Surgical Approach for Aortic Coarctation Influences Arterial Compliance and Blood Pressure Control

Antihypertensive therapy of late arterial hypertension in children following successful coarctation correction

BACKGROUNG

Late arterial hypertension (AH) is the most significant complication of coarctation of the aorta (CoA). Only a few clinical studies described antihypertensive treatment of late AH following successful CoA repair. The primary objective of this multicentre cross-sectional study was to describe real-life antihypertensive therapy for late AH in children after hemodynamically successful CoA repair. The secondary objective was to describe antihypertensive therapy used within different haemodynamic phenotypes of AH.

METHOD

Blood pressure status, echocardiographic parameters and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful CoA repair with right arm blood pressure not exceeding leg blood pressure by at least 20 mmHg.

RESULTS

AH was found in 62 (56%) patients including 47 who were already treated and 15 with new diagnosed AH of whom seven presented with masked hypertension. Among treated patients, 10 presented with masked hypertension. The dominant phenotype of AH among patients with uncontrolled AH was isolated systolic hypertension (32 patients out of 37; 87.5%). AH was controlled in 53% of treated patients. Fifty-three percent of hypertensive patients had elevated central SBP and 39% had left ventricular hypertrophy with various left ventricle geometry patterns, 23% of them had both. β-adrenergic receptor blockers were the most used antihypertensive drugs followed by angiotensin-converting enzyme inhibitors with doses within the lower recommended range.

CONCLUSION

High prevalence of uncontrolled AH despite successful CoA repair and use of relatively low doses of antihypertensive drugs indicates the need of close blood pressure monitoring and more intensive and combined antihypertensive therapy.

Multi-centre cross-sectional study on vascular remodelling in children following successful coarctation correction

Coarctation of the aorta is an arteriopathy with life-long sequelae, with remarkably increased cardiovascular events in young adults even after successful repair and despite blood pressure status. There are data on arterial remodelling in adults after coarctation correction, however, these data are scarce in childhood. Thus, the aim of this cross-sectional study was to evaluate changes in arterial wall function and morphology in children following successful coarctation repair and to compare these changes among patients with different blood pressure status and coarctation correction modes. Blood pressure status, echocardiographic parameters, arterial wall structure and stiffness, endothelial function and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful coarctation repair with right arm blood pressure not exceeding leg blood pressure by ≥20 mmHg. The prevalence of arterial hypertension was 50%. The mean carotid intima-media thickness SDS was 3.1 ± 1.5 and above 1.65 SDS in 91 of 110 patients. Increased right carotid intima-media thickness was associated with left ventricular hypertrophy, office blood pressure difference between leg and right arm, recoarctation in the past and interventional coarctation correction. Increased local common carotid artery stiffness was associated with increased pulse pressure and central systolic blood pressure. Potentially decreased endothelial function was related to a slight increase of peak and mean systolic gradient in the descending aorta. After successful coarctation repair and with a low blood pressure gradient, children still have a high prevalence of arterial hypertension and significant arterial remodelling, indicating accelerated biological age and advanced arteriosclerosis.

Repaired coarctation of the aorta, persistent arterial hypertension and the selfish brain

BACKGROUND

It has been estimated that 20-30% of repaired aortic coarctation (CoA) patients develop hypertension, with significant cardiovascular morbidity and mortality. Vertebral artery hypoplasia (VAH) with an incomplete posterior circle of Willis (ipCoW; VAH + ipCoW) is associated with increased cerebrovascular resistance before the onset of increased sympathetic nerve activity in borderline hypertensive humans, suggesting brainstem hypoperfusion may evoke hypertension to maintain cerebral blood flow: the "selfish brain" hypothesis. We now assess the "selfish brain" in hypertension post-CoA repair.

METHODS

Time-of-flight cardiovascular magnetic resonance angiography from 127 repaired CoA patients (34 ± 14 years, 61% male, systolic blood pressure (SBP) 138 ± 19 mmHg, diastolic blood pressure (DBP) 76 ± 11 mmHg) was compared with 33 normotensive controls (42 ± 14 years, 48% male, SBP 124 ± 10 mmHg, DBP 76 ± 8 mmHg). VAH was defined as < 2 mm and ipCoW as hypoplasia of one or both posterior communicating arteries.

RESULTS

VAH + ipCoW was more prevalent in repaired CoA than controls (odds ratio: 5.8 [1.6-20.8], p = 0.007), after controlling for age, sex and body mass index (BMI). VAH + ipCoW was an independent predictor of hypertension (odds ratio: 2.5 [1.2-5.2], p = 0.017), after controlling for age, gender and BMI. Repaired CoA subjects with VAH + ipCoW were more likely to have difficult to treat hypertension (odds ratio: 3.3 [1.01-10.7], p = 0.049). Neither age at time of CoA repair nor any specific repair type were significant predictors of VAH + ipCoW in univariate regression analysis.

CONCLUSIONS

VAH + ipCoW predicts arterial hypertension and difficult to treat hypertension in repaired CoA. It is unrelated to age at time of repair or repair type. CoA appears to be a marker of wider congenital cerebrovascular problems. Understanding the "selfish brain" in post-CoA repair may help guide management.

JOURNAL SUBJECT CODES

High Blood Pressure; Hypertension; Magnetic Resonance Imaging (MRI); Cardiovascular Surgery; Cerebrovascular Malformations.

Impact of Treatment Modality on Vascular Function in Coarctation of the Aorta: The LOVE - COARCT Study

Background Optimally treated patients with coarctation of the aorta remain at risk for late vascular dysfunction. The effect of treatment modality on vascular function is unknown. The LOVE-COARCT (Long-term Outcomes and Vascular Evaluation After Successful Coarctation of the Aorta Treatment) study was done to compare vascular function in patients with coarctation of the aorta treated with surgery, balloon dilation (BD), or stent implantation. Methods and Results In treated coarctation of the aorta patients without residual coarctation, we prospectively compared aortic stiffness by applanation tonometry and cardiac magnetic resonance; endothelial function by endothelial pulse amplitude testing; blood pressure ( BP ) phenotype by office BP , ambulatory BP monitoring, and BP response to exercise; left ventricular mass by cardiac magnetic resonance; and blood biomarkers of endothelial function, inflammation, vascular wall function, and extracellular matrix. Participants included 75 patients treated with surgery (n=28), BD (n=23), or stent (n=24). Groups had similar age at enrollment, coarctation of the aorta severity, residual gradient, and metabolic profile, but differed by age at treatment. Prevalence of systemic hypertension, aortic stiffness, endothelial function, and left ventricular mass were similar among treatment groups. However, BD patients had more-distensible ascending aortas, lower peak systolic BP during exercise, less impairment in diurnal BP variation, and lower inflammatory biomarkers. Results were unchanged after adjustment for potential confounders, including age at treatment. Conclusions In our cohort of patients without residual coarctation, treatment modality was not associated with major vascular outcomes, even though there were some favorable vascular characteristics in the BD patients. Although this suggests that choice of treatment modality should continue to be driven by likelihood of achieving a good anatomical result, more long-term studies are required to assess the clinical significance of the more-optimal results of secondary markers of vascular function in BD patients. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 03262753.

A review of the clinical anatomy of hypertension

Hypertension is defined as the persistent elevation of blood pressure above normal limits. It can be classified according to whether the contributing factors are genetics and environmental (primary hypertension) or underlying medical conditions and medications (secondary hypertension). The goal of this review is to increase recognition of the various anatomical etiologies of hypertension. Clin. Anat. 32:678-681, 2019. © 2019 Wiley Periodicals, Inc.

[Fatal renal and neurological complications after aortic arch repair in newborns]

AIM

To evaluate effectiveness and safety of various methods of cerebral and visceral protection during aortic arch surgery in infants.

MATERIAL AND METHODS

Retrospective analysis included 60 patients after aortic arch repair followed by different cerebral protection technique who have been assessed for neurological status and visceral injury in early and long-term postoperative period. Aortic arch surgery with deep hypothermic circulatory arrest for congenital diseases was performed in 26 patients (group 1) and antegrade unilateral selective cerebral perfusion in 34 patients (group 2).

RESULTS

Cerebral complications occurred in 28.5% of patients of the 1^st group and in 7.9% of patients of the 2^nd group.

CONCLUSION

Odds ratio for neurological event is significantly lower in group 2: 0.17 (0.06-0.69; p=0.02). However, there were more patients with renal dysfunction in this group compared with group 1: 58.7% vs. 23.7% (p=0.02).

Hypertension in Coarctation of the Aorta: Challenges in Diagnosis in Children

Evidence indicates that patients with coarctation of the aorta (COA) suffer from increased cardiovascular morbidity and mortality in later life despite successful repair of COA in childhood. Systolic arterial hypertension is common, presenting in up to one-third of patients, and is regarded as the main driver of premature cardiovascular events in this group of patients. In this review, we discuss the prevalence and pathophysiology of hypertension in children following successful COA repair with no residual arch obstruction. The challenges in accurate blood pressure assessment at this early phase are considered and non-invasive measures of central blood pressure are discussed. Although the pathways for investigations in adults are well defined, we highlight the need to address the issues of cardiovascular surveillance in children and describe techniques which can provide complementary information for cardiovascular assessment in this group of patients such that timely treatment can occur.

Noninvasive Assessment of Vascular Function in Postoperative Cardiovascular Disease (Coarctation of the Aorta, Tetralogy of Fallot, and Transposition of the Great Arteries)

Using noninvasive techniques, we sought to assess arterial stiffness, impedance, hydraulic power, and efficiency in children with postoperative tetralogy of Fallot (TOF), coarctation of the aorta (COA), and transposition of the great arteries (TGAs). Results were compared with those of healthy peers. Fifty-five children with repaired congenital heart disease (24 TOFs, 20 COAs, and 11 TGAs) were compared with 55 age-matched control subjects (CTRL). Echocardiographic Doppler imaging and carotid artery applanation tonometry were preformed to measure aortic flow, dimensions, and calculate pulse wave velocity, vascular impedance and arterial stiffness indexes, hydraulic power (mean and total), and hydraulic efficiency (HE) which were calculated using standard fluid dynamics equations. All congenital heart disease subgroups had higher pulse wave velocity than CTRL. Only the COA group had higher characteristic impedance. Mean power was higher in TGA than in CTRL and TOF, and total power was higher in TGA than in CTRL and TOF. Hydraulic efficiency was higher in TOF than in COA and TGA. In conclusion, children with TOF, COA, and TGA have stiffer aortas than CTRL. These changes may be related to intrinsic aortic abnormalities, altered integrity of the aorta due to surgical repair, and/or acquired postsurgery. These patients may be at increased long-term cardiovascular risk, and long-term follow-up is important for monitoring and assessment of efforts to reduce risk.

Renal sympathetic denervation in uncontrolled arterial hypertension after successful repair for aortic coarctation

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.

Coarctation of the Aorta: Strategies for Improving Outcomes

Coarctation of the aorta is a common congenital heart defect through which management has rapidly evolved over the last few decades. The role of transcatheter-based therapies is expanding and seems to be an effective treatment option for coarctation, especially in adults. Patients with prior coarctation repair are at risk of long-term complications related to prior surgeries and associated congenital heart defects, in particular, the risk of restenosis and aortic aneurysm development related to the timing and mode of prior intervention. This article outlines the evaluation and management of adults with unrepaired coarctation and patients after coarctation repair.

Surgical modification for preventing a gothic arch after aortic arch repair without the use of foreign material

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.

Aortic coarctation repair in neonates with intracardiac defects: the importance of preservation of the lesser curvature of the aortic arch

BACKGROUND AND AIM

The aim of this study was to evaluate the mid-term outcomes of a strategy for repair of coarctation of the aorta (CoA) and hypoplastic aortic arch (HAA) with a modified, extended end-to-end repair that preserves the lesser curvature of the aortic arch in neonates with intracardiac defects.

METHODS

We studied 21 neonates who underwent CoA repair and remote intracardiac repair (2000-2013). Fifteen patients had HAA, and six patients had no HAA. Follow-up ranged from 0.4 to 12.8 years (median, 7.5 years), and all patients underwent cardiac catheterization and blood pressure measurement in both the arms and legs.

RESULTS

The overall median age at the time of CoA repair was seven days and the median age at the time of intracardiac defect repair was 18.6 months. There were no hospital deaths and one case had recoarctation (4.8%). The overall mean pressure gradient at the latest follow-up was 3.4 ± 5.7 mmHg. Critical deformation of arch geometry was not found. No patient had hypertension or an abnormal arm-leg gradient. There was no difference in the cardiac catheterization data or blood pressure between patients with and without HAA.

CONCLUSIONS

A modified, extended end-to-end repair for CoA and HAA resulted in a low rate of recoarctation, no operative mortality, maintenance of a smooth rounded arch, and normal blood pressures in the arms and legs during mid-term follow-up. These results suggest that this technique may be acceptable for repair of CoA and HAA in neonates with intracardiac defects.

Systemic blood pressure after stent management for arch coarctation implications for clinical care

OBJECTIVES

The goal of this study was to prospectively assess blood pressure (BP) and echocardiographic parameters to delineate the incidence and nature of the hypertension burden in this cohort.

BACKGROUND

Few data are available on the long-term outcomes of aortic stenting.

METHODS

Thirty-one patients with successfully stented coarctation during childhood (mean age 12.4 years) underwent 24-h ambulatory BP monitoring (ABPM), exercise BP measurement, and echocardiographic assessment.

RESULTS

Mean time after stent implantation was 5.3 ± 4 years. Hypertension was noted on one-off right-arm BP assessment in 3 patients (10%), but on the basis of the 24-h ABPM assessment in 14 patients (45%). Twenty-four of 31 patients (80%) had an abnormally elevated exercise BP response. Peak exercise BP correlated with left ventricular mass index (r = 0.51; p < 0.05), which was also significantly increased in the entire cohort (mean = 91.3 g/m(2); p < 0.05). In patients with significant somatic growth since implantation, the indexed diameter of the stent (to aortic diameter) had significantly decreased from the 48th percentile at the implantation to the 4th percentile during the study (p < 0.05). There was no difference in any parameter between patients with native or those with recurrent coarctation.

CONCLUSIONS

Hypertension is endemic in patients with stented coarctation, irrespective of the absence of residual obstruction. Due to abnormal BP homeostasis, hypertension should be aggressively pursued by ABPM assessment and exercise stress testing in this population. Relative hypoplasia of the stented arch after somatic growth may contribute to this tendency and should provoke consideration of elective serial redilation of coarctation stents.

Hypertension after repair of aortic coarctation--a systematic review

Hypertension continues to be a common and potentially serious problem in patients who have undergone anatomically successful repair of aortic coarctation.

OBJECTIVE

To assess the prevalence of hypertension after aortic coarctation repair, the factors that affect the prevalence and the hypotheses behind hypertension in this cohort of patients.

DESIGN

A systematic review of all articles reporting on systolic blood pressure (SBP) in patients who have undergone aortic coarctation repair.

DATA SOURCES

An electronic search of all English articles using PUBMED and The Cochrane Controlled Trials Register was performed. A manual search of references lists of relevant studies and a search of conference abstracts were also conducted.

INCLUSION CRITERIA

We restricted inclusion to articles published between 1987 and 2012 that reported on SBP in patients who have undergone aortic coarctation repair.

DATA EXTRACTION

Independent extraction of articles was performed by two authors using predefined data fields. One author then proceeded to extract information of interest from these articles.

RESULTS

The first search yielded 12,914 articles. After screening titles, abstracts and full text articles 26 articles were included in this review article. In papers reporting the prevalence of hypertension late after anatomically satisfactory coarctation repair, the median prevalence was 32.5% (range 25-68%).

CONCLUSION

Hypertension remains a common complication following aortic coarctation repair. Factors that influence the reported prevalence of hypertension include the age at the time of surgery, age at follow up, the method used to measure blood pressure and the type of intervention performed.

Pulse wave velocity and the non-invasive methods used to assess it: Complior, SphygmoCor, Arteriograph and Vicorder

Pulse wave velocity (PWV) is a known indicator of arterial stiffness and cardiovascular risk. We critically evaluated the evidence supporting the four main non-invasive devices available to assess it: Complior, SphygmoCor, Arteriograph and Vicorder. PubMed and Medline databases (1960-2011) were searched to identify studies reporting carotid-femoral PWV in humans using one or more of the four devices. Of the 183 articles retrieved, 43 met inclusion criteria. The Arteriograph device demonstrated least variance but had poor agreement with the other devices. Undisputable reference values for PWV need to be established and internationally agreed, and a standardized method for superficial distance measurement generated to reduce variability. Further studies comparing all four devices with invasive assessment are necessary.

Relationship of aortic pulse wave velocity and baroreceptor reflex sensitivity to blood pressure control in patients with repaired coarctation of the aorta

BACKGROUND

Increased aortic stiffness and reduced baroreceptor reflex sensitivity have been described independently after coarctation of the aorta (CoA) repair. This study sought to determine the relationship between these variables and blood pressure control in adolescents after early CoA repair.

METHODS

Spontaneous baroreceptor reflex sensitivity (sBRS) and aortic pulse wave velocity (PWV) were measured in 29 adolescents after CoA repair and compared with 20 age-matched controls. Patients treated for hypertension or having residual aortic narrowing were excluded. Ambulatory blood pressure (ABP), heart rate variability, and cardiac output were also recorded. After ABP measurement, CoA subjects were classified as normotensive or hypertensive.

RESULTS

Nine patients (31%) were hypertensive according to standard definitions, and this subgroup had higher aortic PWV than the normotensive subgroup (P = .004). There was a significant positive correlation between ABP and PWV seen in the whole CoA group (r(2) = 0.5, P < .01). The normotensive subgroup had increased sBRS compared with controls (P = .02). This difference was not seen between the hypertensive subgroup and controls. There was a significant inverse relationship between sBRS and aortic PWV in the whole CoA group (r(2) = 0.25, P = .01). The normotensive subgroup had a significant reduction in stroke index compared with controls (P = .02), which was not seen in the hypertensive subgroup (P = .96).

CONCLUSIONS

Adolescents with hypertension after CoA repair have increased aortic PWV and a relative reduction in sBRS compared with normotensive CoA patients. Thus, failure of the baroreceptor reflex to compensate for increasing arterial stiffness may herald the onset of hypertension in these patients.

Underrecognition of elevated blood pressure readings in children after early repair of coarctation of the aorta

Hypertension after repair of coarctation of the aorta (CoA) is the outcome variable most closely associated with adverse long-term events such as stroke and myocardial infarction. This study sought to evaluate the outpatient management of casual blood pressure (BP) measurements in young children after early repair of CoA. A retrospective analysis was performed of clinical findings, echocardiographic data, casual BP recordings, and subsequent BP management of 114 children with CoA repair aged 1-13 years during 338 outpatient visits managed at two congenital cardiac centers. Children with associated significant congenital heart disease or corrective surgery after the age of 6 months were excluded from the study. Blood pressure was documented at 233 clinic visits (69%), and systolic BP (SBP) was above 95th percentile for age and sex in 45 instances (19%). This represented an elevated SBP recording for 31 children (27%), with two or more successive elevated recordings for 11 children (10%). Of 12 subjects receiving antihypertensive medication, three had inadequate BP control. Blood pressure is not documented at approximately 30% of outpatient visits of children with repaired CoA. When elevated BP is documented, in all cases no recorded action was taken. This may have significant implications for cardiovascular outcomes in this cohort of patients.