates of balloon angioplasty were found to be slightly low in children with aortic coarctation. Although recoarctation rates were high, clinical and echocardiographic data were shown to be insufficient in predicting the risk of recoarctation. By comparing the long-term results of balloon angioplasty, surgical repair, and stenting and choosing the optimal modality for each patient, the rate of recoarctation could be minimized.

Figure 1. Interventions and reinterventions in patients with CoA. Following the first treatment, 35% of patients (45.3% in the balloon angioplasty group and 22.7% in the surgery group) underwent reintervention. In the stent group, no reintervention was required.

Figure 2. Kaplan–Meier analysis comparing median reintervention-free survival of patients whose initial treatment was balloon angioplasty or surgery (95% confidence interval).

Table 1. Characteristics of the Patients with CoA

Age at first admission (month, mean ± SD (range))	30.03 ± 47.89 (0.0-201.0)	
Weight at first admission (kg, mean ± SD (range))	12.46 ± 14.45 (2.0-88.0)	
Sex [n (%)]
	
 Male	85 (61.6)	
 Female	53 (38.4)	
Reason for admission [n (%)]	
 Cardiac murmur	46 (33.3)	
 Fatigue	41 (29.7)	
 Respiratory distress	28 (20.3)	
 Headache	4 (2.9)	
 Cyanosis	4 (2.9)	
 Hypertension	3 (2.2)	
 Chest pain	2 (1.4)	
 Epistaxis	1 (0.7)	
 Co-incidence	9 (6.5)	
Family history of congenital heart disease [n (%)]	5 (3.6)	
A diagnosis of genetic syndrome [n (%)]	
 Turner	4 (2.9)	
 Down	2 (1.4)	
 Williams	1 (0.7)	
 Kabuki	1 (0.7)	
Lower extremity pulse [n (%)]	
 Palpable	38 (27.5)	
 Weakly palpable	52 (37.7)	
 Not palpable	48 (34.8)	
SBP [mmHg, mean ± SD (range)]	105.32 ± 24.56 (60.0-180.0)	
DBP [mmHg, mean ± SD (range)]	63.18 ± 16.87 (24.0-140.0)	
Systemic hypertension [n (%)]	41 (29.7)	
Follow-up [month, mean ± SD (range)]	75.17 ± 58.51 (1-223)	
DBP, diastolic blood pressure; SBP, systolic blood pressure.

Table 2. Echocardiographic Findings of the Patients with CoA

Bicuspid aortic valve [n (%)]	77 (55.8)	
Systolic dysfunction [n (%)]	21 (15.2)	
Left ventricular dilatation [n (%)]	23 (16.7)	
Diastolic flow pattern [n (%)]	94 (71.7)	
Left ventricular ejection fraction [%, mean ± SD (range)]	64.66 ± 8.46 (35-80)	
Pressure gradient [%, mean ± SD (range)]	51.68 ± 18.94 (17-100)	

Table 3. Effects of Demographic and Hemodynamic Data on Early Success in Balloon Angioplasty and Surgery

	Balloon	Surgery	
Early Success [n (%)]	P	Early Success [n (%)]	P	
Yes	No		Yes	No		
Male (n = 72)	31 (68.9)	14 (31.1)	.53*	22 (81.5)	5 (18.5)	.71*	
Female (n = 41)	19 (79.2)	5 (20.8)		13 (76.5)	4 (23.5)		
DFP (+) (n = 83)	44 (74.6)	15 (25.4)	.69*	20 (83.3)	4 (16.7)	.43*	
DFP (−) (n = 23)	6 (66.7)	3 (33.3)		10 (71.4)	4 (28.6)		
BAV (+) (n = 63)	26 (70.3)	11 (29.7)	.86*	21 (80.8)	5 (19.2)	.93*	
BAV (−) (n = 50)	24 (75.0)	8 (25.0)		14 (77.8)	4 (22.2)		
Age (months, median (minimum-maximum))	4 (0-102)	5 (0-133)	.44†	3 (0-201)	4 (0.198)	.84†	
Weight (months, median (minimum-maximum))	6.2 (2.5-27)	7.4 (3.1-33)	.34†	5.5 (2.3-60)	4.4 (2.4-45)	.64†	
LVEF (%, median (minimum-maximum))	64.5 (45-77)	68.0 (35-77)	.28†	65 (35-78)	66 (54-80)	.73†	
PG (mmHg, mean ± SD)	54.0 ± 16.4	60.0 ± 16.0	.19††	63.57 ± 23.04	48.14 ± 17	.052††	
BAV, bicuspid aortic valve; DFP, diastolic flow pattern; LVEF, left ventricular ejection fraction; PG, pressure gradient in echocardiography.

*Chi-squared test; †Mann–Whitney U-test; ††Student’s t-test.

Table 4. Initial Treatment Methods and Recurrence Rates for CoA Patients

*First treatment	124	
 Balloon angioplasty	75	
 Surgery	44	
 Resection and end-to-end anastomosis	40	
 Subclavian flap aortoplasty	2	
 Patch aortoplasty	1	
 Aortic arch reconstruction	1	
 Stenting	5	
*Recoarctation after first treatment [n (%)]	59 (47.6)	
 Balloon angioplasty	42 (56)	
 Surgery	17 (38.6)	
 Stenting	None	
Recoarctation time [month, mean ± SD (range)]	17.01 ± 34.17 (0.5-192)	
Reintervention time [month, mean ± SD (range)]		
 Balloon angioplasty to surgery	8.39 ± 10.52 (0.5-198)	
 Surgery to balloon angioplasty	37.58 ± 49.44 (1.5-192)	
*P > .05.

Table 5. Evaluation of Factors Associated with Recoarctation After First Treatment

	Total [n/total (%)]	P	Balloon [n (%)]	P	Surgery [n (%)]	P	
Male with reCoA	40/79 (50.6)	.47*	28 (57.1)	.97*	12 (44.4)	.49*	
Female with reCoA	19/45 (42.2)		14 (53.8)		5 (29.4)		
DFP (+) with reCoA	43/89 (48.3)	.78*	35 (57.4)	.95*	8 (33.3)	.27*	
DFP (−) with reCoA	15/28 (53.6)		7 (53.8)		8 (57.1)		
BAV (+) with reCoA	33/69 (47.8)	.95*	22 (55.0)	.93*	11 (42.3)	.77*	
BAV (−) with reCoA	26/55 (47.3)		20 (57.1)		6 (33.3)		
Age [months, median (minimum-maximum)]	
 ReCoA (+)	4 (0-201)	.54†	3 (0-149)	.11†	30 (0-201)	.07†	
 ReCoA (−)	5 (0-198)		6 (0-198)		2 (0-198)		
Weight [kg, median (minimum-maximum)]	
 ReCoA (+)	5.8 (2.4-60)	.62†	5.8 (2.5-37)	.09†	12.8 (2.4-60)	.08†	
 ReCoA (−)	6.6 (2.3-88)		7.5 (3-70)		4.5 (2.3-37)		
PG [mmHg, median (minimum-maximum)]	
 ReCoA (+)	55 (23-100)	.50†	52 (23-100)	.71†	55 (28-100)	.34†	
 ReCoA (−)	50 (22-100)		50 (22-100)		45 (22-80)		
BAV, bicuspid aortic valve; DFP, diastolic flow pattern; PG, pressure gradient in echocardiography; ReCoA, recoarctation.

*Chi-squared test; †Mann–Whitney U-test.

Table 6. Univariate and Multivariable Cox Proportional Hazard Analyses

Variable	Univariate Hazard Ratio (95% CI)	P	Multivariable Hazard Ratio (95% CI)	P	
First treatment method (surgery/balloon)	0.42 (0.19-0.93)	.03	0.36 (0.15-0.85)	.02	
Sex	0.75 (0.37-1.49)	.41			
Diastolic flow pattern	0.98 (0.46-2.10)	.96			
Bicuspid aortic valve	1.40 (0.71-2.76)	.33			
Age (months)	1.00 (0.99-1.01)	.65			
Weight (kg)	0.99 (0.96-1.03)	.65			
PG (mmHg)	1.01 (1.00-1.03)	.12	1.01 (0.99-1.03)	.27	
LVEF (%)	0.98 (0.94-1.01)	.19	0.97 (0.93-1.01)	.17	
CI, Confidence Interval; LVEF, left ventricular ejection fraction; PG, pressure gradient in echocardiography.

Ethics Committee Approval: Ethics committee approval was received from the Ethics Committee of Bursa Uludag University (approval no: 2022-16/39, approval date: November 08, 2022).

Informed Consent: Verbal informed consent was obtained from the patients who agreed to take part in the study.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – H.T., F.U., O.M.B.; Design – A.G., I.S.S.; Resources – F.U., O.M.B.; Materials – H.T., A.G.; Data collection and processing – H.T., F.U., A.G.; Analysis – H.T., F.U., O.M.B., I.S.S.; Literature search – A.G., H.T.; Writing – H.T., F.U.; Critical Review – I.S.S., O.M.B., F.U.

Declaration of Interests: The authors have no conflict of interest to declare.
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