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Eriksson P, Pihkala J, Jensen AS, Dohlen G, Liuba P, Wahlander H, Sjoberg G, Hlebowicz J, Furenas E, Leirgul E, Settergren M, Vithessonthi K, Nielsen NE, Christersson C, Sondergaard L, Sinisalo J, Nielsen-Kudsk JE, Dellborg M, Larsen SH. Transcatheter Intervention for Coarctation of the Aorta: A Nordic Population-Based Registry With Long-Term Follow-Up. JACC Cardiovasc Interv 2023; 16:444-453. [PMID: 36858664 DOI: 10.1016/j.jcin.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Coarctation of the aorta (CoA), a congenital narrowing of the proximal descending thoracic aorta, is a relatively common form of congenital heart disease. Untreated significant CoA has a major impact on morbidity and mortality. In the past 3 decades, transcatheter intervention (TCI) for CoA has evolved as an alternative to surgery. OBJECTIVES The authors report on all TCIs for CoA performed from 2000 to 2016 in 4 countries covering 25 million inhabitants, with a mean follow-up duration of 6.9 years. METHODS During the study period, 683 interventions were performed on 542 patients. RESULTS The procedural success rate was 88%, with 9% considered partly successful. Complications at the intervention site occurred in 3.5% of interventions and at the access site in 3.5%. There was no in-hospital mortality. During follow-up, TCI for CoA reduced the presence of hypertension significantly from 73% to 34%, but despite this, many patients remained hypertensive and in need of continuous antihypertensive treatment. Moreover, 8% to 9% of patients needed aortic and/or aortic valve surgery during follow-up. CONCLUSIONS TCI for CoA can be performed with a low risk for complications. Lifetime follow-up after TCI for CoA seems warranted.
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Affiliation(s)
- Peter Eriksson
- University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden.
| | - Jaana Pihkala
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (http://guardheart.ern-net.eu)
| | - Annette S Jensen
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (http://guardheart.ern-net.eu); Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Gaute Dohlen
- Oslo University Hospital Rikshospitalet, Oslo, Norway
| | | | - Hakan Wahlander
- University of Gothenburg, Institute of Clinical Science, Sahlgrenska Academy, Gothenburg, Sweden
| | - Gunnar Sjoberg
- Astrid Lindgren Children's Hospital and Department of Children's and Women's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Eva Furenas
- University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Magnus Settergren
- Department of Cardiology, Karolinska University Hospital and Division of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | | | | | | | - Lars Sondergaard
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (http://guardheart.ern-net.eu); Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
| | - Juha Sinisalo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (http://guardheart.ern-net.eu)
| | | | - Mikael Dellborg
- University of Gothenburg, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Signe H Larsen
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart: ERN GUARD-Heart (http://guardheart.ern-net.eu); Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark; Aarhus University Hospital, Aarhus, Denmark
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 964] [Impact Index Per Article: 241.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Millar PJ, Oechslin EN. Hypertensive Response With Exercise to Reveal Increased Cardiovascular Risk in Adults With Aortic Coarctation Repair: Value and Caution. Can J Cardiol 2018; 34:536-539. [PMID: 29731016 DOI: 10.1016/j.cjca.2018.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 11/27/2022] Open
Affiliation(s)
- Philip J Millar
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada; Toronto General Research Institute, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Erwin N Oechslin
- Division of Cardiology, Peter Munk Cardiac Center, Toronto Congenital Cardiac Center for Adults, and University of Toronto, Toronto, Ontario, Canada
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Assessment of ventriculo-vascular properties in repaired coarctation using cardiac magnetic resonance-derived aortic, left atrial and left ventricular strain. Eur Radiol 2016; 27:167-177. [DOI: 10.1007/s00330-016-4373-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 02/10/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
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Lurz P, Okon T, Riede T, Wagner R, Schuler G, Daehnert I, Desch S. Renal sympathetic denervation in uncontrolled arterial hypertension after successful repair for aortic coarctation. Int J Cardiol 2016; 202:322-7. [PMID: 26422021 DOI: 10.1016/j.ijcard.2015.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/14/2015] [Accepted: 09/19/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Uncontrolled arterial hypertension is a frequent problem after successful repair of CoA and has been attributed to increased central sympathetic drive as well as a blunted baroreceptor reflex. RSD is a promising therapy to reduce central sympathetic drive and improve baroreflex sensitivity. METHODS 8 patients (age: 27±6 years) with previous surgical and/or percutaneous repair of CoA, absence of any relevant restenosis (invasive gradient across the site of previous treatment 3±4 mmHg) and resistant arterial hypertension (daytime SBP≥140 mmHg on 24 hour ambulatory blood pressure measurements [ABPM] in spite of the concurrent use of 3 antihypertensive agents of different classes or intolerance to BP medications) were included. Bilateral RSD was performed using the Symplicity Flex™ catheter (Medtronic, MN, USA). RESULTS RSD was successful in all patients with no procedural complications and no evidence for renal artery stenosis 6 months post procedure. From baseline to 6 month follow-up, RSD was followed by a significant reduction in average daytime systolic BP (150.4±7.8 to 143.1±8.0 mmHg; p=0.0117) as well as systolic BP throughout 24 h (146.8±7.3 vs. 140.5±7.8, p=0.04). CONCLUSION The BP reductions observed in these patients justify engaging in a larger clinical trial on the efficacy of RSD in this specific type of secondary hypertension and bares the hope that RSD might extend the currently very limited armory against arterial hypertension in young adults with previous repair of CoA.
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Affiliation(s)
- Philipp Lurz
- Dept. of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany.
| | - Thomas Okon
- Dept. of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Thomas Riede
- Dept. of Paediatric Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Robert Wagner
- Dept. of Paediatric Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Gerhard Schuler
- Dept. of Internal Medicine/Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Ingo Daehnert
- Dept. of Paediatric Cardiology, University of Leipzig-Heart Center, Leipzig, Germany
| | - Steffen Desch
- Medical Clinic II, University Heart Center Luebeck, Luebeck, Germany
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Seo DM, Park J, Goo HW, Kim YH, Ko JK, Jhang WK. Surgical modification for preventing a gothic arch after aortic arch repair without the use of foreign material. Interact Cardiovasc Thorac Surg 2015; 20:504-9. [PMID: 25583648 DOI: 10.1093/icvts/ivu442] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Systemic hypertension is the main late complication after arch reconstruction in patients with arch obstruction. Gothic arch geometry is suspected to be one of its possible causes. Accordingly, we evaluated here if a modified arch repair technique using an autologous pulmonary patch is effective in preventing gothic arch development. METHODS Fifty infants who underwent arch repair with either a modified (n = 17) or conventional (n = 33) technique between January 2006 and August 2012 by a single surgeon were retrospectively reviewed. Arch geometry was compared using three categories (gothic, crenel or roman), classified by the height/width (H/W) ratio and the arch angle measured in computed tomography. RESULTS No gothic arch geometry was observed in the modified group, whereas it was observed in 9 cases in the conventional group (P = 0.005). Moreover, reintervention for arch restenosis was performed only in the conventional group (n = 4; P = 0.29). No associated complications were observed, although the selective cerebral perfusion time was longer in the modified group than in the conventional group (28.5 ± 6.2 vs 17.1 ± 9.9 min; P < 0.001). Otherwise, there were no significant differences in clinical variables between the groups. The mean follow-up duration was 55.3 ± 26.7 months. Significant systemic hypertension was not observed in our study cohort. CONCLUSIONS Our modified technique was proven to be not only highly effective in preventing gothic arch geometry, but also as equally safe in terms of early clinical outcomes as conventional arch reconstruction techniques.
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Affiliation(s)
- Dong-Man Seo
- Department of Cardiothoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jiyoung Park
- Department of Cardiothoracic Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Hyun Woo Goo
- Department of Radiology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea
| | - Young Hwue Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan, College of Medicine, Seoul, Korea
| | - Jae-Kon Ko
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan, College of Medicine, Seoul, Korea
| | - Won Kyoung Jhang
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan, College of Medicine, Seoul, Korea
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8
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Ntsinjana HN, Biglino G, Capelli C, Tann O, Giardini A, Derrick G, Schievano S, Taylor AM. Aortic arch shape is not associated with hypertensive response to exercise in patients with repaired congenital heart diseases. J Cardiovasc Magn Reson 2013; 15:101. [PMID: 24219806 PMCID: PMC3833644 DOI: 10.1186/1532-429x-15-101] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 11/05/2013] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Aortic arch geometry is linked to abnormal blood pressure (BP) response to maximum exercise. This study aims to quantitatively assess whether aortic arch geometry plays a role in blood pressure (BP) response to exercise. METHODS 60 age- and BSA-matched subjects--20 post-aortic coarctation (CoA) repair, 20 transposition of great arteries post arterial switch operation (ASO) and 20 healthy controls--had a three-dimensional (3D), whole heart magnetic resonance angiography (MRA) at 1.5 Tesla, 3D geometric reconstructions created from the MRA. All subjects underwent cardiopulmonary exercise test on the same day as MRA using an ergometer cycle with manual BP measurements. Geometric analysis and their correlation with BP at peak exercise were assessed. RESULTS Arch curvature was similarly acute in both the post-CoA and ASO cases [0.05 ± 0.01 vs. 0.05 ± 0.01 (1/mm/m²); p = 1.0] and significantly different to that of normal healthy controls [0.05 ± 0.01 vs. 0.03 ± 0.01 (1/mm/m²), p < 0.001]. Indexed transverse arch cross sectional area were significantly abnormal in the post-CoA cases compared to the ASO cases (117.8 ± 47.7 vs. 221.3 ± 44.6; p < 0.001) and controls (117.8 ± 47.7 vs. 157.5 ± 27.2 mm²; p = 0.003). BP response to peak exercise did not correlate with arch curvature (r = 0.203, p = 0.120), but showed inverse correlation with indexed minimum cross sectional area of transverse arch and isthmus (r = -0.364, p = 0.004), and ratios of minimum arch area/ descending diameter (r = -0.491, p < 0.001). CONCLUSION Transverse arch and isthmus hypoplasia, rather than acute arch angulation plays a role in the pathophysiology of BP response to peak exercise following CoA repair.
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Affiliation(s)
- Hopewell N Ntsinjana
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Giovanni Biglino
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Claudio Capelli
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Oliver Tann
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Alessandro Giardini
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Graham Derrick
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Silvia Schievano
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
| | - Andrew M Taylor
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Trust, London, UK
- Cardiorespiratory Unit, Level 7, Nurses Home, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK
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Usefulness of cardiopulmonary exercise testing to predict the development of arterial hypertension in adult patients with repaired isolated coarctation of the aorta. Int J Cardiol 2013; 168:2037-41. [DOI: 10.1016/j.ijcard.2013.01.171] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Revised: 12/20/2012] [Accepted: 01/13/2013] [Indexed: 11/22/2022]
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10
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Kenny D, Polson JW, Martin RP, Paton JFR, Wolf AR. Hypertension and coarctation of the aorta: an inevitable consequence of developmental pathophysiology. Hypertens Res 2011; 34:543-7. [PMID: 21412243 DOI: 10.1038/hr.2011.22] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Patients with coarctation of the aorta develop early onset hypertension in spite of early effective repair. This is associated with significant morbidity and is arguably the single most important outcome variable in this patient group. We discuss the potential pathophysiological mechanisms involved in the development of hypertension with clinical reference to monozygotic twins, and review potential strategies for therapy and prevention in this setting.
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Affiliation(s)
- Damien Kenny
- Bristol Congenital Heart Center, Bristol Royal Hospital for Children, Bristol, UK
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Martínez-Quintana E, Rodríguez-González F, Medina-Gil J. Respuesta hipertensiva severa al ejercicio en paciente con coartación de aorta corregida y presión arterial basal normal. HIPERTENSION Y RIESGO VASCULAR 2011. [DOI: 10.1016/j.hipert.2010.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Mid-term results, and therapeutic management, for patients suffering hypertension after surgical repair of aortic coarctation. Cardiol Young 2009; 19:451-5. [PMID: 19674497 DOI: 10.1017/s1047951109990734] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We designed our study to investigate the efficacy of a new therapeutic approach to late onset hypertension in patients after surgical repair of aortic coarctation. Several studies have shown a higher incidence of hypertension during daily activities, and during exercise, in patients after surgical correction of coarctation. To the best of our knowledge, however, no data exists concerning haemodynamics, the response of arterial pressures, and the effects of medications for lowering blood pressure during exercise or during daily activities.We studied 128 patients, aged 15.6 +/- 4.3 years, to determine the response of blood pressure as we administered treatment in the attempt to achieve a normotensive state. We excluded patient with associated cardiac abnormalities, apart from those with bicuspid aortic valves. We evaluated blood pressure at rest in both the right arm and leg to establish presence of any gradient, as well as the blood pressure in the arm during exercise testing, and by 24-hour ambulatory monitoring.Atenolol was prescribed for those with elevated values of blood pressure but with a normal increment of heart rate during exercise. We prescribed Candesartan for those with elevated levels of blood pressure but with reduced increments of heart rate, specifically maximal heart rates of less than 85% of their predicted value. Both drugs were used when one alone was not effective. We found that, in young patients, candesartan provided better control of blood pressure with no side-effects, especially as demonstrated using 24-hour ambulatory monitoring, while atenolol was less effective, with more side-effects. Our experience suggests that both drugs should be used in patients who are non-responsive to monotherapy.
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Senzaki H, Kumakura R, Ishido H, Masutani S, Seki M, Yoshiba S. Left Atrial Systolic Force in Children: Reference Values for Normal Children and Changes in Cardiovascular Disease With Left Ventricular Volume Overload or Pressure Overload. J Am Soc Echocardiogr 2009; 22:939-46. [DOI: 10.1016/j.echo.2009.05.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Indexed: 10/20/2022]
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Senzaki H, Iwamoto Y, Ishido H, Masutani S, Taketazu M, Kobayashi T, Katogi T, Kyo S. Ventricular–Vascular Stiffening in Patients With Repaired Coarctation of Aorta. Circulation 2008; 118:S191-8. [PMID: 18824754 DOI: 10.1161/circulationaha.107.757096] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite successful repair, patients with coarctation of the aorta (COA) often show persistent hypertension at rest and/or during exercise. Previous studies indicated that the hypertension is mainly due to abnormalities in the arterial bed and its regulatory systems. We hypothesized that ventricular systolic stiffness also contributes to the hypertensive state in these patients in addition to increased vascular stiffness.
Methods and Results—
The study involved 43 patients with successfully repaired COA and 45 age-matched control subjects. Ventricular systolic stiffness (end systolic elastance) and arterial stiffness (effective arterial elastance) were measured invasively by ventricular pressure–area relationship during varying preload before and after β-adrenergic stimulation. The mean systolic blood pressure was significantly higher with concomitant increases in both end systolic elastance and effective arterial elastance in patients with COA compared with control subjects (113.2±16.8 versus 91.0±9.1 mm Hg, 44.5±17.0 versus 19.2±6.7 mm Hg/mL/m
2
, and 27.8±11.4 versus 20.2±4.8 mm Hg/mL/m
2
, respectively;
P
<0.01 for each). End systolic elastance and effective arterial elastance of patients with COA showed exaggerated responses to β-adrenergic stimulation, further amplifying blood pressure elevation. Quantification analyses assuming that ventricular systolic stiffness of patients with COA is equal to that of the control revealed that ventricular systolic stiffness accounts for approximately 50% to 70% of the elevated blood pressure in patients with COA. Furthermore, combined ventricular–arterial stiffening amplified systolic pressure sensitivity to increased preload during abdominal compression and limited stroke volume gain/relaxation improvement induced by β-adrenergic stimulation.
Conclusions—
Increased ventricular systolic stiffness, coupled with increased arterial stiffness, plays important roles in hypertension in patients with repaired COA. Thus, ventricular systolic stiffness is a potentially suitable target for reduction of blood pressure and improvement of prognosis of patients with COA.
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Affiliation(s)
- Hideaki Senzaki
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Yoichi Iwamoto
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Hirotaka Ishido
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Satoshi Masutani
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Mio Taketazu
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Toshiki Kobayashi
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Toshiyuki Katogi
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
| | - Shunei Kyo
- From the Department of Pediatric Cardiology and Cardiovascular Surgery, Saitama Medical School Hospital, Saitama, Japan
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Lashley D, Curtin J, Malcolm P, Clark A, Freeman L. Aortic Arch Morphology and Late Systemic Hypertension Following Correction of Coarctation of Aorta. CONGENIT HEART DIS 2007; 2:410-5. [DOI: 10.1111/j.1747-0803.2007.00133.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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De Caro E, Trocchio G, Smeraldi A, Calevo MG, Pongiglione G. Aortic arch geometry and exercise-induced hypertension in aortic coarctation. Am J Cardiol 2007; 99:1284-7. [PMID: 17478158 DOI: 10.1016/j.amjcard.2006.12.049] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Revised: 12/07/2006] [Accepted: 12/07/2006] [Indexed: 11/16/2022]
Abstract
Hypertension at rest or during effort is not uncommon in patients with aortic coarctation (CoA), even those with a successful repair or mild degree of obstruction. Anatomic factors and functional abnormalities have been proposed as causes of this finding. Recently, aortic arch geometry was reported in association with hypertension at rest in patients with successful CoA repair. Forty-one patients (age 15.7 +/- 4.6 years) without significant obstruction at rest (mean systolic Doppler gradient at rest < or =25 mm Hg) were selected for the study. All patients underwent a maximal cardiopulmonary exercise test and magnetic resonance imaging of the aorta. Aortic arch shape was defined on global geometry as normal, gothic, and crenel. Percentage of anatomic narrowing (AN) was also calculated. Twenty-four patients (58%) showed exercise-induced hypertension (EIH). Regarding the shape of the aortic arch, normal geometry was present in 17 patients (41%), 9 (21%) had gothic geometry, and 15 (36%) had crenel geometry. There were no differences among the 3 geometries in regard to the incidence of EIH (70.6% in normal, 55.6% in gothic, and 46.7% in crenel) or AN (36.9% in normal, 33.5% in gothic, and 36.6% in crenel). In conclusion, our results fail to show a correlation between a specific aortic arch shape and the incidence of EIH and significant AN in patients with native or residual CoA or repeat CoA. Therefore, at present, the role of aortic arch geometry in identifying patients at risk of EIH is still uncertain.
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Affiliation(s)
- Enrico De Caro
- Cardiovascular Department, Scientific Directorate, Istituto Giannina Gaslini Children's Hospital, Genoa, Italy
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Polson JW, McCallion N, Waki H, Thorne G, Tooley MA, Paton JFR, Wolf AR. Evidence for Cardiovascular Autonomic Dysfunction in Neonates With Coarctation of the Aorta. Circulation 2006; 113:2844-50. [PMID: 16769911 DOI: 10.1161/circulationaha.105.602748] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background—
Coarctation of the aorta (CoA) is associated with hypertension and abnormalities of blood pressure control, which persist after late repair. Assumptions that neonatal repair would prevent development of blood pressure abnormalities have not been supported by recent data. We hypothesized that early pathological adjustment of autonomic cardiovascular function may already be established in the neonate with coarctation.
Methods and Results—
We studied 8 otherwise well neonates with simple CoA and compared measures of spontaneous baroreflex sensitivity, heart rate variability, and blood pressure variability with 13 healthy newborn babies. Spontaneous baroreflex sensitivity was calculated with sequence methodology from an ECG, and noninvasive blood pressure was recorded with a Portapres. Heart rate variability was determined with time- and frequency-domain measures. Blood pressure variability was measured in the frequency domain. In comparison with normal controls, neonates with CoA had raised blood pressure (78.9±3.8 versus 67.1±2.1 mm Hg), depressed baroreflex sensitivity (8.7±1.5 versus 13.8±1.1 ms/mm Hg), reduced heart rate variability (total power 16.5±3.1 versus 31.5±2.2 ms
2
), and an increase in the high-frequency component of blood pressure variability (3.1±0.3 versus 2.2±0. 2 mm Hg
2
). This is not the pattern expected if neonates with CoA simply had subclinical cardiac failure.
Conclusions—
These data suggest that infants with CoA already show signs of pathological adjustment of autonomic cardiovascular homeostasis. Further longitudinal studies are required to determine whether these alterations play a role in the increased risk of late hypertension in these patients.
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Affiliation(s)
- Jaimie W Polson
- Department of Clinical Sciences at South Bristol, School of Medical Sciences, Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2004). Hypertens Res 2006; 29 Suppl:S1-105. [PMID: 17366911 DOI: 10.1291/hypres.29.s1] [Citation(s) in RCA: 189] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract
This article discusses exercise physiology and its application in the pediatric population. This article discusses exercise physiology and its application in the pediatric population. The authors briefly review the normal physiologic response to exercise. They then discuss populations in which exercise testing is most useful, the indications and contraindications for graded exercise, and the usual parameters that are measured during testing. Finally, the authors review some of the recent data on exercise performance in specific pediatric populations.
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Affiliation(s)
- Paul Stephens
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Abstract
Cardiologists have often described aortic coarctation as "simple" rather than "complex" congenital heart disease; nothing could be further from the truth.
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Johnson D, Perrault H, Vobecky SJ, Trudeau F, Delvin E, Fournier A, Davignon A. Resetting of the cardiopulmonary baroreflex 10 years after surgical repair of coarctation of the aorta. Heart 2001; 85:318-25. [PMID: 11179275 PMCID: PMC1729634 DOI: 10.1136/heart.85.3.318] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To characterise cardiopulmonary baroreflex responses and examine the effects of a 45 minute cycling bout late after successful repair of coarctation of the aorta. SUBJECTS 10 young adults (mean (SEM) age 18.1 (2.6 years)) operated on for coarctation of the aorta 12.7 (3.5) years earlier, and 10 healthy controls. DESIGN Forearm blood flow (venous occlusion plethysmography) and vascular resistance, left ventricular internal diastolic diameter, and central venous pressure estimated from an antecubital vein were measured in the supine position at baseline and during five minute applications of lower body negative pressure (LBNP) at -15 mm Hg (LBNP(-15)) and -40 mm Hg (LBNP(-40)). Venous samples were obtained at baseline and during LBNP(-40) for noradrenaline (norepinephrine), adrenaline (epinephrine), renin activity, and aldosterone. The tests were repeated after 45 minutes of moderate exercise. RESULTS Baseline heart rate (78 (9) v 64 (6) beats/min), echocardiographic cardiac output (6.9 (1.1) v 5.0 (0.2) l/min), shortening fraction (41.7 (1.8)% v 33.3 (1.3)%), and forearm blood flow (3.4 (0.4) v 2.3 (0.3) ml/100 g/min) were higher in the coarctation group than in the controls (p < 0.05). Changes in forearm blood flow and forearm vascular resistance from baseline to LBNP(-40) were similar in both groups, but the relation between forearm vascular resistance and estimated central venous pressure or left ventricular internal diastolic diameter was shifted downward in the coarctation group. Plasma adrenaline was increased in the coarctation group (baseline: 3.2 (0.6) v 2.4 (0.3) pmol/l in controls; LBNP(-40): 687 (151) v 332 (42) pmol/l) (p < 0.05). Both groups showed a similar downward displacement of forearm vascular resistance (p < 0.05) after exercise. CONCLUSIONS There appears to be resetting of the cardiopulmonary baroreflex to a lower forearm vascular resistance in young adults operated on for coarctation of the aorta, associated with hyperdynamic left ventricular function. Raised circulating adrenaline could contribute to the lower forearm vascular resistance.
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Affiliation(s)
- D Johnson
- Cardiology Unit, Ste-Justine Hospital, Montreal, Quebec, Canada
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23
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Hauser M, Kuehn A, Wilson N. Abnormal responses for blood pressure in children and adults with surgically corrected aortic coarctation. Cardiol Young 2000; 10:353-7. [PMID: 10950332 DOI: 10.1017/s1047951100009653] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite successful surgical repair of aortic coarctation, life expectancy is reduced, and up to one-third of patients remain or become hypertensive. So as to characterize the responses for blood pressure, we have studied 55 patients with surgically repaired coarctation. Their mean age was 11.3 +/- 5.97 years. We documented maximal uptake of oxygen, anaerobic threshold, plasma renin activity and blood pressures during a Bruce protocol treadmill test. The velocity across the site of repair as imaged by cross-sectional echocardiography was measured before and after exercise. We measured the changes in heart rate and blood pressure subsequent to an infusion of 1 ug per kg of isoprenalin, monitoring blood pressure over 24 hours in all patients. RESULTS When compared with 40 healthy age-matched controls, the patients with coarctation had a normal exercise capacity. Resting systolic blood pressures above the 95th percentile were present in 45% of the patients. Exercise-induced hypertension, and an elevation in the average systolic 24 hour blood pressures, were observed, but less frequently than elevated baseline values, suggesting that so-called white-coat" hypertension may be present in this population. Abnormal reactions and elevation of plasma renin activity were related to a history of paradoxical hypertension at the time of surgery. Attenuation of the circadian rhythm for blood pressure was a frequent finding, and may have implications in the development of long-term damage to end-organs. A high correlation was found between mean systolic blood pressure measured by 24 hour monitoring and left ventricular hypertrophy (r=0.65, p<0.05). CONCLUSIONS Abnormalities in blood pressure occurred independently of significant mechanical obstruction. Despite successful surgical repair, abnormalities in the shape of the aortic arch, reduced sensitivity of baroreceptor reflexes, and neurohumoral factors may all contribute to the development of hypertension.
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Affiliation(s)
- M Hauser
- Deutsches Herzzentrum, Department of Paediatric Cardiology, Munich, Germany.
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Therrien J, Thorne SA, Wright A, Kilner PJ, Somerville J. Repaired coarctation: a "cost-effective" approach to identify complications in adults. J Am Coll Cardiol 2000; 35:997-1002. [PMID: 10732900 DOI: 10.1016/s0735-1097(99)00653-1] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The study was done to determine the most "cost-effective" approach to follow adults after repair of coarctation of the aorta. BACKGROUND Recoarctation and/or aneurysm formation following surgical repair or angioplasty for coarctation of the aorta carry a significant morbidity and mortality. Various screening tests to detect such complications are used, but little is known of their sensitivities and specificities; as a consequence, the most "cost-effective" approach to follow such patients is undefined. METHODS Retrospective analysis was done on the sensitivity and specificity of symptomatology, physical examination, electrocardiogram, chest radiograph, exercise testing and transthoracic echocardiography to detect recoarctation and/or aneurysm formation in 84 adult patients following surgical repair or angioplasty of coarctation of the aorta, using magnetic resonance imaging (MRI) as the gold standard test. RESULTS Echocardiography had the highest sensitivity in detecting recoarctation (87%) and chest radiograph the highest sensitivity in detecting aneurysm formation (67%). Combined clinical visit and echocardiography had a high sensitivity for diagnosing recoarctation and/or aneurysm formation (97%), but performing a clinical visit and an MRI on every patient without any prior screening test emerged as the most "cost-effective" strategy. CONCLUSIONS The most "cost-effective" approach to diagnose complications at the site of repair in patients after surgical repair or balloon angioplasty of coarctation of the aorta appears to be the combination of clinical assessment and MRI scan on every patient. If MRI resources are scant, performing a clinical assessment plus a transthoracic echocardiography and an MRI on patients with positive results is an acceptable alternative.
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Affiliation(s)
- J Therrien
- Jane Somerville Grown Up Congenital Heart Unit, Royal Brompton and Harefield NHS Trust, National Heart and Lung Institute, Imperial College School of Medicine, London, United Kingdom.
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26
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Tantengco MV, Ross RD, Humes RA, Sullivan NM, Joshi VM, Clapp SK, Epstein ML. Enhanced resting left ventricular filling in patients with successful coarctation repair and exercise-induced hypertension. Am Heart J 1997; 134:1082-8. [PMID: 9424069 DOI: 10.1016/s0002-8703(97)70029-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
M-mode and Doppler echocardiographic analyses of left ventricular (LV) shortening and filling were performed in 50 patients who underwent coarctectomy (median follow-up 9.5 years) and in 16 athletes in a control group before an exercise stress test with upright bicycle ergometry was performed. Thirty-two of 50 patients and 18 of 50 patients had a normotensive and hypertensive response to exercise, respectively. Preexercise echocardiographic data were compared among the control, normotensive, and hypertensive patient groups. LV peak filling rates (dD/dt, diastole) were increased in the hypertensive group (18.3 +/- 3.5) compared with those in the normotensive group (14.4 +/- 3.2; p < 0.001) and the control group (13.6 +/- 2.8; p < 0.001). LV shortening was enhanced in the coarctectomy group compared with that in the control group. A higher aortic isthmus Doppler gradient at peak exercise was not found in the hypertensive group compared with that in the normotensive group. Therefore patients with successful coarctectomy in childhood have enhanced LV shortening and relaxation at rest. Demonstration of enhanced LV peak filling rates may help identify patients at risk for exercise-induced hypertension.
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Affiliation(s)
- M V Tantengco
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit 48201, USA
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27
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Johnson D, Bonnin P, Perrault H, Marchand T, Vobecky SJ, Fournier A, Davignon A. Peripheral blood flow responses to exercise after successful correction of coarctation of the aorta. J Am Coll Cardiol 1995; 26:1719-24. [PMID: 7594109 DOI: 10.1016/0735-1097(95)00382-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The purpose of this study was to characterize peripheral flow kinetics in response to progressive discontinuous maximal exercise in 10 patients who underwent repair of coarctation of the aorta and 11 age-matched healthy adolescents. BACKGROUND An impairment of leg blood flow has been suggested on the basis of exaggerated femoral muscle lactate accumulation in patients with successful repair of coarctation. Few data are available describing blood flow kinetics of the exercising leg in such patients. METHODS Duplex ultrasound provided transcutaneous measurements of peak systolic and end-diastolic flow velocities of the femoral, humeral and renal arteries at rest and immediately after mild, moderate and maximal exercise intensities for computation of mean velocity, resistance index and femoral blood flow. RESULTS Femoral mean velocity and femoral blood flow increased linearly with exercise intensity in both groups, but the slope of this increase was significantly lower in patients. Similarly, humeral mean velocity increased significantly less in patients than in control subjects. Femoral resistance index sharply decreased from that at rest (patients [mean +/- SE] 1.4 +/- 0.04; control subjects 1.4 +/- 0.03) to mild exercise intensity in both groups (patients 0.69 +/- 0.03; control subjects 0.72 +/- 0.03). A further decrease was observed at maximal exercise in patients (0.60 +/- 0.04, p = 0.08) but not in control subjects (0.69 +/- 0.02). CONCLUSIONS These observations suggest that despite a greater exercise-induced femoral vasodilation, patients with successful correction of coarctation of the aorta demonstrate an impaired lower limb blood flow in response to strenuous dynamic exercise. In the absence of stenosis at rest, this alteration could result from exaggerated flow turbulence in the descending aorta distal to the site of correction because of loss of elasticity at the site of the resection of the coarcted segment.
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Affiliation(s)
- D Johnson
- Cardiology and Cardio-Thoracic Surgery Units, Sainte-Justine Hospital, Montreal, Quebec, Canada
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Schräder R, Bussmann WD, Jacobi V, Kadel C. Long-term effects of balloon coarctation angioplasty on arterial blood pressure in adolescent and adult patients. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1995; 36:220-5. [PMID: 8542628 DOI: 10.1002/ccd.1810360306] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In patients with coarctation of the aorta arterial hypertension frequently persists when surgical repair is performed after age 20 years. There are little data on the long-term effect of angioplasty and the question remains to be determined whether hypertension is sufficiently treated by this procedure. Twenty-nine consecutive patients (9 females and 20 males) 14 to 54 years old (median, 25) underwent angioplasty for native coarctation of the aorta. Twenty-five patients (86%) had pre-existing systolic arterial hypertension (> 140 mm Hg). The mean peak systolic pressure gradient decreased from 62 +/- 18 to 21 +/- 13 mm Hg immediately after angioplasty. At hospital discharge 13 patients still had hypertension. After a mean follow-up interval of 4.0 years (range, 0.3-9.5) the residual peak pressure gradient was 14 +/- 13 mm Hg. Blood pressure was normal without antihypertensive therapy in 23 patients (79%). In the six hypertensive patients the pressure gradients were 7, 13, 30, 30, 35, and 60 mm Hg. One patient died 8 months after angioplasty and another underwent surgery for aortic aneurysm. Although this was an uncontrolled study the data suggest that normalization of blood pressure may occur more frequently after angioplasty than after surgery in adolescents and adults with native coarctation.
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Affiliation(s)
- R Schräder
- Red Cross Hospital and Heart Center, Division of Cardiology, University Hospital, Johann-Wolfgang-Goethe University, Frankfurt am Main, Germany
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29
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Ross RD, Clapp SK, Gunther S, Paridon SM, Humes RA, Farooki ZQ, Pinsky WW. Increased atrial natriuretic factor response to exercise after coarctation repair. Am J Cardiol 1992; 69:1370-2. [PMID: 1533990 DOI: 10.1016/0002-9149(92)91241-u] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- R D Ross
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University School of Medicine, Detroit 48201
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