Treatment of Aortic Coarctation in Germany

Aortic coarctation accounts for up to 30% of all congenital defects of the cardiovascular system. The defect is characterized by congenital narrowing or complete closure of the aortic lumen in a limited area. Most often, aortic coarctation is located in the isthmus of the aorta. Other localizations are possible in the ascending, descending thoracic or abdominal aorta. Aortic coarctation can be combined with other congenital heart defects. Without surgical treatment, the life expectancy of patients is significantly limited. The cause of death can be cerebral hemorrhage, heart failure, and other complications.

Content

1. Overview
2. What happens if aortic coarctation is not treated?
3. Why does aortic coarctation occur?
4. Symptoms of aortic coarctation
5. How is aortic coarctation diagnosed?
6. Treatment of aortic coarctation
7. Rehabilitation after aortic coarctation repair
8. The prognosis for patients with aortic coarctation
9. Best hospitals for treatment in Germany
10. The cost of treatment in hospitals in Germany
11. Undergoing treatment in Germany with Booking Health

Overview

Aortic coarctation is the narrowing of the isthmus of the aorta. It occurs more often in men, sometimes in combination with other congenital defects. Patients have a well-developed torso, which contrasts with the less developed hips.

Patients with aortic coarctation complain of headaches and intermittent claudication. It is not uncommon for them to come under medical observation due to arterial hypertension or even the unexpected development of left ventricular failure or cerebral hemorrhage. The heart is usually mildly enlarged, and a mild systolic murmur is heard in the second to fourth intercostal space at the edge of the sternum and behind, between the shoulder blades. Increased arterial pressure in the arms, predominantly systolic, is characteristic, while the femoral artery pressure remains normal or decreased.

An ECG may reveal a left bundle branch block. Radiological examination reveals rib bumps, which is a consequence of dilation of intercostal vessels as anastomoses providing collateral circulation. Symptoms of collateral circulation development can be manifested by increased pulsation of both intercostal arteries and arteries in the scapular region, sometimes, in the epigastrium.

The timely surgical repair makes the prognosis good, although the natural course of this malformation is unfavorable.

What happens if aortic coarctation is not treated?

High pressure in the upper half of the body leads to many problems. Almost all patients with aortic coarctation suffer from high blood pressure. Sometimes patients struggle with hypertension during all of their lives without knowing they have an aortic coarctation. In some patients, blood pressure at rest may be normal and rise sharply during physical activity. High pressure in the nasal vessels leads to frequent nosebleeds. High pressure in the cerebral vessels leads to their rupture and the development of a life-threatening hemorrhagic stroke. High pressure in the aorta itself above the constriction leads to its enlargement and thinning of its walls. This pathology is called an aortic aneurysm. Aortic aneurysms grow rapidly and tend to rupture spontaneously. A ruptured aortic aneurysm is a fatal complication that leads to immediate death in 95% of clinical cases. Also, patients with aortic coarctation develop coronary heart disease earlier. Therefore, all patients diagnosed with aortic coarctation require the earliest possible treatment, careful control of blood pressure, and medical monitoring of aortic size.

The severity of symptoms depends on the degree of narrowing. Thus, if the narrowing is severe, aortic coarctation can manifest itself in the first days or weeks of life. The fact is that the little newborn heart has to pump blood against pronounced resistance. Working in this mode of overload, the heart gets tired over time and begins to contract poorly. Symptoms of such pronounced aortic coarctation will be frequent breathing, frequent heartbeat, the baby's refusal to eat, and lack of body weight. Some young patients may go into shock due to poor heart contractility, and treatment of their malformation will begin in the intensive care unit.

Why does aortic coarctation occur?

The cause of aortic coarctation is the improper fusion of the aortic arches during the embryonic development. The defect is located at the transition point to the descending aorta. There is hypertension proximal to the obstruction, and hypotension distal to it. Several compensatory mechanisms aimed at combating hemodynamic disorders are involved.

With the proper development of collateral vessels, there is sufficient blood supply to the lower half of the body. This explains the absence of significant hypertension in children. During puberty, against the background of the rapid growth of the body, the available collaterals are unable to provide adequate blood flow, and the blood pressure proximal to the coarctation site rises sharply. In the pathogenesis of hypertension syndrome, a decrease in pulse pressure in the renal arteries, affecting the renal juxtamedullary apparatus, responsible for the vasopressor mechanism activation, is also important.

Symptoms of aortic coarctation

The disease is often latent until puberty. As the child grows, the body puts more and more demands on blood circulation, so hypertension increases in the proximal aorta, the load on the myocardium increases, and the clinical picture becomes clearer.

As a consequence of hypertension, patients experience headaches, poor sleep, irritability, heaviness and a throbbing sensation in the head, nosebleeds, memory, and vision deterioration. Because of the overload of the left ventricle, they experience heart pain, palpitations, heart rhythm interruptions, and sometimes shortness of breath. Insufficient blood supply to the lower half of the body causes rapid fatigue, weakness, coldness of the lower extremities, pain in the calf muscles when walking. A diagnostic examination may reveal disproportion in the development of the muscular system of the upper and lower half of the body due to hypertrophy of the shoulder girdle muscles, increased pulsation of the arteries of the upper extremities (axillary and brachial), more noticeable with raised arms, and the chest wall (intercostal and subclavian). Increased pulsation of vessels in the neck, subclavian region, and jugular fossa is always visible. On palpation, there is a pronounced pulsation in the radial arteries and its absence or weakening in the lower extremities.

Aortic coarctation is characterized by high values of systolic BP in the upper extremities in patients aged 16-30 years, with a moderate increase of diastolic pressure. Arterial pressure in the lower limbs can be undetectable, while diastolic pressure is normal. The life expectancy of patients if the clinical condition is not treated is 25-30 years.

How is aortic coarctation diagnosed?

During a medical examination, attention is paid to the presence of an athletic physique (predominant development of the shoulder girdle with thin lower extremities), increased pulsation of the carotid and intercostal arteries, weakening or absence of pulsation in the femoral arteries, increased BP in the upper extremities with decreased BP in the lower extremities, systolic murmur above the apex and base of the heart, in the carotid arteries, etc.

Instrumental medical investigations play a crucial role in the diagnosis of aortic coarctation, mainly the data from ECG, EchoCG, aortography, chest X-ray, and cardiac X-ray with esophageal contrasting, cardiac cavity probing, ventriculography, etc.

Electrocardiographic findings suggest overload and hypertrophy of the left and/or right heart, and ischemic myocardial changes. The radiological picture is characterized by cardiomegaly, bulging of the pulmonary arch, changes in the configuration of the aortic arch shadow, and usurped ribs.

Echocardiography allows direct visualization of aortic coarctation and determination of the degree of stenosis. Older children and adults may undergo transesophageal EchoCG.

Cardiac cavity catheterization determines hypertension and hypotension, as well as decreased partial oxygen pressure in the aorta. With ascending aortography and left ventriculography, doctors can detect stenosis, assess its degree and anatomic variant. Coronarography for aortic coarctation may be indicated in the presence of angina episodes, and when planning surgery in patients over 40 years of age to rule out CHD.

Coarctation of the aorta should be differentiated from other clinical diagnoses with the phenomena of pulmonary hypertension, namely vasorenal and essential hypertension, aortic heart disease, and nonspecific aortitis (Takayasu disease).

Treatment of aortic coarctation

Drug therapy does not eliminate aortic coarctation, but it can be used to manage blood pressure. Although surgical repair of aortic coarctation normalizes blood pressure, many patients still have to undergo therapy with medication to manage their blood pressure even after successful surgical repair. Children with severe pathology may be prescribed drugs that preserve the arterial duct open. This provides bypass blood flow until the pathology can be surgically repaired.

Today, there are two ways to treat aortic coarctation: endovascular repair and surgery, which involves excising the narrow section and restoring aortic patency by sewing the two ends together. The choice of treatment method depends on the degree of narrowing, the extent and the exact location of the narrowing, as well as the general health condition and age of the patient. Currently, surgical treatment is preferred in children under one year of age, and endovascular treatment is preferred in children after 5 years of age and adults. The method of treatment for children from one to five years of age is determined on a case-by-case basis.

In some patients, the aorta is not amenable to simple balloon angioplasty. In such cases, an aortic stenting procedure is applicable. The stent is a metal weave in the form of a tube. Sometimes it is covered to prevent damage to the vessel wall. This kind of stent is called a stent graft. When folded, the stent is placed on top of the balloon catheter.

Aortic stenting is a more effective and less traumatic procedure than standard surgical treatment. Stenting can also sometimes be performed in younger patients who cannot be treated surgically because of their severe health conditions.

Endovascular repair surgery lasts about two hours. After surgery, patients are monitored in the intensive care unit for the first 24 hours, because careful monitoring of their blood pressure is necessary.

Rehabilitation after aortic coarctation repair

Patients are usually discharged two days after the intervention. Antibiotic prophylaxis against infective endocarditis in case of infectious or cold-related diseases is performed for half a year after the operation. During one month after the repair procedure, physical activity will need to be limited. One month after the elimination of coarctation, patients can lead a habitual way of life. However, patients after coarctation elimination are contraindicated participating in professional sports. Patients who have undergone surgical repair, regardless of the method, should be regularly checked with EchoCG, CT, and MRI.

In 25% of adult patients, even after the elimination of aortic coarctation, blood pressure remains slightly elevated. It follows that all patients after aortic coarctation repair require careful monitoring of blood pressure.

During 6 months after the procedure, patients should refrain from routine vaccinations and pregnancy planning.

The prognosis for patients with aortic coarctation

The natural course of aortic coarctation is determined by the variant of aortic narrowing, the presence of other heart pathologies but, in general, has an extremely unfavorable prognosis. In the absence of cardiac repair, 40-55% of patients die in the first year of life. With timely surgical treatment of aortic coarctation, good long-term results can be achieved in 80-95% of patients, especially if the repair was performed before the age of 10 years.

The operated patients with aortic coarctation are monitored by a cardiologist and cardiac surgeon for life. They are recommended to restrict physical activity and loads, and also regular dynamic examinations to exclude postoperative complications.

The outcome of pregnancy after repair surgery for aortic coarctation is usually favorable. During pregnancy management, hypotensive drugs are prescribed to prevent aortic rupture, prevention of infectious endocarditis is carried out.

Best hospitals for treatment in Germany

High standards of treatment, unique research programs, medical centers with modern facilities, a significant number of general practitioners, and subspecialty doctors in hospitals in Germany are the main reasons why the hospitals in Germany have such low mortality statistics and high treatment success.

The leading hospitals in Germany that specialize in the treatment of aortic coarctation are considered to be:

• University Hospital Oldenburg.
• University Hospital Essen.
• University Hospital Ulm.
• University Hospital Frankfurt am Main.
• University Hospital Tuebingen.
• University Hospital Erlangen.

More information regarding the services the hospitals in Germany provide is available on the Booking Health website.

The cost of treatment in hospitals in Germany

Treatment in Germany can offer prices for diagnostic and therapeutic measures that are loyal. This very fact, combined with high-quality standards of provided medical services, makes Germany one of the world leaders in the field of medical tourism. The cost of treatment in Germany usually consists of multiple factors, such as diagnostics, the treatment itself, and additional medical care (if needed).

The cost of treatment with angioplasty and stenting for aortic coarctation starts at 7,481 EUR.

The cost of treatment with graft repair starts at 8,894 EUR.

The cost of treatment with patch aortoplasty starts at 8,838 EUR.

The prices for aortic coarctation diagnosis start at 473 EUR.

Feel free to contact Booking Health regarding extended information about the prices for aortic coarctation treatment in Germany.

Undergoing treatment in Germany with Booking Health

In recent years, medical tourism has become a popular tendency. Treatment in Germany allows patients to save money and get the quality medical services they need. 

Booking Health makes the option of treatment in Germany easy and accessible, making it something that would be available to anyone who needs treatment or wants to undergo check-up and preventative measures against any type of disease.

Booking Health allows you to concentrate on your recovery, while all the organizational nuances are being dealt with.

If you have any questions about how the treatment of aortic coarctation in Germany will be organized, fill in the request form on the Booking Health website.

Authors: Dr. Nadezhda Ivanisova, Dr. Sergey Pashchenko