High pulse pressure is not associated with abnormal activation of the renin-angiotensin-aldosterone system in repaired aortic coarctation

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.

Acute Effects of Hibiscus Sabdariffa Calyces on Postprandial Blood Pressure, Vascular Function, Blood Lipids, Biomarkers of Insulin Resistance and Inflammation in Humans

Background/Objectives: The acute impact of Hibiscus sabdariffa calyces (HSC) extract on postprandial vascular function and other cardiometabolic risk factors have not been studied previously. This study investigated the acute impact of HSC extract consumption on blood pressure (BP), vascular function and other cardiometabolic risk markers. Subjects/Methods: Twenty-five men with 1% to 10% cardiovascular disease (CVD) risk (determined by QRISK^®2) were randomised to consume either 250 mL of the aqueous extract of HSC or water with breakfast in a randomised, controlled, single-blinded, 2-meal cross-over study (ClinicalTrials.gov, NTC02165553) with a two weeks washout period between study days. BP was measured at baseline and hourly for 4 h. Flow mediated dilatation (FMD) of the branchial artery was measured at baseline, 2 and 4 h post intervention drink consumption. Results: Acute consumption of aqueous extract of HSC caused a significant increase in % FMD (p < 0.001), a non-significant decrease in systolic BP (SBP) and diastolic BP (DBP); non-significant increase in urinary and plasma nitric oxide (NOx) and reduced response of serum glucose, plasma insulin, serum triacylglycerol and C-reactive protein (CRP) levels; significant (p = 0.026) improvement in the area under systemic antioxidant response curve (0 to 2 h); no significant changes in arterial stiffness following the acute consumption of the extract of HSC. Gallic acid, 4-O-methylgallic acid, 3-O-methylgallic acid and hippuric acid reached a maximum plasma concentration at 1 to 2 h post consumption of the extract of HSC. Conclusion: The extract of HSC improved postprandial vascular function and may be a useful dietary strategy to reduce endothelial dysfunction and CVD risk, although this requires confirmation.

Impaired aortic distensibility and elevated central blood pressure in Turner Syndrome: a cardiovascular magnetic resonance study

BACKGROUND

Women with Turner Syndrome have an increased risk for aortic dissection. Arterial stiffening is a risk factor for aortic dilatation and dissection. Here we investigate if arterial stiffening can be observed in Turner Syndrome patients and is an initial step in the development of aortic dilatation and subsequent dissection.

METHODS

Fifty-seven women with Turner Syndrome (48 years [29-66]) and thirty-six age- and sex-matched controls (49 years [26-68]) were included. Distensibility, blood pressure, carotid-femoral pulse wave velocity (PWV), the augmentation index (Aix) and central blood pressure were determined using cardiovascular magnetic resonance, a 24-h blood pressure measurement and applanation tonometry. Aortic distensibility was determined at three locations: ascending aorta, transverse aortic arch, and descending aorta.

RESULTS

Mean aortic distensibility in the descending aorta was significantly lower in Turner Syndrome compared to healthy controls (P = 0.02), however, this was due to a much lower distensibility among Turner Syndrome with coarctation, while Turner Syndrome without coarctation had similar distensibility as controls. Both the mean heart rate adjusted Aix (31.4% vs. 24.4%; P = 0.02) and central diastolic blood pressure (78.8 mmHg vs. 73.7 mmHg; P = 0.02) were higher in Turner Syndrome compared to controls, and these indices correlated significantly with ambulatory night-time diastolic blood pressure. The presence of aortic coarctation (r = - 0.44, P = 0.005) and a higher central systolic blood pressure (r = - 0.34, P = 0.03), age and presence of diabetes were inversely correlated with aortic distensibility in TS.

CONCLUSION

Aortic wall function in the descending aorta is impaired in Turner Syndrome with lower distensibility among those with coarctation of the aorta, and among all Turner Syndrome higher Aix, and elevated central diastolic blood pressure when compared to sex- and age-matched controls.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov ( #NCT01678274 ) on September 3, 2012.

Arterioventricular interaction after coarctation repair

BACKGROUND

Hypertension is common in patients with coarctation of the aorta (CoA), even after successful repair. Increased aortic stiffness has been implicated in the pathology of CoA-associated hypertension. This study aimed to investigate aortic vascular function and its relationship with hypertension in well-repaired CoA-patients at long-term follow-up. Furthermore, we assessed the additive effect of hypertension to adverse arterioventricular coupling associated with increased aortic stiffness.

METHODS

Twenty-two CoA-patients (age 30 ± 10.6 years) with successful surgical repair (n = 12) or balloon angioplasty (BA) (n = 10) between 3 months and 16 years of age with a follow-up of >10 years and 22 healthy controls underwent cardiac magnetic resonance imaging (CMR), at mean follow-up of 29.3 years, to study aortic pulse wave velocity (PWV), aortic distensibility, global left ventricular (LV) function, LV dimensions, and LV myocardial deformation.

RESULTS

CoA-patients had significantly increased aortic arch PWV (5.6 ± 1.9 m/s vs. 4.5 ± 1.0 m/s, P = .02) and decreased distensibility (4.5 ± 1.8 × 10-3 mmHg^-1 vs. 5.8 ± 1.8 × 10-3 mmHg^-1, P = .04) compared to controls. Significant differences in aortic arch PWV were found between hypertensive patients, normotensive patients and controls (6.1 ± 1.8 m/s vs. 4.9 ± 1.9 m/s and 4.5 ± 1.0 m/s, respectively, P = .03). Aortic arch PWV and distensibility were correlated with systolic blood pressure (R = 0.37 and R = -0.37, respectively, P = .03 for both). Global LV function, LV mass, LV dimensions and myocardial deformation were similar in CoA-patients when compared to controls.

CONCLUSIONS

Central aortic stiffness is significantly increased in well-repaired CoA-patients long-term after repair, and is associated with hypertension. Global LV function, myocardial deformation indices and LV dimensions are however preserved.

Rationale and design of Long-term Outcomes and Vascular Evaluation after Successful Coarctation of the Aorta Treatment study

Background:

Coarctation of the aorta (CoA) can be treated using surgery, balloon angioplasty, or stent implantation. Although short-term results are excellent with all three treatment modalities, long-term cardiovascular (CV) morbidity and mortality remain high, likely due to persistently abnormal vascular function. The effects of treatment modality on long-term vascular function remain uncharacterized. The goal of this study is to assess vascular function in this patient population for comparison among the treatment modalities.

Methods:

We will prospectively assess vascular Afunction in large and small arteries fusing multiple noninvasive modalities and compare the results among the three groups of CoA patients previously treated using surgery, balloon angioplasty, or stent implantation after frequency matching for confounding variables. A comprehensive vascular function assessment protocol has been created to be used in 7 centers. Our primary outcome is arterial stiffness measured by arterial tonometry. Inclusion and exclusion criteria have been carefully established after consideration of several potential confounders. Sample size has been calculated for the primary outcome variable.

Conclusion:

Treatment modalities for CoA may have distinct impact on large and small arterial vascular function. The results of this study will help identify the treatment modality that is associated with the most optimal level of vascular function, which, in the long term, may reduce CV risk.

Preserved Myocardial Deformation after Successful Coarctation Repair: A CMR Feature-Tracking Study

Arterial vasculopathy and residual aortic obstruction can lead to left ventricular (LV) dysfunction in patients with coarctation of the aorta (CoA) related to adverse ventriculo-arterial coupling. This study aimed to investigate potential differences in LV myocardial deformation indices between repaired CoA patients and healthy controls. Twenty-two CoA patients (age 30 ± 10.6 years) after surgical repair (n = 12) or balloon angioplasty (BA) (n = 10) without residual stenosis, between 3 months and 16 years of age with > 10 years follow-up were compared to 22 healthy age- and gender-matched controls (age 30 ± 3.8 years). Cardiac magnetic resonance feature tracking (CMR-FT) was used for LV longitudinal-, circumferential-, and rotational deformation indices. Global systolic LV function was preserved in CoA patients (LV ejection fraction 58 ± 4.8 vs. 60 ± 6.8%, p = 0.56) when compared to controls, with normal LV dimensions and mass (p > 0.05). Twelve CoA patients (55%) were hypertensive, of whom 4 were on anti-hypertensive medication. LV global longitudinal strain was preserved in the four-chamber (- 18 ± 4.4 vs. - 16 ± 4.7%, p = 0.06) and two-chamber (- 22 ± 5.1 vs. - 20 ± 6.0%, p = 0.22) orientations in CoA patients. Global circumferential strain was preserved at basal (- 29 ± 4.1 vs. - 28 ± 4.8%, p = 0.43), mid-ventricular (- 27 ± 4.2 vs. - 25 ± 3.0%, p = 0.09), and apical levels (- 35 ± 7.8 vs. - 32 ± 34.9%, p = 0.32). No differences were found in global torsion (2.4 ± 1.3° vs. 2.0 ± 1.4°/cm, p = 0.28), twist (14 ± 5.8° vs. 12 ± 6.3°, p = 0.34), and recoil rate (- 17 ± 9.7° vs. - 17 ± 7.1°/cm s, p = 0.97). Analysis of intra-observer variability demonstrated good reproducibility for all CMR deformation indices. Global and rotational myocardial deformation indices are preserved in CoA patients long-term after repair without residual stenosis, despite a high incidence of hypertension.

The Medium-Term Effects of Treatment for Mild Aortic Recoarctation

Objective:

To assess medium-term effects of treatment for mild to moderate recoarctation in an adult population.

Design:

We identified all patients who had coarctation repair between 1965 and 1985 in our institution. They were all (n = 156) invited to a thorough outpatient examination, which was accepted by 133. Eleven (median age 36 [28-53] years) were identified with isolated mild to moderate recoarctation and received reintervention. They comprise the patient population of the current study. We performed bicycle exercise testing, transthoracic echocardiography, magnetic resonance imaging, and 24-hour blood pressure monitoring before and 14 to 29 months after reintervention.

Results:

Compared to the values before reintervention, 24-hour blood pressures were reduced, but only significantly so for nighttime values. On echocardiography, wall thickness was reduced (1.2 ± 0.3 vs 1.1 ± 0.2, P > .05), and maximum flow velocity in the distal aortic arch decreased (2.8 ± 0.5 m/s vs 2.1 ± 0.4 m/s, P < .05). The invasive coarctation gradient was significantly reduced (15 ± 7 mm Hg vs 5 ± 9 mm Hg, P < .05), and the diameter at the coarctation site was increased (11 ± 3 mm vs 15 ± 3 mm, P < .05). Maximum achieved workload increased (182 ± 51 W vs 205 ± 65 W, P < .05). Cardiac symptoms were overall reduced.

Conclusion:

Reintervention was overall beneficial in increasing exercise capacity and reducing symptoms in the medium term, but the effects on established myocardial hypertrophy and blood pressures were less profound. Larger studies are needed in order to establish the definite role of reintervention for patients with milder recoarctation.