COARCTATION OF THE AORTA WITH CONGESTIVE HEART FAILURE IN INFANCY—MEDICAL TREATMENT

(1)

45

COARCTATION

OF

THE

AORTA

WITH

CONGESTIVE

HEART

FAILURE

IN INFANCY-MEDICAL

TREATMENT

By Henry T. Lang, Jr., M.D., and Alexander S. Nadas, M.D.

Sharon Cardiovascular Unit of time Children’s \feclical Center and Department of Pediatrics, Harvard Medical Sc/moo!

C

OARCTATION of

tue

aorta has been

suc-cessfully relieved by various surgical

techniques during the past 9 years.’ The

mere presence of this anomaly is regarded

today as an indication for surgery in most

large centers. The optimum age for

opera-tion is stated to be between 8 and 20 years,

because of the relatively optimal size and

elasticity of the aorta, and because in

in-fants “there is little assurance that the

growth of the anastomotic site will keep

pace with that of the individual.”

Postponement of the operation to late

childhood is predicated on the observation

that most of these patients show no

syrnp-toms during early childhood. The

appear-ance of congestive heart failure and

cardio-megaly in a few young infants with

coarcta-tion of the aorta has prompted a number

of investigators’4 to seek relief of the

aortic block within the first few months of

life in selected cases.

The considerations against early operative

intervention cited above, plus the high

op-erative mortality in the reported cases, per-suaded us to treat all such infants by

mcdi-cal means. The present report surveys our

experience with the medical treatment of

coarctation of the aorta with congestive

failure in infancy.

MATERIAL AND METHODS

Nine infants in congestive failure, whose

only major cardiac amiomalv was coarctatiomi of

the aorta, form the basis of this report. To the

best of our knowledge, in none of these

pa-tiemits was the coarctation of the aorta

associ-ated with an open ductus arteriosus or other

cardiac amiomalv. \Ve have no information a

to the position of the higamentuni arteriosum

relative to the site of the coarctation. These

infants represemit all the patients with this

condi-tion admitted to the Children’s Medical

Cemi-ter between 1949 amid 1954. In addition to the

routine history, physical examinatiomi, amid

laboratory stu(hes, complete

electrocardio-gram, heart fluoroscopv, and roentgenographic

(lata vere available on each patient.

The diagnosis of coarctation of the aorta

was based on the finding of a blood presstmre

iii the upper extremities at least 20 mm. of

mercury higher (relative hypertension) than

that in the lower extremities. Blood presstmres

were determined by usimig the same technique

iii the upper amid lower extremities. The

atis-cultatory teciimiique was the method of choice

wherever possible. The so-called “flush”

tech-nique15 has beemi used duriiig the past 3 years

because of the absence of atmscultatory signs in

the legs in most of these infants. On the l)asis

of our observatiomis, we l)elieve the flush

pres-sure to be neamlv identical with the direct

arterial meami Iressmre.

The diagmiosis of congestive failure was

based on man or all of the following sigmis:

tachycardia, tachypmiea, dyspmiea, cyanosis,

iul-monary rales, hepatomegal, peripheral edema,

amid a satisfactory response to (lecongestive

meastmres.

CLINICAL OBSERVATIONS

There were 5 girls and 4 boys in this

group. Their ages at the time of admission

ranged from 12 days to 13 months. Eight

infants were less than 4 months of age when

first seen.

The family, gestational, and delivery

his-tories were unremarkable in all instances.

Five infants, however, weighed less than

2.5 kg. at birth.

(Submitted May 25, accepted July 6, 1955.)

l)r. Lang is a Trainee of The National Heart Institute.

(2)

9

8

7

5:

4

FEEDING POOR IRRITABILITY DVSPP4EA POOR COLOR SWEATING ATTACKS

PROBIIMS WEIGHT GAIN S TACHYCARDIA

RELATJV( TO THr COARCTATj RELATiVE TO CONGESTIVE FAILURE

LATIV *aso’ o

HVERTE4 D(tAS(D

FtOtN. PIA.*S

p(covL TCHCMDI*

FIG. 2. Physical signs at the timiie of admission.

2

FIG. 1. Symriptomatologv.

Onset of Symptoms

Symptonis occuried within tile first 3

IlTIOIltiiS of life iii all patiellts; witilin

tue

first 14 days of life in 6 infants. All infants

had feediiig l)rollemlls consisting of anorexia,

vomiting, and fatigue during feeding (Fig.

1). Their weight gain was considered poor:

they failed to regain their birth weight in

the expected time, and did not show normal

increments of gain in weight. Irritability,

as evidenced by “colitilluous crying,” was

noted in all patients. Dyspnea, coupled

with rapid, forceful heart beat, and “poor

color” was observed by the parents in 7

instances. Excessive perspiration as a

promi-nent symptonl was nientioned in 3 cases.

Two infants had “attacks” consisting of

(3)

9

PULMONARY CONGESTION

LEFT AURICULAR

ENLARGMEN 7

at the time of

AUSO.RTATORY SYSTOLIC

- FLUSH

TOP NO..ARM PRESSURE ,,, IIq LONERNO.LEGPRESIURE,,mm H

240

220

200

I 80

60

40

20

00

80

60

40

20

I 40

Fir.. 3. Blood pressures at the time of admission.

Physical Findings

The findings by physical examination

divided into 2 groups as may be seen in

Figure 2.

One group represents the findings related to the coarctation itse1f. The characteristic

changes in blood pressure have been

dis-cussed and these represent our definition

of the syndrome. The femoral pulses were

either absent, or when palpable, weak and

delayed in comparison with the radial

pulses.

Systolic murmurs of varying character,

in-tensity, and distribution were noted in 7

infants. The murmur was maximal along

the left sternal border in 6. In only 1 infant

was the murmur maximal over the back.

Two infants had no murmurs. A definite

prominence of the left chest was observed

at the time of admission in 6 patients. A

thrill was palpable in the left mid-clavicular linein 1.

The other group of physical findings

re-hates to the presence of congestive failure.

All infants at the time of admission had

pulse rates greater than 150/mm.; 1 infant

had paroxysmal auricular tachycardia, the

260

80

I

o

25

‘liii’

116 03 I00

80 80 75 65

40

Fic. 4. Roentgenographic findings

.aliIijssO):l.

others had sinus tachycardia. The

respira-tory rate was also increased in every

in-stance. Dyspnea was evidenced by flaring

of the aiae nasi, and snbcostal, intercostal

and supraclavicular retraction. The liver

edge was palpable more than 3.5 cm. below

the right costal margin in all. Cyanosis,

re-lieved somewhat by the administration of

oxygen, was noted in 6 cases. Moist rales

and wheezes were present in 5 patients.

Pc-ripheral edema was observed in 1 case, and

suspected in another.

Figure 3 illustrates the levels of the blood

pressures at the time of admission. As

pointed out previously, a relative

hyperten-sion of the arms was present in all. In the

2 patients whose blood pressures were

deter-mined by the auscultatory technique,

pres-sures in the legs were not measurable. This

we believe did not represeiit

tue

actual

systolic pressure, but rather is an expression

of the inadequacy of the method. In 6 of

the 7 infants Oil wllonl the “flush” technique

was used, the pressure in the legs varied

be-tween 60 and 80 mm. of mercury,

(4)

..

:,

!#{149} 4

0

(1T

0

Fic. 5. Roentgenograrns o patient, J.M., age 2 mouths.

a (Left). Postero-anterior position.

li (Rig/ut). Left anterior oblique position.

infant, admitted in shock, the “flush” pres- graphic and fluoroscopic findings. All

pa-sure in the leg was 40 mm., but rose within tients had generalized cardiac enlargement

a few days to 60 mm. with the cardiothoracic ratio varying

be-tween 0.6 and 0.85. The cardiac silhouette

Roentgenographic Findings was globular with

slight

prominence of

Figure 4 summarizes the roentgeno- tile left ventricle. Selective left atrial

en-.. -- .

. . I

. -, ‘ -_*

*

:.

:

,

Y

,

‘-,

k

i - -.

, ,‘ .

f_

I

(5)

In’

RVH LVH CVH

largement was noted in 4 cases. Passive

congestion of the lungs was not:

At fluoroscopy, the cardiac beat #{226}jeaieTd

feeble in 5 patients. Characteristic

roent-genograms are presented in Figure 5. A

survey of the roentgenograms of all 9

in-fants at the time they were admitted is

shown in Figure 6.

Electrocardiographic Findings

These at the time of admission are

de-picted in Figure 7. Five patients had

pat-terns of rigilt ventricular hypertrophy

(R.V.H.), 3 had patterns of left ventricular

hypertrophy (L.V.H.), and 1 suggested

com-bined ventricular hypertrophy (C.V.H.).16

The incidence of incomplete right-bundle-branch block (I.C.R.B.B.B.), left ventricular T-wave changes prior to the administration of digitoxin, and tall, peaked P-waves within

these 3 electrocardiographic groups may

also be seen in Figure 7.

These electrocardiograms are abnormal

- LVII

.. VH

: CVII

ICRBBB 5 I I

TALL PEAKED PWAVES I 3 0

LV T WAlE CHANGES 5 2 0

(NO DIGITALIS)

FIG. 7. Sumismisary of electrocardiograms taken at

the time of admission.

LVH = left ventricular hpertrophy;

RVH = right ventrictmlar hypertrophy;

CVH = combined (right and left) ventricular

hyper-trophy;

ICRBBB = inconiplete right bundle branch bhok;

LV = left ventricular.

FIG. 8. Typical electrocardiographic patterns of left ventricular hypertrophy (LVH) and right

veatrkular hypertrophy (RVH) in 2 patients.

according to our criteria; L.V.H. and C.V.H.

are abnormal under all circumstances. Of

the 5 electrocardiograms with R.V.H., 3

were considered abnormal because of tall

voltages; the other 2 because of left

yen-tricular T-wave changes and tall peaked

P-waves. Typically abnormal R.V.H. and

L.V.H. patterns are shown in Figure 8.

Treatment and Course

In consequence of the reasoning outlined

earlier, all these infants with coarctation of

the aorta and congestive failure were

treated medically. Digitoxin (0.033 to 0.066

mg/kg. of body weight) was given to all

within a 24- to 36-hour period in divided

doses. One-tenth of the digitalizing dose

was given daily for maintenance.

Mercuhy-drin#{174} (0.25 ml. intramuscularly), and a

so-dium-free formula, Lonolac1c, were given to

the 2 infants who appeared edematous.

Oxygen and broad-spectrum antibiotics

were administered to every patient.

The immediate clinical results of the

above therapy were gratifying in every

in-stance (Fig. 9). All infants survived. Their

irritability and evidence of congestive

(6)

I FEEDING IRRITA8IUTY PULSE RATE LIVER SIZE

lPROBLEMS I

IMPRPNT IN

Fic. 9. Results of medical therapy.

iii .5, with weight loss varying between 5 ing digitoxin, within 2 to 3 weeks after

ad-1i1(I 7 per cent of body weight within 48 mission, and were followed in the cardiac

hours. clinic.

The patients were discharged, still receiv- All of the patients were followed for

pe-. ALEc1LTATORY SYSTOLIC

0 FLLSH

. . .

.

AGE IN MONTHS

lm(;. 10. Survey of blood pressures in the armiis at varying ages. Each dot or

circle represents an individual determination.

Hg

255

250

240

230

220

210

200

190

180

ITO

I 60

150

40

I30

120

I 10

I00

90

80

70 9

(7)

6 9 2 5 8 24 30 36 42 48 54 60

ORIGINAL ARTICLES

Hg

240

230

220

210

200

90

I80

I70

I 60

I50

I40

I30

I20

110

I00

90

80

. AUSCULTATORY SYSTOLIC

, . 0 USH

AGE IN MONTHS

Fic. 11. Progression of blood pressures in the arni in the individual patients.

nods varying from 3 months to 5 years,

with an average of 24 months. All but 2

are still receiving digitoxin, 1 for as long as

4% years. Tile 2 children who now receive

no medication are 21 and 26 months old,

respectively. Antibiotics were given when

indicated for febrile illnesses.

By and large, all these children are doing

well and are free of symptoms. Although

they tend to be somewhat short in stature, their nutritional state is satisfactory. Re-currence of congestive failure was observed in 2 instances. In 1 of these patients,

digi-toxin was discontinued by the parents; in

another infant, severe pneurnonitis

precipi-tated cardiac failure. Both patients

re-sponded well to appropriate measures.

The level of the systolic blood pressure in

the arms noted (luring the period of

ob-servation is shown in Figure 10. In general, there has been a rise of the systolic blood

pressure in the arms through the years.

Figure 1 1 demonstrates the progression of

the systolic blood pressures of the arms of

tile individlilal patients. It is clearly seen

that the changes in blood pressure are

tin-predictable iii tile individual cases. Most

children showed a rise in blood pressttre;

in others, no change was noted, and in 3, the

blood pressure even dropped.

The pressure (flush teciinique) in the legs

of all patients except 1 (J.M.) has remained

at the level recorded at the time of

admis-sion.

Changes in the roentgenograms were

dis-appointing on the whole. In spite of the

very favorable clinical response, none of

the patients showed a normal sized heart

during the period of observation. However,

the heart size has not increased in any, and

in most, the cardiothoracic ratio has

de-creased. The diminution in 1 case was as

much as 18 per cent. The degree of

pul-monary congestion lessened considerably,

but did not disappear entim-ely. The changes in the electrocar(liographic

I)ltterns during infancy are iicttmrecl in

Figure 12. The left half of the figure

pre-sents data referable to Patients less than

6 months of age; the right half, to patients

more than 6 months of age. Six of the 8

infants less than 6 months old are also

rep-resented in the older group; 2 are still less

(8)

writ-UHEIER 6 MONTStR

8 INFANTS

OVER 6 MONTI

7 INFANTS

5t147R10JL2? ICRISS LV TALL PEAKED VENTRIcILAR cReel LV TALL PEAKED

HYPERTROPWY T WAVE PWAVES HYPERIROPHY TE P WAVES

HANS O4A4GES

INODIOITAIIS) ION D$GITWJSI

I

LEFT VENTULAR HYPERTROPHY

....-. RIGHT VENTRICULAR H’VPERTROPHY

00M8INED VENTRICULAR HYPERTROPHY

lI(;. 12. PrOgrtssiOmi of electrocardiographic patterns (set’ text for explanation).

ing of this report. The older group, in

addi-tion, includes 1 patient vhom we first saw

at tile age of 1 year.

It may be seen from this coiiiparative

chart, as pointed out earlier, that the

young-est infants max’ show patterns of right, left,

Or cOIiIi)ilie(l ventricular hypertrophy. All

l)atieflts niore than 6 months of age showed

electrocar(liographic patterns of L.V. H. The

only other significant difference between the

2 groups was the more common occurrence

of auricular iivpertrophy in the older group.

Figure 13 demonstrates the typical change

ill

tue

ek’ctrocar(liograpilic pattern in 1

in-fant.

DISCUSSION

The diagnosis of cocarctation of tile aorta

shOUl(l not 1)e difficult to establish if one

remenli)ers to feel for the femoral pulses of

ever’ patient, and to obtain blood pressures

iii both ariii and leg in all suspicious cases.

If the iressure in the legs is significantly

(at least 20 mm. of mercury) lower than that

iii the arms, au aortic block exists. The only

tv1)e of coarctatioii of the aorta that may be

accompanied by a pressure in the legs equal

to or higher than that in the arms, is tile

“infantile” type, in which an open (luctus

enters tile aorta distal to the constriction.

Fic. 13. Development ot lelt ventricular pattern in coarctation of the aorta (patient J.M.).

RVH = right ventricular hypertrophy.

(9)

These cases often, but not invariably, may

be distinguished by cyanosis of the lowei’

half of the body.

To differentiate coarctation of the aorta

from other causes of congestive failure in

infancy is usually not difficult. Tile oiie

con-dition most commonly considered in the

differential diagnosis was “primary

myo-cardial disease.”17 This clinical group, coal-posed of 5 etiological entities, exhibits

cvi-dence of congestive failure without

signi-ficant murmurs, left ventricular type

dcc-trocardiograms and roentgenograms, and is

similar to the patients under discussion.

Pa-tients with these conditions, as with all

other types of heart disease except coarcta-tion of the aorta, will have blood pressures in the legs equal to or iligher than those in the arms.

Thiere is no uniformly accepted explana-tion for a minority of patients with

coarc-tation developing congestive failure in

in-fancy whereas most of them grow up into

childhood and adolescence without

signifi-cant symptoms.

Bahn, Edwards, and Dushan&8 maintain that patients with coarctation of the aorta

who develop congestive failure in infancy

are characterized by the insertion of a

cbs-ing

ductus or ligamentum arteriosum distal

to the aortic constriction, and hence an

inadequate development of collateral

cir-culation. It is their opinion that absence of collaterabs to by-pass the aortic constric-tion, results in obstructive hypertension, left ventricular strain, failure and death.

Conversely, they assume that postnatal

closure of a ductus inserting proximiil to

the

coarctation

has

no

deleterious

effects

on the left ventricle because of the presence

of adequate collaterabs, acting as escape

valves for the systemic blood flow.

Attractive as this hypothesis may be, there

is some evidence that it does not operate

under all circumstances. Ziegler19 in his

re-cent report cites 2 infants and Scaly and

Webb12 cite another infant with coarctation of the aorta and congestive failure, in whom

the ligamentum arteriosum was found at

operation to insert proximal to the aortic

block. Conversely, we have seen several

completely asymptomatic patients wilo at

operation for coarctation sllowed a

liga-mentum arteriosum inserting distal to the

aortic constriction. #{176} Furthermore, tue

cvi-(lence presented by Bahn et a!. in regard to

the existence of collaterals in utero is not

completely convincing.

We therefore feel that the presemice or

absence of collaterals, based OIl

tue

site of

insertion of the ligamentuni arteriosum may

not be the only explanation for the

occur-rence of congestive failure in some infants with coarctation of the aorta. We would like to propose that in addition to the presence

or absence of collaterals, other factors

should be considered, such as the severity

of the coarctation at birth, the time of

closure of the ductus arteriosus, and the

presence of infection.

Zieglerl states that

“tue

electrocardio-gram in uncomplicated coarctation of the

aorta in infants reflects the pattern of the fetal circulation and serves as a useful

prog-nostic guide.” He maintains, on the basis of

an analysis of electrocardiograms, that in

infancy, a pattern of R.V.H. is associated

with an open ductus or a ligamentum

ar-teriosum inserting proximal to tile aortic

constriction, whereas patterns of L.V.H. or

left bundle-branch block (L.B.B.B.) are

associated with a bigamentum arteriosum

inserting distal to the aortic constriction.

He further states that congestive failure

associated with patterns of R.V.H. or of

I.C.R.B.B.B. are retrogressive with an

excel-lent prognosis; whereas with patterns of

L.V.H. or of L.B.B.B., it is progressive and

the prognosis poor.

As none of our 9 patients have died, we

cannot confirm or deny the validity of the

assumption that the site of insertion of the

ligamentum arteriosum is reflected in the

electrocardiograms of these infants. On the

other hand, we cannot agree with the

con-elusion that the presence of patterns of

L.V.H. in patients even under 6 months of

age is necessarily an unfavorable sign.

Among 8 patients less than 6 months of age,

(10)

Fic. 14. Roentgenogramns of a patient with coarctation of the aorta with congestive failure imi infancy.

a (Left). Age 2 weeks, cardiothoracic ratio = 0.78.

h (Right). Sonic patient, preoperative, age 14 years, cardiothoracic ratio = 0.46. Resection of a typical

coarctatioms was performed 1 week later.

LANG COARCTATION OF THE AORTA

a pattern of C.V.H. Tilese 3 patients

re-S1)ollded just as well to conservative medical

management as did the remaining 5 with

1)tttterlls of R.V.H.

The seriousness of the problem presented

l)y au infant with uncomplicated coarctation

and congestive failure is uniformly

appre-catted. A total of 35 such infants treated

i)y mnedictl means has been collected from

the literature.7 I’ 2I Only 7 survived.

Froiii analysis of these cases, it is our

con-elusion that failure of nledical management

was due to 1 of 3 factors : inadequate initial

(hgitalization amid lack of use of diuretics;

failure to maintain digitalization

through-out infaiicy, or 5u)ervening infection.

These discouraging experiences have led

a number of surgeons amid cardiologists to

conclude that oI)eration is the treatment of

choice. Table I presents the results of opera-tion in cases collected from the literature. It

may be seen that of 31 cases operated upon

in infancy, 11 died at the time of surgery,

and the result was unsatisfactory in 4

be-cause of I)ersistelit ily)ertensiOn in the arms.

It should be stated that congestive failure,

present in at least 20 of these cases,

re-sponded to medical management

preopera-tively in at least 10 instances. The only

(leatil in tue series reported by NouaillelI

was attributed to inadequate decongestive

therapy preoperatively.

Our experience with the medical

treat-ment of this condition is encouraging. All of our 9 patients ilave recovered satisfactorily

and contiilue to thrive. Others have Iladi

similar experience. ‘ #{176}We recomilmendl that

digitalis be administered in doses causing

either the desired effect, or mild toxicity; in

the infant

age group

digitoxin 0.044 to 0.066

mg./kg. of body weight usually is necessary

to achieve full digitalization.25 Diuretics,

such as Mercuhydrin (0.1 to 0.5 ml.

intra-muscularly) should be administered to

edematous infants and to those who fail

to respond to digitalis alone. Oxygen, anti-biotics, sodium restriction, and careful

feed-ing techniques contribute significantly to

the success of the regimen. Digitalization,

we feel, should be maintained throughout

infancy. Continuous chemoprophylaxis for

the first 6 months of life and prompt,

vig-orous treatment of intercurrent infections is

recommended in all.

The only disturbing feature of the

mcdi-cal care, previously noted, is tilat the heart

size did not return to normal in any of our

patients during the relatively short period of

observation. On the other hand, that the

(11)

.4 m,thor \I). Insertion

Relatire to Coarciation

Stephens an(l Grimes6 1 at ? + 13 moo. tiled

Calodney and Carsomi7 at opemi (‘2 mmii.) ₊ ‘35days (lied Olney and Stephens8 3 proximal pro)). closed + 14 mao. died

Lynxwiler et a!.9 4 at open + 3 mo. good

Kirkhin et a/.” 5 (listal (lOse(i 0 10 wk. good

Baronofsky et al.#{176} 6

7 (listal ? opemi ? + + 14 days 6wk. survived good

Sealy and Webb’2 8 proximal closed + 14 mo. persistemit hypertension

Nouaille et al.mz 9

10 I 1 1

13

at or prox-imal proximal proximal proximal proximal chosed closed clOsed closed closed + + + + + 7 mno. ii nmo. 9 mno. 9 mno. 2 yr. died good good good good 1)eGroot et al.tm’ 14 proximal open (1 mismmi.) ₊ 4 IHO. (lied

Ziegler’9 15 16 17 18 (histal at proximal distal open closed open open (I + 0 I) yr. <2 yr. 2 yr. 5 rib. (lie(l survived survived survived Keith’3 19 2() ‘l ‘23 24 5 26 l7 ‘28 l9 so 31 proximisal proximmmah proximal proximal (listal (listoll distal dishui distal distal distal distal (hiStal prob. closed prol). closed proh. closed prol). (hose(l open open open open open opemm open open 0J5C11 0 (I -f + + -f. + + ? ? ? ? ‘ 3 1110. I I 1110.

.51110. 5 wk. i’.2 clays 5 1110. 3 1110. uk.

< hyr.

<1 yr.

< I yr.

< 1yr.

< I yr.

persistent hypertemision persistent hmypertemision persistellt hiypertemisioii good good good good good (lied (lie(l died died (hell TABLE I

CoAncTAV OF THE AORTA (Operated UJX)fl when less than 2 years (f age.)

!)uclus

-

_Failure

Paleney (preoper-atively)

Age at Result Operation

is possible, is demonstrated in Figure 14.

The 2 roentgenograms presented are those

of a girl, not included in our series, who

was operated upon for coarctation of the

aorta at the age of 14 years. Tile small film

shows significant cardiomegaly at 2 weeks

of age when she demonstrated frank clinical

congestive failure. She responded well at

that time to decongestive measures and

re-mained asymptomatic through subsequent

infancy and childhood. The larger film on

the right, showing the normal sized heart,

was taken I week prior to surgery. At

operation, she was found to have severe

co-arctation of the aorta with the ligainentum

arteriosum nlserting I)roximnal to the aortic

constriction.

SUMMARY

Nine infants with uncomplicated

coarcta-tion of the aorta in congestive heart failure are presented.

The symptomatobogy was dominated by

feeding problems, failure to thrive, dyspnea, and cyanosis.

(12)

56 LANG COARCTATION OF THE AORTA

signs referable to the coarctation, signs of

both left and right-sided congestive heart

failure were noted.

The roentgenographic survey revealed

marked generalized cardiomegaly and

pul-monary congestion.

Electrocardiograms in the infants less

than 6 months of age showed left, right, or

combined ventricular hypertrophy, whereas

those more than 6 months of age all showed left ventricular hypertrophy.

Medical treatment, consisting of digitalis,

oxygen, mercurial diuretics, diet low in

sodium, and antibiotics, was successful in

all instances. Digitalization was maintained

throughout infancy. Operative intervention

can be safely postponed until late

child-1100(1 unless medical management is not

sue-cessful.

A review of the pertinent literature is

presented.

CONCLUSION

Congestive failure in infants with

uncom-plicated coarctation of the aorta can be

treated medically. Our experience, though

not unique, suggests that the majority of

these infants can be managed satisfactorily

l)y medical means until they reach late

childhood or early adolescence at which time

complete and probably permanent surgical

relief of the aortic coarctation can be

per-formed with an operative mortality of less

than 5 per cent. Although surgery in infants

ilas been successful in most instances, it is

attended by a higher mortality and less

satisfactory end result. We recognize and

recommend, however, that surgery be

per-formed early if medical management fails,

or if signs of hypertensive encephalopathy develop.

ACKNOWLEDGMENT

The authors express appreciation to Dr.

R. E. Gross for his assistance in the

prepara-tion of this paper.

REFERENCES

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SPANISH ABSTRACT

Coartaci#{243}n de la Aorta con Insuficiencia

Congestiva en la Infancia

El presente artIculo se bas#{243}en ci cstudio de

9 lactantes con coartaci#{243}n de Ia aorta no

com-plicada, pero en estado de insuficiencia cardiaca

tratada medicamente; comprendieron el

n#{241}m-ero total de pacientes con este sIndromc

oh-servado de 1949 a 1954 en ci Children’s

Medical Center de Boston.

Todos iniciaron su padecimiento dtmrante los

primeros tres meses de ha vida; la

sinto-matologla abarc#{243} problemas de alimentaci#{243}n,

retardo en ci desarrohlo, disnea y cianosis. Los

signos fIsicos encontrados, aparte de los

cor-respondientes a Ia coartaci#{243}n de Ia aorta,

in-cluyeron manifestaciones de insuficiencia

con-gestiva tanto izquierda como derecha. Radio-gr#{225}ficamente todos tuvieron cardiomegalia

generalizada acentuada y congestion pulmonar;

los electrocardiograms en los niflos menores de

6 meses de edad mostraron hipertrofia

ventricu-bar izquierda, derecha o combinada, en tanto

que los mayores de 6 meses de edad solo

hi-pertrofia ventricular izquierda. El tratamiento

medico consisti#{243}en Ia administraci#{243}n de digital, diur#{233}ticos mercuriales, oxIgeno, antibi#{243}ticos y

dicta baja en sodio; la respuesta fu#{233}favorable

en todos los casos. Dc estos datos los autores

concluyen que Ia intervenci#{243}mi quirurgica puede

posponerse con seguridad para los pacientes

hasta Ia segumida infancia en Ia mayoria de los

casos.

Los autores presemitan adem#{225}suna revision de

la literatura sobre el sIndrome de coartaci#{243}n de

la aorta con insuficiencia congestiva, Ia

pato-genesis de los cambios electrocardiogr#{225}ficos y

la mortahidad asociada al tratamiento quirimrgico

y medico de los pacientes.

INTERLINGUA ABSTRACT

Coarctation del Aorta con

Dysfunctio-namento Congestive in Infantia

Le base del presente reporto cs he casos de

9 infantes con non-complicate cearctatiomi del

aorta in dvsfunctionamento congestive qimi

es-seva tractate per therapia medical. Iste serie

representa Ic totalitate del patientes con Ic

syndrome mentionate qui esseva observate

inter 1949 e 1954 al Centro Medical pro

Juveniles (“Children’s Niedical Center”) a

Bos-ton. In omnc he patientes Ic svmptomas se

declarava durante he prime 3 menses del vita.

Le symptomatologia esscva dominate per

problemas de alimentation, nori-prosperation,

dyspnea, e cyanosis. Le constatationes physic,

ultra illos attribuibile al coarctation dci aorta,

includeva signos de dysfunctionamento

con-gestive al latere sinistre como etiam al latere

dextere. Le examine roentgenographic

reve-lava in omnes un marcate cardiomegahia

ge-neralisate e congestion pulmonar. Le

electro-cardiogrammas del infantes de minus que 6

menses de etate monstrava hypertrophia

yen-tricular sinistre, dextere, o combinate, sed in

omne infantes de plus que 6 menses de etate Ic

electrocardiogrammas monstrava hypertrophia

ventricular sinistre. In omne casos hon

sue-cessos esseva obtenite per tin tractamento

medical consistente de digitalis, diureticos

mer-curial, oxygeno, dicta a basse contento de

natrium, e antibioticos.

Nos conclude quc in le majoritate del casos

on curre nulle risco si on postpone he

inter-vention chirurgic usque al annos de

pre-adolescentia. Es presentate un revista del

litteratura pertinente a iste syndrome, al

genese del cambiamentos electrocardiographic,

e al mortalitate associate con he tractamento

(14)

1956;17;45

Pediatrics

Henry T. Lang, Jr. and Alexander S. Nadas

MEDICAL TREATMENT

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INFANCY