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Ann Thorac Surg 2005;80:1657-1658
© 2005 The Society of Thoracic Surgeons
a Pediatric Cardiothoracic Surgery, Children's Hospital of Wisconsin & Medical College of Wisconsin, Mail Stop 715, 9000 West Wisconsin Ave, Milwaukee, WI53226
b Pediatric Cardiology, Children's Hospital of Wisconsin & Medical College of Wisconsin, Mail Stop 713, 9000 West Wisconsin Ave, Milwaukee, WI53226
(Email: rjaquiss{at}chw.org; pfrommelt{at}chw.org).
This article [1] describes a novel and potentially important new echocardiographic index for the diagnosis of coarctation of the aorta in neonates and infants. The authors have proposed the index because of the frequent difficulty in confidently establishing the diagnosis of coarctation, particularly in the smallest and youngest patients. Three anatomic features create this difficulty: the coexistence of a large ductus arteriosus, the presence of hypoplasia of the aortic arch, and the lack of "co-planarity" of the aortic arch, ductus, and descending aorta. Previous investigators [2, 3] have suggested that specific dimensional thresholds for the aortic isthmus of 4.5 mm [2] or 3 mm [3] allow the diagnosis of coarctation. However the specificity and sensitivity of such a measure are far from perfect, and the application of either standard to very small infants will certainly lead to overdiagnosis of coarctation. The addition of Doppler assessments has variously been believed to be of limited value [4] or of significant help if combined with size criteria [3]. In present day practice, despite the several proposed diagnostic tests for coarctation, it is still quite common to allow the ductus to close under observation to allow a coarctation to "declare itself" if present. Such a declaration will take the form of the acute development of aortic obstruction with potential consequences of distal hypoperfusion and metabolic acidosis, renal injury, left ventricular dysfunction, pulmonary edema, and pulmonary hypertension. In effect, the patient is forced to prove he has a disease by becoming ill.
The validation of the carotid-subclavian artery index would allow the relegation of observed ductal closure to the slagheap of history where it rightly belongs. The measurements required to calculate the index are readily obtained from standard suprasternal views of the distal arch. Accurately aligned Doppler windows are not required, and there is no necessity for co-planarity of the aortic arch, ductus, and descending aorta. There is also no requirement for detecting a "coarctation shelf" as described by other authors [5]. Another advantage of using the index is the fact that it is a ratio, and thus it would not be confounded by extremely small patient size.
However several caveats are worth mentioning in regard to the new measure, which has not yet been tested in other centers. Despite the excellent sensitivity and specificity of this index, it is important that it not be applied in isolation. There is the occasional neonate, with transverse aortic arch hypoplasia and a large patent ductus arteriosus, who does not develop coarctation of the aorta, and an aggressive strategy of surgical intervention in these patients based on an as-yet unconfirmed echocardiographic index that could result in unnecessary procedures and exposure to potential late complications, such as recurrent arch obstruction and distortion. Beyond the application of the carotid-subclavian artery index, other evidence of coarctation should therefore be sought, including the transverse aortic arch hypoplasia described in this study, the bicuspid aortic valve, and the presence of a posterior juxtaductal aortic shelf. The authors did not describe the presence of mitral annular hypoplasia or mitral chordal abnormalities in their cohort, and it is therefore not clear whether their index is applicable to patients with Shone's complex. Despite these reservations, the carotid-subclavian artery index demonstrates great promise as a diagnostic tool and should be added to the diagnostic armamentarium as it undergoes prospective analysis in a cohort of infants with and without suspected arch abnormalities and other left heart obstructive lesions.
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This article has been cited by other articles:
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  Y. Mivelaz, S. Di Bernardo, E. J. Meijboom, and N. Sekarski Validation of two echocardiographic indexes to improve the diagnosis of complex coarctations Eur. J. Cardiothorac. Surg., November 1, 2008; 34(5): 1051 - 1056. [Abstract] [Full Text] [PDF]
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