Repair of coarctation of the aorta and hypertension: does age matter?

Descending thoracic aortic dissection after covered stent for adult aortic coarctation: Technical or physiopathologic?

Covered stent graft implantation is currently the most commonly used modality for the management of adult aortic coarctation. Although the risk of descending thoracic aortic dissection after covered stent graft implantation is low, sometimes it may cause serious medical consequences or even death. We report one adult aortic coarctation patient with early postoperative descending thoracic aortic dissection after covered stent graft implantation. The patient underwent second operation of thoracic endovascular aortic reconstruction and was discharged 6 days after the operation. This case is not rare, but we hope that the complete diagnosis and treatment process of this case and discussion pertaining to surgical treatment method and its complications could serve as a reference for clinicians in dealing with such situations.

The Real Need for Regenerative Medicine in the Future of Congenital Heart Disease Treatment

Bioabsorbable materials made from polymeric compounds have been used in many fields of regenerative medicine to promote tissue regeneration. These materials replace autologous tissue and, due to their growth potential, make excellent substitutes for cardiovascular applications in the treatment of congenital heart disease. However, there remains a sizable gap between their theoretical advantages and actual clinical application within pediatric cardiovascular surgery. This review will focus on four areas of regenerative medicine in which bioabsorbable materials have the potential to alleviate the burden where current treatment options have been unable to within the field of pediatric cardiovascular surgery. These four areas include tissue-engineered pulmonary valves, tissue-engineered patches, regenerative medicine options for treatment of pulmonary vein stenosis and tissue-engineered vascular grafts. We will discuss the research and development of biocompatible materials reported to date, the evaluation of materials in vitro, and the results of studies that have progressed to clinical trials.

Management of adults with coarctation of aorta

Coarctation of the aorta (CoA) is a relatively common congenital cardiac defect often causing few symptoms and therefore can be challenging to diagnose. The hallmark finding on physical examination is upper extremity hypertension, and for this reason, CoA should be considered in any young hypertensive patient, justifying measurement of lower extremity blood pressure at least once in these individuals. The presence of a significant pressure gradient between the arms and legs is highly suggestive of the diagnosis. Early diagnosis and treatment are important as long-term data consistently demonstrate that patients with CoA have a reduced life expectancy and increased risk of cardiovascular complications. Surgical repair has traditionally been the mainstay of therapy for correction, although advances in endovascular technology with covered stents or stent grafts permit nonsurgical approaches for the management of older children and adults with native CoA and complications. Persistent hypertension and vascular dysfunction can lead to an increased risk of coronary disease, which, remains the greatest cause of long-term mortality. Thus, blood pressure control and periodic reassessment with transthoracic echocardiography and three-dimensional imaging (computed tomography or cardiac magnetic resonance) for should be performed regularly as cardiovascular complications may occur decades after the intervention.

Muscle-sparing aortic coarctation repair

Objective

Surgery for aortic coarctation repair provides excellent hemodynamic results but may be complicated by musculoskeletal issues. The purpose of the study was to determine the midterm results of a muscle-sparing surgical approach to aortic coarctation repair, with special emphasis on the repair and on the musculoskeletal changes associated with a posterior thoracotomy.

Methods

We included all children with aortic coarctation operated on with our minimally invasive approach between June 2002 and October 2004, with a follow-up of ≥4.5 years. Patients were assessed clinically and echocardiographically. The spine, left chest, and shoulder were assessed clinically and radiographically.

Results

Thirty-one children were included. The age at operation ranged from 1 day to 15 months and weight ranged from 980 g to 10 kg. All patients underwent an extended end-to-end anastomosis coarctation repair through a minimal (n = 19) or total-muscle sparing (n = 12) or extrapleural (n = 18) approach. Five patients had an additional enlargement procedure on the aortic arch. 27 patients had no residual or recurrent gradient. Four patients exhibited restenosis, for which 1 underwent a percutaneous angioplasty and 2 underwent surgical reintervention. All patients were free of hypertension. One patient had borderline values. The musculoskeletal assessment was normal in all but 3 patients. Two patients who underwent other subsequent thoracic surgeries developed thoracogenic scoliosis of moderate severity. A third patient had a left winged scapula. No rib fusion or intercostal space enlargement was found.

Conclusions

Compared with a conventional approach, our minimally invasive surgical approach led to excellent musculoskeletal outcomes without compromising the hemodynamic results.

Safety and efficacy of stenting for aortic arch hypoplasia in patients with coarctation of the aorta

Background

Despite a successful repair procedure for coarctation of the aorta (CoA), up to two-thirds of patients remain hypertensive. CoA is often seen in combination with abnormal aortic arch anatomy and morphology. This might be a substrate for persistent hypertension. Therefore, we performed endovascular aortic arch stent placement in patients with CoA and concomitant aortic arch hypoplasia or gothic arch morphology. The goal of this retrospective analysis was to investigate the safety and efficacy of aortic arch stenting.

Methods

A retrospective analysis was performed in patients who underwent stenting of the aortic arch at the University Medical Center Utrecht. Measurements collected included office blood pressure, use of antihypertensive medication, invasive peak-to-peak systolic pressure over the arch, and aortic diameters on three-dimensional angiography. Data on follow-up were obtained at the date of most recent outpatient visit.

Results

Twelve patients underwent stenting of the aortic arch. Mean follow-up duration was 14 ± 11 months. Mean peak-to-peak gradient across the arch decreased from 39 ± 13 mm Hg to 7 ± 8 mm Hg directly after stenting (p < 0.001). There were no major procedural complications. Mean systolic blood pressure decreased from 145 ± 16 mm Hg at baseline to 128 ± 9 mm Hg at latest follow-up (p = 0.014).

Conclusion

This retrospective study shows that stenting of the aortic arch is successful when carried out in a state-of-the-art manner. A direct optimal angiographic and haemodynamic result was shown. No major complications occurred during or after the procedure. At short- to medium-term follow-up a decrease in mean systolic blood pressure was observed.

Figure of 3-sign: a case report

Background

Case summary

Discussion

The effect of including increased arterial stiffness in the upper body when modelling Coarctation of the Aorta

Coarctation of the Aorta is a congenital narrowing of the aorta and diagnosis can be difficult. Treatments result in idiopathic sequelae including hypertension. Untreated patients are known to develop increased arterial stiffness in the upper body, which worsens with time. We present results from simulations with a one-dimensional mathematical model, about the effect of stiffness, stenting, surgery and coarctation severity on blood pressure, Pulsatility and Resistivity Index. One conclusion is that increased stiffness may explain both hypertension in treated patients and why diagnosis can be difficult.

Enhanced Aortic Pressure Wave Reflection in Patients with Aortic Coarctation after Aortic Arch Repair

Background

In patients with aortic coarctation after successful aortic arch repair, it is well known that early-onset cardiovascular diseases can develop.

Summary

We studied the pressure waveform in patients after aortic arch repair focusing on a pressure wave reflection. In patients after aortic arch repair, the repaired portion generates a new reflected pressure wave. As a result, the newly generated pressure wave causes aortic pressure augmentation, loss of pressure amplification, and left ventricular hypertrophy with fibrosis. Balloon dilatation of the aortic arch may also generate a new pressure wave reflection.

Key Messages

In patients with aortic coarctation after aortic arch repair, the reconstructed site generates a new pressure wave reflection. This could be one of the causes of their future cardiovascular diseases.

Effect of stent implantation on blood pressure control in adults with coarctation of the aorta

BACKGROUND

Stenting of coarctation of the aorta (CoA) generally results in good angiographic results and a decrease in transcoarctation pressure gradient. However, effect on blood pressure control is less clear. The goal of the current retrospective analysis was to investigate the effects of CoA stenting on blood pressure control.

METHODS

A retrospective analysis was conducted in consecutive adult patients with a CoA who underwent a percutaneous intervention at one of the three participating hospitals. Measurements included office blood pressure, invasive peak-to-peak systolic pressure over the CoA, diameter of the intima lumen at the narrowest part of the CoA and use of medication. The follow-up data were obtained, based on the most recent examination date.

RESULTS

There were 26 native CoA and 17 recurrent CoAs (total n = 43). Seven of them underwent two procedures. Mean peak-to-peak gradient decreased from 27 mmHg to 3 mmHg (p < 0.001), and minimal diameter increased from a mean of 11 mm to 18 mm (p < 0.001). Mean systolic blood pressure decreased from 151 ± 18 mmHg to 135 ± 19 mmHg at first follow-up of 3.8 ± 1.9 months and 137 ± 22 mmHg at latest follow-up of 19.5 ± 10.9 months (p = 0.001 and p = 0.009, compared to baseline, respectively). The total number of hypertensive patients decreased from 74% to 27% at latest follow-up. No significant change in antihypertensive medication was observed.

CONCLUSION

A clinically significant decrease in systolic blood pressure of approximately 16 mmHg was shown after (re)intervention in CoA patients, which sustained at follow-up. This sustained decrease of blood pressure can be expected to lead to less future adverse cardiovascular events.

Low Peak dP/dt in the Descending Aorta in Patients After Successful Aortic Arch Repair

One of the most important problems in patients with aortic coarctation or interruption of the aortic arch after successful aortic arch repair is developing cardiovascular disease in the future. It has been reported that the repaired site is stiff and generates a new pressure wave reflection, which could lead to cardiovascular disease. The purpose of this study was to clarify the influence of the repaired portion's stiffness on the pressure waveform in patients. Fifteen patients (age: 7.4 ± 3.2 years) who had successful aortic arch repair were enrolled. Their peak dP/dt in the ascending aorta (AAo) and the descending aorta (DAo) were compared with those of age-matched controls with a normal aortic arch. The ascending and descending aortic systolic blood pressures in aortic arch repair patients were higher than those in age-matched controls (AAo: 103.1 ± 13.3 vs. 91.9 ± 9.2 mmHg, p = 0.012 and DAo: 108.7 ± 16.4 vs. 96.5 ± 9.9 mmHg, p = 0.020). Although no difference existed in the peak dP/dt in the AAo between the aortic arch repair patients and the controls (572.1 ± 100.1 vs. 543.3 ± 110.2 mmHg/s, p = 0.460), the peak dP/dt in the DAo in the aortic arch repair patients was significantly lower than that in the controls (489.3 ± 75.2 vs. 579.4 ± 106.0 mmHg/s, p = 0.013). The peak dP/dt in the DAo in aortic arch repair patients is low. The stiff repaired site may attenuate pulsation.

Preserved Cardiac Blood Supply-Workload Balance in Pediatric Patients After Aortic Arch Repair

One of the most important problems in patients with aortic coarctation after aortic arch repair is future cardiovascular disease. We have previously reported that the enhancement of aortic pressure wave reflection in patients could be one of the causes of future cardiovascular diseases, because it results in an increase of the left ventricular workload and is disadvantageous for coronary circulation. Seventeen patients who had undergone aortic arch repair without pressure gradient in their aortic arch were enrolled. An ascending aortic pressure waveform was recorded by a pressure-sensor-mounted catheter, and a subendocardial viability ratio, which measures cardiac blood supply-workload balance, was calculated. The values were compared with those in age-matched controls. The patients' mean age was 6.8 ± 2.8 years. The mean ascending aortic systolic pressure was higher (100.4 ± 12.9 vs. 90.2 ± 8.9 mmHg, p = 0.0011) and the pulse pressure was wider (38.1 ± 7.1 vs. 32.5 ± 5.4 mmHg, p = 0.0072) in patients than in control subjects. There was no difference in the mean subendocardial viability ratio (1.01 ± 0.25 vs. 1.01 ± 0.24, ns), while the mean tension time index (27.4 ± 5.6 vs. 23.0 ± 3.3, p = 0.0001) and diastolic pressure time index (28.4 ± 11.1 vs. 23.6 ± 8.0, p = 0.0082) were higher in patients than in controls. The cardiac blood supply-workload balance was preserved in patients after aortic arch repair, despite an increase in their cardiac workload.

Aortic surgery is one of the risk factors for enhancement of pressure wave reflection in adult patients with congenital heart disease

BACKGROUND

Excessive aortic pressure wave reflection is one of the risk factors of cardiovascular diseases. In some clinical course of congenital heart diseases, the elevated pressure wave reflection has been reported. The purpose of this study is to elucidate the risk factors of the enhanced pressure wave reflection in adult patients with congenital heart disease.

METHODS

We enrolled 99 adult (≥20 years) patients with congenital heart disease. We measured their radial pressure augmentation index and examined the relationship between it and various clinical variables.

RESULTS

The radial pressure augmentation index was 77.1 ± 19.1% and it had a significant correlation with the history of aorto-pulmonary shunt (t=4.194; p<0.0001), age (t=4.091; p<0.0001), height (t=-3.580; p=0.001) and the history of direct aortic surgery (t=2.253; p=0.027). Forty-four patients (44.4%) demonstrated high radial augmentation index (>1SD of age- and gender matched control) and the determinants of the elevated radial augmentation index were the history of aorto-pulmonary shunt (odds ratio, 21.32; 95% confidence interval, 5.47-83.14; p<0.0001) and the direct aortic surgery (4.18; 1.38-12.72; p=0.012).

CONCLUSIONS

The history of aortic surgeries enhances aortic pressure wave reflection in adult patients with congenital heart disease. The enhanced aortic pressure wave reflection is one of the risk factors for cardiovascular diseases. Therefore, the adult patients with congenital heart disease after aortic surgeries should be carefully observed and tightly controlled concerning the risk factors for cardiovascular diseases.

Coarctation of the aorta associated with Dandy-Walker variant

This article reports a rare case of coarctation of the aorta associated with Dandy-Walker variant in a 17-year-old girl. Differential diagnoses of coarctation of the aorta and Dandy-Walker variant are extensively discussed. In addition, standard surgical treatment of coarctation as well as new approaches such as endovascular stenting are described in detail to provide therapeutic insights into her management. Although surgical or endovascular repair of coarctation results in significant improvement of systemic hypertension and is associated with better survival, cardiovascular complications are still very common. Thus, long-term follow-up after repair is required, and high-quality imaging studies such as echocardiography, CT and MRI are warranted.

Aortic pressure wave reflection in patients after successful aortic arch repair in early infancy

Despite the apparently successful surgical repair of aortic coarctation, subsequent cardiovascular complications have sometimes been encountered. Aortic pressure wave reflection is one of the risk factors for developing cardiovascular diseases, and an enhancement of the pressure wave reflection has been reported in patients after aortic arch repair. To clarify this issue, the increase in pressure wave reflection was evaluated in patients <15 years old who underwent aortic arch repair. This study enrolled 35 patients after aortic arch repair in early infancy. All patients underwent cardiac catheterization, and in 20 patients, there was no pressure difference within the repaired aortic arch. The aortic pressure waveforms in patients after successful aortic arch repair were recorded using a pressure sensor-mounted catheter, and the augmentation index in the ascending aorta was calculated. The augmentation index in patients after an aortic arch repair was increased compared with control subjects, although there was no pressure difference between the ascending and descending aorta (P<0.0001). The increase in the augmentation index was correlated with the patient's age (r=0.8932, P<0.0001) and with the left ventricular posterior wall thickness (r=0.4075, P=0.0373). In patients who undergo aortic arch repair, the pressure wave reflection is accelerated, even when the aortic arch repair is 'successful'. This increase is one of the possible causes of left ventricular hypertrophy.

Endovascular management of coarctation of the aorta

Untreated thoracic aortic coarctation leads to early death predominantly because of hypertension and its cardiovascular sequelae. Surgical treatment has been available for > 50 years and has improved hypertension and survival. More recently, endovascular techniques have offered a minimally invasive alternative to traditional open repair. Early and intermediate results suggest angioplasty and stenting have an important role in the management of aortic coarctation, particularly in adults and older children.

Vascular remodeling in adults after coarctation repair: impact of descending aorta stenosis and age at surgery

BACKGROUND

Patients after successful repair of coarctation of aorta (CoAo) are at risk of hypertension at rest and associated end-organ damage. The aim of the study was to assess arterial stiffness and function in adults after coarctation repair in relation to descending aorta (AoD) residual coarctation and patient's age at operation.

METHODS

85 patients after CoAo repair (53 males) aged 34.6 ± 10.3 years; median age at operation 0.9 ± 8.2 years. The control group-30 individuals (18 males) at mean age 33.6 ± 8.2 years. The following central parameters: augmentation pressure (AP) and augmentation index (AI) as well as peripheral vascular parameters: flow-mediated dilatation (FMD), nitroglycerin-mediated vasodilatation (NMD), intima-media thickness (IMT) and pulse wave velocity (PWV) were measured.

RESULTS

47 CoAo-repaired patients were normotensive, and compared to control, they presented higher values of central parameters AP (7.3 ± 4.6 vs. 4.4 ± 3.6 mmHg; p = 0.002) and AI (18.6 ± 10.4 vs. 13.5 ± 4.3%; p = 0.03); as well as the increased PWV (6.8 ± 1.2 vs. 5.4 ± 0.9 m/s; p = 0.003), while IMT was comparable (0.53 ± 0.01 vs. 0.51 ± 0.01 mm; p = 0.06). The vasodilatation was impaired in the normotensive patients: FMD (4.8 ± 2.8 vs. 8.5 ± 2.3%; p = 0.00003) and NMD (11.3 ± 4.6 vs. 19.8 ± 7.2%; p = 0.00001). The comparison of recoarctation (46, 54%) to non-recoarctation (39, 46%) patients did not reveal any significant differences in resting systolic and diastolic pressures, as well as the values of AI and the peripheral vascular parameters; the value of AP was higher in the recoarctation patients (10.5 ± 6.9 vs. 7.5 ± 4.1; p = 0.02) and correlated positively with the gradient across AoD (r = 0.295, p = 0.01). There was no significant linear correlation between age at the time of surgery and any of peripheral arterial parameters.

CONCLUSIONS

Residual stenosis in AoD does not affect the arterial vasodilatation nor stiffness in patients after CoAo repair. Early operation has no impact on peripheral vascular remodeling or central pressure which supports the claim that coarctation of the aorta is a systemic vascular disorder which leads to progressive vascular and end-organ damage despite early correction.

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.

Parameters of arterial function and structure in adult patients after coarctation repair

Regardless of a successful operation, patients with coarctation of aorta (CoAo) are exposed to the risk of hypertension and a propensity to vascular and end-organ damage. The aim of this study is to evaluate the influence of residual aorta stenosis as well as the age at the operation on the parameters of arterial function and structure in patients after CoAo repair. Eighty-five patients after CoAo repair (53 males; mean age: 34.6 ± 10.3 years, mean age at the repair: 10.9 ± 8.2 years) were enrolled in the study. The control group consisted of 30 healthy subjects (18 males; mean age: 33.6 ± 8.2 years). Indices of systemic arterial remodeling [flow-mediated dilatation (FMD), nitroglycerine-mediated vasodilatation (NMD), carotid intima-media thickness (IMT), pulse wave velocity (PWV)] were analyzed in all study patients. In normotensive patients after CoAo repair (47/55%), a significantly increased PWV was observed in comparison to the control group (6.8 ± 1.2 vs. 5.4 ± 0.9 m/s; p = 0.003), with no difference in IMT values (0.53 ± 0.1 vs. 0.51 ± 0.1 mm; p = 0.06). Mean FMD (4.8 ± 2.8 vs. 8.5 ± 2.3%; p = 0.00003) and NMD (11.3 ± 4.6 vs. 19.8 ± 7.2%; p = 0.00001) were lower than in the controls. In patients with a residual aorta stenosis (46/54%), defined as an arm-leg pressure gradient ≥ 20 mmHg, no differences were found within the scope of both systolic and diastolic blood pressure and of all of the examined vascular parameters. No significant correlations were revealed between the vascular parameters and the gradient across descending aorta as well as the age at the operation. Residual stenosis in the descending aorta does not affect the arterial vasodilatation nor stiffness in patients after CoAo repair. An early surgery does not influence the remodeling of the vessels, which supports the thesis that CoAo is a generalized vascular disease and that even an early operation cannot prevent the progressive and vascular changes and end-organ damage.

Impaired elastic properties of the ascending aorta persist within the first 3 years after neonatal coarctation repair

Abnormal elastic properties of the ascending aorta in patients with coarctation of the aorta (CoA) are already present in neonates before and after successful repair. To prove the midterm outcome for vascular pathology, a cohort of 15 patients was prospectively reevaluated. In this study, 15 patients after neonatal CoA repair (study group) and 15 healthy normal children (control group) were examined (mean age, 3.0 +/- 1.0 years). The aortic wall stiffness index and distensibility were calculated using ascending and abdominal aortic M-mode diameters and noninvasive estimation of pulse pressure. The study group was compared with the control group and with its own previously obtained pre- and postoperative measurements. After a mean follow-up period of 2.9 +/- 0.9 years, the elastic properties of the ascending aorta remained impaired in the study group compared with the control group (distensibility: 62 +/- 28 vs 94 +/- 34; p = 0.01; stiffness index: 4.4 +/- 1.9 vs 2.7 +/- 1.0; p = 0.008). At follow-up evaluation, the elasticity of the ascending aorta in the study group showed no change from the initial neonatal findings (distensibility: 63 +/- 24 vs 62 +/- 28; p = 0.82; stiffness index: 4.0 +/- 1.6 vs 4.4 +/- 1.9; p = 0.65). In both groups, descending aortic elasticity increased during the follow-up period. Our data suggest that the diminished elastic properties of the prestenotic arteries remain unchanged years after successful CoA repair. Comparisons with the neonatal data showed no evidence for remodeling of the ascending aorta in this group.

Self-expanding and balloon expandable covered stents in the treatment of aortic coarctation with or without aneurysm formation

OBJECTIVES

We describe our complete experience with covered stent implantation for aortic coarctation including short- to medium-term outcomes.

BACKGROUND

Coarctation of the aorta is a heterogeneous disease process with multiple associated complications both with and without treatment. Covered stents have evolved to provide greater support to the aortic wall and a varied approach with choice of stent tailored to the anatomy of the patient is required.

METHODS

We retrospectively analyzed consecutive patient data from two congenital heart centers from March 2003 to October 2007.

RESULTS

We implanted 38 covered stents in 37 patients (20 female) of which three were self-expanding stents. Median age was 29.6 years (9-65) with median weight of 71.5 kg (35-95). The indications for stent placement were native coarctation (n = 13); recurrent coarctation following surgical treatment (n = 11); aneurysm associated with previous coarctation surgery (n = 7); aorto-bronchial fistula leading to acute hemoptysis (n = 2); stent fracture (n = 1); associated arterial duct (n = 2). One patient had a combination of acquired coarctation and false aneurysm. The median screening time was 10 min (3-22). The median systolic gradient of 26 mm Hg (10-60) was reduced to 4 mm Hg (0-20) postprocedure (P < 0.001). There were no deaths on median follow up of 11.5 months (1-56). One patient developed aortic rupture during the procedure and required emergency surgery.

CONCLUSION

Covered stent implantation for treatment of aortic coarctation is safe and highly effective in selected patients. Self-expanding stent grafts may be preferable to balloon expandable stents when there is aneurysm formation in the setting of aortopathy.

Repair of Aortic Coarctation in Adults: The Fate of Hypertension

The benefit of coarctation repair on the resolution of systolic hypertension in adults has been questioned. In this retrospective study, hypertension was assessed in 38 adults (22 men, 16 women; mean age, 25.6 ± 6.9 years; range, 16–39 years) who underwent coarctation repair between 1996 and 2006. Thirty patients had preoperative hypertension (mean systolic pressure, 158.3±18.6; range 140–200 mm Hg). At preoperative catheterization, the peak mean systolic gradient across the coarctation was 70.6 ± 21.2 mm Hg (range, 38–120 mm Hg). Operative procedures were resection and end-to-end anastomosis (11 patients), patch aortoplasty (24) and resection with interposition of a Dacron tube graft (3). The patients were followed up for 2–90 months (mean, 37 ± 23 months). Of the 30 patients with preoperative hypertension, 25 (83%) were normotensive at the last follow-up. The mean postoperative systolic blood pressure was significantly lower than the preoperative level. More than half of the patients (58%) were still taking antihypertensive medication. Surgical repair of coarctation of the aorta in adults can lead to regression of systolic hypertension and a decreased requirement for antihypertensive medication.

Vascular Remodeling After “Successful” Repair of Coarctation

OBJECTIVES

This study was designed to investigate the influence of aortic arch geometry on vascular remodeling after anatomically successful repair of coarctation of the aorta (CoA).

BACKGROUND

Abnormalities of the precoarctation vasculature are known to occur after CoA repair and appear related to adverse outcomes. The influence of aortic arch geometry on such abnormalities is unknown.

METHODS

Sixty-three postcoarctectomy subjects (age 15.9 +/- 6.3 years) were compared with 63 control volunteers. Aortic arch shape was characterized on magnetic resonance imaging using both qualitative classification, identifying 3 subtypes of arch geometry (Gothic, Crenel, Romanesque), and a quantitative index, height/width ratio (H/W) of the aorta. Using ultrasound, we measured carotid artery intima-media thickness (IMT) and stiffness index and distensibility, as well as right brachial artery flow-mediated dilation (FMD) and glyceryl trinitate (GTN)-induced dilatation, to assess the precoarctation vasculature of these subjects.

RESULTS

Gothic arch type was associated with higher carotid IMT and stiffness index, lower carotid distensibility (p < 0.001 for all), and lower brachial reactivity (FMD, p < 0.01; GTN response, p < 0.001) compared with Crenel and Romanesque geometries and with control subjects. The height/width ratio was also significantly related to these vascular abnormalities. Even in CoA subjects with Romanesque arch geometry, arterial function and stiffness parameters were significantly impaired compared with control subjects.

CONCLUSIONS

In young adult survivors of anatomically successful CoA repair, a gothic-type aortic arch with high H/W is associated with abnormal IMT, higher aortic stiffness index, and impaired arterial reactivity in the pre-CoA vasculature.

Increased carotid and femoral intima-media thickness in patients after repair of aortic coarctation: influence of early repair

BACKGROUND

In patients, after repair of aortic coarctation, abnormal function of the proximal precoarctation arterial conduits has been demonstrated, but data on arterial wall structure of proximal and distal arteries in patients are scarce. The aim of our study is to compare intima-media thickness (IMT) of the carotid and femoral arteries in controls and patients after coarctation repair and to identify independent predictors of carotid and femoral IMT.

METHODS

A total of 137 patients after repair of aortic coarctation (89 male, median age 29.7 years, range 17-74 years, and median age at repair 6.3 years, range 0.01-46 years) and 46 age-matched controls underwent ambulatory blood pressure monitoring and B-mode ultrasound of the carotid and femoral arteries.

RESULTS

Twenty (15%) of the 137 patients were operated on before the age of 1 year ("early repair"). The patients with an early repair were younger compared to the controls and compared with the patients with a late repair (24.5 [10.5] vs 31.6 [8.4] years, P = .005, and vs 32.1 [10.5] years, P < .001, respectively). Eighty patients (59%) had hypertension on the basis of the results of the ambulatory blood pressure monitoring (mean daytime blood pressure > or = 135/85 mm Hg). The prevalence of hypertension was not significantly different between patients with an early or late repair. Although patients with an early repair were younger, both carotid and femoral IMT were increased in these patients compared to controls (common carotid artery 0.57 [0.11] vs 0.49 [0.07] mm, P < .001; common femoral artery 0.48 [0.10] vs 0.44 [0.05] mm, P = .033). In multivariable regression analyses, age at repair was only an independent predictor of femoral and not of carotid IMT.

CONCLUSIONS

Patients, after repair of aortic coarctation, have increased carotid and femoral IMT despite normal ambulatory blood pressures and successful previous repair. Early repair seems to preserve postcoarctation arterial wall structure, but seems to have only limited effect on precoarctation vessel walls, which supports the theory of a developmental defect of the proximal aorta and its branches.

Arterial hypertension and cardiovascular prognosis after successful repair of aortic coarctation: a clinical model for the study of vascular function

Despite successful surgical repair, aortic coarctation is associated with unfavourable prognosis mainly due to cardiovascular disease. Late timing of repair and arterial hypertension represent adverse prognostic factors. Arterial hypertension can recur after coarctation repair, despite the absence of residual obstruction, with a prevalence of up to 45%. Furthermore, even subjects with normal blood pressure values at rest may show an abnormal blood pressure elevation during exercise and daily life activities. The pathophysiology of such abnormal blood pressure behaviour is unclear. Different mechanisms have been proposed: resetting of the renin-angiotensin system, neurological dysfunction and impaired vascular reactivity and/or elastic properties. Several studies have supported these hypotheses, although the suggestion of a causative role of vascular dysfunction persisting late after coarctation repair has recently become more popular. Further studies are needed to investigate this issue; this particular syndrome may represent an important study model for the understanding of systolic hypertension.

Enhanced Aortic Pressure Wave Reflection in Patients After Repair of Aortic Coarctation

BACKGROUND

Despite the relative successes in cardiac surgical repair, early onset of heart disease (hypertension, myocardial infarction, cardiac failure, and sudden death) is a common late complication in patients who have undergone repair of occlusive aortic vessels. Many hypotheses for the cause of this complication have been proposed, but these mechanisms are still controversial.

METHODS

We enrolled 20 patients who had undergone arch repair for coarctation or interruption of the aortic arch. We analyzed the ascending and descending aortic pressure waveforms using a pressure sensor mounted catheter during mid-term or long-term follow-up cardiac catheterization. We compared the pressure waveforms with those of age-matched control subjects who had never undergone aortic arch surgery.

RESULTS

In patients after an arch repair, the inflection time was short (0.095 +/- 0.024 vs 0.19 +/- 0.05 s; p < 0.0001) and the augmentation index increased (27.5 +/- 15.4 vs -3.47 +/- 8.8 %; p < 0.0001). Moreover, they demonstrated high systolic blood pressure (105.2 +/- 12.2 vs 94.7 +/- 11.7 mm Hg; p = 0.0018) and a greater range in pulse pressure variation (40.4 +/- 7.2 vs 32.7 +/- 5.3 mm Hg; p = 0.0004).

CONCLUSIONS

Our results show the early return of the pressure wave reflection and augmented ascending aortic pressure wave in patients after repair of the aortic arch. The elevated ventricular afterload resulting from the enhanced pressure wave reflection may contribute to subsequent late cardiovascular complications (hypertension, myocardial infarction, cardiac failure, and sudden death) in patients after repair of the aortic defects.

Blood Pressure Changes After Aortic Coarctation Surgery Performed in Adulthood

OBJECTIVE

The aim of this study was to assess the effect of aortic coarctation surgery in adult patients on arterial blood pressure in the early postoperative period.

METHODS

Ninety-three adult patients (61 male, 32 female) aged 15-43 years who had operation since 1962 for aortic coarctation in Siyami Ersek Cardiovascular Surgery Center were retrospectively evaluated. Tube graft interposition was done in 31 patients; resection and end-to-end anastomosis were performed in 32 patients; 24 patients had undergone pathchplasty; and 6 patients by-pass shunting performed. The effect of surgery on the blood pressure was investigated.

RESULTS

The mean systolic and diastolic blood pressure significantly reduced after operation (systolic 193.6 +/- 33.7 mmHg vs 147.4 +/- 22.0 mmHg, diastolic 99.8 +/- 17.9 mmHg vs 82.0 +/- 10.8 mmHg). From 93 patients (all with hypertension) 54 (58%) became normotensive after operation according to VIth Joint National Committee classification. The number of normotensive patients after operation was 28 (of 37) for 15-19 years age group, 14 (of 23) for the 20-24 years age group, 4 (of 16) for 25-29 years age group, 6 (of 11) for 30-34 years age group, and 2 (of 6) for the over 35 years old age group.

CONCLUSION

The diastolic and systolic blood pressures reduce significantly in the adult patients operated for aortic coarctation. On the other hand, persistent hypertension seemed to increase in the older age groups in spite of the surgery.

Late complications in patients after repair of aortic coarctation: implications for management

Survival of patients with aortic coarctation has dramatically improved after surgical repair became available and the number of patients who were operated and reach adulthood is steadily increasing. However, life expectancy is still not as normal as in unaffected peers. Cardiovascular complications are frequent and require indefinite follow-up. Concern falls chiefly in seven categories: recoarctation, aortic aneurysm formation or aortic dissection, coexisting bicuspid aortic valve, endocarditis, premature coronary atherosclerosis, cerebrovascular accidents and systemic hypertension. In this review, these complications, with particular reference to late hypertension, are discussed and strategies for the clinical management of post-coarctectomy patients are described.

Predictive value of mild, residual descending aortic narrowing for blood pressure and vascular damage in patients after repair of aortic coarctation

AIMS

The significance of mild residual descending aortic narrowing in post-coarctectomy patients is not known. The aim of our study was to investigate the influence of mild residual descending aortic narrowing on blood pressure and vascular damage in patients after repair of aortic coarctation.

METHODS AND RESULTS

In 107 consecutive post-coarctectomy patients, magnetic resonance imaging, ambulatory blood pressure monitoring, and B-mode ultrasound of the carotid arteries were performed. A significant residual aortic narrowing was defined as: (i) a resting blood pressure gradient > or =30 mmHg with hypertension or exercise-induced hypertension (European Society of Cardiology guidelines); and/or (ii) a site of repair/diaphragmatic aorta ratio <0.7. Thirty-four patients (32%) had a significant residual aortic narrowing and were excluded from the analysis. Of the remaining 73 patients (43 male) with no or only mild residual descending aortic narrowing, median age was 29.8 years (range 17.1-52.5 years), mean age at repair 8.1 years (range 0.02-37.3 years), mean arm/leg gradient 2+/-12 mmHg, and mean common carotid intima-media thickness 0.612+/-0.118 mm. Thirty-three (45%) of these patients had hypertension. In multivariable regression analysis the site of repair/diaphragmatic aorta ratio was a strong and independent predictor of mean daytime systolic blood pressure (P<0.001) and common carotid intima-media thickness (P=0.027).

CONCLUSION

Mild residual descending aortic narrowing in post-coarctectomy patients is independently associated with mean daytime blood pressure and carotid intima-media thickness. Our data suggest that a threshold for re-intervention of residual aortic narrowing lower than posed in current guidelines may be desirable to improve long-term outcome in these patients. However, further research on such aggressive interventional approaches is needed.

Risk factors for aortic complications in adults with coarctation of the aorta

OBJECTIVES

We sought to determine the prevalence and predisposing condition for aortic wall complications in adults with either repaired or non-repaired coarctation of the aorta.

BACKGROUND

Aortic wall complications may develop in adults with coarctation of the aorta, despite successful surgical repair in childhood.

METHODS

A total of 235 adults with coarctation (mean age 27 +/- 13 years) were retrospectively reviewed. Treatment had been performed by surgery in 181 patients (group I) or by balloon angioplasty or stenting in 28 patients (group II). No previous intervention had been carried out in 26 patients with mild coarctation at diagnosis (group III).

RESULTS

Forty-four aortic wall complications were found in 37 patients (16%). There were no differences among the three groups with respect to total complications (15%, 18%, and 15%, respectively), ascending aortic aneurysms (9%, 11%, and 12%), or descending aortic aneurysms (4% in all three groups). Multivariate analysis did not show a significant relationship between previous repair, type of repair, age at repair, residual Doppler pressure gradient, or systemic hypertension and the occurrence of aortic complications. Only aging (risk ratio [RR] 1.4 per decade of age, 95% confidence interval [CI] 1.1 to 1.8, p = 0.002) and bicuspid aortic valve (RR 3.2, 95% CI 1.3 to 7.5, p = 0.005) were significantly related to these complications.

CONCLUSIONS

Aortic wall complications are frequent in adults with coarctation of the aorta beyond that attributable to associated hemodynamic derangement or previous repair. The only independent risk factors appear to be advanced age and bicuspid aortic valve.

Ambulatory blood pressure, left ventricular mass, and conduit artery function late after successful repair of coarctation of the aorta

OBJECTIVES

We sought to evaluate the determinants of hypertension during daily life and left ventricular (LV) hypertrophy in patients with successfully repaired coarctation of the aorta (CoA), as well as their relationship to abnormalities of arterial function.

BACKGROUND

Arterial hypertension may recur late after repair of CoA, which is related to a more adverse outcome. Furthermore, patients with normal resting blood pressure (BP) may have hypertension during daily life and LV hypertrophy. The determinants of these two adverse prognostic factors have not been investigated.

METHODS

We studied 72 patients (9 to 58 years of age) who underwent coarctation repair at age 0.1 to 480 months (42 [60%] at <1 year) and had been followed up for 155 +/- 76 months. They underwent ambulatory BP monitoring, echocardiography for LV mass, studies of brachial artery responses to flow (i.e., flow-mediated dilation [FMD]) and glyceryl trinitrate (GTN), and determination of pulse wave velocity (PWV) and measures of arterial reactivity and stiffness. Findings were compared with those of 53 healthy volunteers.

RESULTS

Patients had higher 24-h systolic BP and LV mass than controls. Both endothelium-dependent FMD and the response to the smooth muscle dilator GTN were reduced, and PWV was increased. There was a negative independent correlation between GTN response and 24-h systolic BP in both patients and control subjects. Systolic BP at 24 h was an independent predictor of LV mass, having an accentuated impact in coarctation subjects as compared with controls.

CONCLUSIONS

In patients with repaired coarctation, reduced vascular reactivity is associated with hypertension during daily life and with increased LV mass, both of which are important predictors for late morbidity and mortality.

Pediatric hypertension: recent literature

This article reviews selected recent literature specifically concerning pediatric hypertension, much of which has focused on measurement and monitoring of blood pressure, as well as on evaluating antihypertensive medications. Normative data for blood pressure in children have been widely available for some time, based upon seated in-office measurements. In recent years, ambulatory blood pressure monitoring (ABPM), facilitated by user-friendly instrumentation, has become more commonplace, though norms are not based on large populations. However, ABPM has important uses in assessing blood pressure as well as in monitoring antihypertensive. This review discusses issues involved in determining blood pressure, as well as the utility of ABPM in several situations. Recent developments concerning pediatric antihypertensive therapy are considered, as well as new information relevant to the diagnosis, course and treatment of hypertension in children and adolescents.