Critical Coarctation of the Aorta in Selective Fetal Growth Restriction and the Role of Coronary Stent Implantation

Abstract

<b><i>Introduction:</i></b> Monochorionic twins are at increased risk of congenital heart defects (CHDs). Up to 26% have a birth weight <1,500 g, a CHD requiring neonatal surgery, therefore, poses particular challenges. <b><i>Objective:</i></b> The aim of the study was to describe pregnancy characteristics, perinatal management, and outcome of monochorionic twins diagnosed with critical coarctation of the aorta (CoA). <b><i>Methods:</i></b> We included monochorionic twins diagnosed with critical CoA (2010–2019) at 2 tertiary referral centers, and we systematically reviewed the literature regarding CoA in monochorionic twins. <b><i>Results:</i></b> Seven neonates were included. All were the smaller twin of pregnancies complicated by selective fetal growth restriction. The median gestational age at birth was 32 weeks (28–34). Birth weight of affected twins ranged as 670–1,800 g. One neonate underwent coarctectomy at the age of 1 month (2,330 g). Six underwent stent implantation, performed between day 8 and 40, followed by definitive coarctectomy between 4 and 9 months in 4. All 7 developed normally, except for 1 child with neurodevelopmental delay. Three co-twins had pulmonary stenosis, of whom 1 required balloon valvuloplasty. The literature review revealed 10 cases of CoA, all in the smaller twin. Six cases detected in the first weeks after birth were treated with prostaglandins alone, by repeated transcatheter angioplasty or by surgical repair, with good outcome in 2 out of 6. <b><i>Conclusions:</i></b> CoA specifically affects the smaller twin of growth discordant monochorionic twin pairs. Stent implantation is a feasible bridging therapy to surgery in these low birth weight neonates.

Congenital heart defects in monochorionic twin pregnancy complicated by selective fetal growth restriction

“…Gijtenbeek et al 14 . reported a series of seven cases of CoA in MCDA pregnancies complicated by sFGR without TTTS.…”

“…In smaller twins, the most common subtype of CHD was CoA, with a prevalence of 1.0% (3/296), which is over 30-times higher compared with the general population (0.03%) 1 . Gijtenbeek et al 14 reported a series of seven cases of CoA in MCDA pregnancies complicated by sFGR without TTTS. As in our series, several pregnancies with CoA in the smaller twin were accompanied by PS in the larger cotwin, with AFD at some point during the pregnancy.…”

Stenting of critical aortic coarctation in neonates between 600 and 1,350 g. Using a transfemoral artery approach. A single center experience

“…Only a few studies about CoA-stenting in VLWB < 1,500 g ( 11 ) and in ELWB < 1,000 g ( 9 , 12 ) were published in the last 10 years due to a very small number of patients underwent stenting of aortic coarctation in this very special population. The pre-mounted coronary stent was used for CoA-stenting in all studies included patients weighting under 1,500 g. One case report ( 13 ) about use and limitation Magmaris?…”

Neonatal Cardiac Disease:

“…(137) More studies are confirming our encouraging results that CoA stenting is effective and safe in selected small children with severe symptomatic CoA. (137)(138)(139)(140) For the future we should focus more on the long-term safety profile of alternative routes of vascular access (as percutaneous or surgical cutdown of the carotid artery) in VLBW infants. The other challenge is the inherent somatic aortic growth requiring subsequent intervention to remove or modify the stent.…”