Aortic elasticity after aortic coarctation relief: comparison of surgical and interventional therapy by cardiovascular magnetic resonance imaging

Association of Plasma Renin Activity with Risk of Late Hypertension in Pediatric Patients with Early Aortic Coarctation Repair: A Retrospective Study

BACKGROUND

Coarctation of the aorta (CoA) represents 5% to 7% of all congenital heart diseases. Surgery and interventional methods offer great short-term results, but the occurrence of postoperative hypertension associated with cardiovascular and cerebral vascular disease increases mortality and morbidity in the long term. This study aims to investigate risk factors associated with postoperative hypertension in pediatric patients with early repair of isolated aortic coarctation.

SUBJECTS AND METHODS

A total of 41 patients with isolated aortic coarctation were included. The mean age was 35.3 ± 46.34 days. Early repair under one month was performed in 65.9% of patients. In all except two patients, end-to-end anastomosis was used. A follow-up at two years revealed an incidence of 58.5% of hypertension. Using logistic regression, preoperative renin plasma concentration above the upper normal level (46.1 μUI/mL) was independently associated with the occurrence of hypertension (OR = 2.49, 95% CI = 2.001-5.03, p = 0.001).

CONCLUSION

Coarctation of the aorta is not just a simple mechanical obstruction of the aorta and should be seen and managed as a systemic disease. Abnormal preoperative renin concentrations were independently associated with the occurrence of HT at follow-up, suggesting that vascular dysfunction could play a role in hypertension development after successful CoA repair, negatively influencing the long-term prognostic of these patients.

Hypertension in aortic coarctation

Aortic coarctation (AoC) is a common congenital heart defect, affecting 5%-8% of patients with structural congenital anomalies. Despite advances in surgical and percutaneous interventions, hypertension remains a significant complication in AoC patients, even after successful repair. Chronic hypertension develops in 20%-70% of patients and is a leading cause of long-term cardiovascular morbidity. In these patients, hypertension is associated to renin-angiotensin system activation, residual aortic arch abnormalities, and impaired aortic elasticity. Additionally, exercise-induced hypertension and masked hypertension contribute to adverse outcomes. Management of hypertension in AoC patients requires both perioperative and long-term care. Early after correction, intravenous antihypertensive agents, such as sodium nitroprusside, esmolol, and labetalol, are commonly used to stabilize blood pressure and reduce the risk of complications like cerebral hemorrhage. Oral beta-blockers, ACE inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) are most commonly used for chronic hypertension. In this review, we discussed about diagnostic workup and therapeutical strategies for hypertension in AoC patients.

Computational model of coarctation of the aorta in rabbits suggests persistent ascending aortic remodeling post-correction

Coarctation of the aorta (CoA) is a common congenital cardiovascular lesion that presents as a localized narrowing of the proximal descending aorta. While improvements in surgical and catheter-based techniques have increased short-term survival, there is a high long-term risk of hypertension and a reduced average lifespan despite correction. Computational models can be used to estimate aortic remodeling and peripheral vascular compensation, potentially serving as key tools in developing a mechanistic understanding of the interplay between pre-treatment dynamics, post-treatment recovery, and long-term hypertension risk. In this study, we developed a lumped-parameter model of the heart and circulation to simulate CoA. After fitting model parameters using imaging and catheterization data from healthy rabbits, we then used the model to estimate differences in ascending aortic compliance and peripheral resistance between the healthy group and rabbits with both untreated and corrected CoA using their imaging and catheterization data. CoA was defined by the current putative clinical treatment threshold (a pressure gradient > 20 mm Hg). Model inputs were fitted such that outputs matched reported stroke volume, ejection fraction, systolic and diastolic aortic pressure, peak aortic flow, mean and peak blood pressure gradients, and upper-to-lower body flow split, with all results falling within one standard deviation of the data for all groups. In the untreated CoA and corrected simulations, a decrease in ascending aortic compliance was necessary to match reported hemodynamics. This suggests exposure to a pressure gradient > 20 mm Hg results in vascular remodeling that persists after repair, a process strongly correlated with hypertension.

Coarctation of the aorta and accelerated atherosclerosis: A contemporary review on the burden of atherosclerotic cardiovascular disease

Coarctation of the aorta (CoA) is one of the most common types of congenital heart disease. Unfortunately, there is a high prevalence of hypertension and late cardiovascular mortality in patients with CoA despite successful repair. The growing impact of acquired cardiovascular disease remains a significant concern as the adult congenital heart disease population continues to rapidly expand and age. This review aims to explore (1) the determinants of vascular health and atherosclerosis including endothelial dysfunction and vascular wall abnormalities, (2) the prevalence of atherosclerosis and associated sequelae in repaired CoA including coronary artery disease, coronary artery calcium, aortic calcium, stroke, and peripheral artery disease, and (3) the contributing factors specific to CoA. This review aims to guide optimization of long-term cardiovascular health to ultimately reduce mortality and morbidity in this young high-risk population.

Artificial intelligence-based, non-invasive assessment of the central aortic pressure in adults after operative or interventional treatment of aortic coarctation

BACKGROUND

Aortic coarctation (CoA) is a congenital anomaly leading to upper-body hypertension and lower-body hypotension. Despite surgical or interventional treatment, arterial hypertension may develop and contribute to morbidity and mortality. Conventional blood pressure (BP) measurement methods lack precision for individual diagnoses and therapeutic decisions. This study evaluated the use of artificial intelligence-based pulse wave analysis (AI-PWA) to assess central aortic blood pressure (CABP) and related parameters in post-treatment CoA patients.

METHODS

This exploratory, cross-sectional study enrolled 47 adults with CoA, between June 2023 and May 2024. Peripheral BP (PBP) was conventionally measured, and CABP was assessed using the VascAssist2 (inmediQ, Butzbach, Germany). Hypertension was defined by systolic BP≥140 mm Hg and/or diastolic BP≥90 mm Hg for PBP. Using AI-PWA, patients with systolic CABP≥130 mm Hg and/or diastolic BP≥90 mm Hg were classified as hypertensive.

RESULTS

The study cohort's age was 41.5±13.7 years, with all patients having undergone previous aortic surgery or intervention. PBP measurements showed a systolic BP of 135.4±14.4 mm Hg at the upper and 147.8±20.3 mm Hg at the lower extremities. CABP measurements were significantly lower, with a systolic BP of 114.3±15.8 mm Hg (p<0.001). Overall, 32 patients (68.1%) were diagnosed as hypertensive, either by PBP measurement (n=13/27.7%), because of antihypertensive treatment (n=9; 40.4%), or a combination of both. The measurement of PBP was more likely to indicate arterial hypertension than the measurement of CABP (n=12; 25.5% vs n=4; 8.5%). Pulse wave velocity, indicative of aortic stiffness, averaged 9.1 m/s, with higher values in 13 patients (27.7%), including 4 after end-end anastomosis, 2 after graft interposition and 7 after stent placement/angioplasty as the most recent procedure. An increased augmentation index as an indicator of arterial stiffness was observed in nine patients (19.1%). Comparing PBP and CABP in the entire collective, significant differences were found for CABP in relation to the procedure performed, with higher values in patients after prosthesis interposition as their last treatment (p<0.05).

CONCLUSION

AI-PWA provides valuable insights into cardiovascular stress in CoA patients, beyond PBP measurements. The study highlights the need to incorporate CABP measurements into clinical practice to avoid overdiagnosis of hypertension. Further research with larger cohorts is needed to validate these findings and refine management strategies for CoA patients.

Unveiling the gothic aortic arch and cardiac mechanics: insights from young patients after arterial switch operation for d-transposition of the great arteries

The arterial switch operation (ASO) has become the standard surgical treatment for patients with d-transposition of the great arteries. While ASO has significantly improved survival rates, a subset of patients develop a unique anatomical anomaly known as the gothic aortic arch (GAA). Understanding cardiac mechanics in this population is crucial, as altered mechanics can have profound consequences for cardiac function and exercise capacity. The GAA has been associated with changes in ventricular function, hemodynamics, and exercise capacity. Studies have shown a correlation between the GAA and decreased ascending aorta distensibility, loss of systolic wave amplitude across the aortic arch, and adverse cardiovascular outcomes. Various imaging techniques, including echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography, play a crucial role in assessing cardiac mechanics and evaluating the GAA anomaly. Despite significant advancements, gaps in knowledge regarding the prognostic implications and underlying mechanisms of the GAA anomaly remain. This review aims to explore the implications of the GAA anomaly on cardiac mechanics and its impact on clinical outcomes in young patients after ASO. Advancements in imaging techniques, such as computational modeling, offer promising avenues to enhance our understanding of cardiac mechanics and improve clinical management.

Coarctation of the Aorta: Diagnosis and Management

Coarctation of the aorta (CoA) accounts for approximately 5-8% of all congenital heart defects. Depending on the severity of the CoA and the presence of associated cardiac lesions, the clinical presentation and age vary. Developments in diagnosis and management have improved outcomes in this patient population. Even after timely repair, it is important to regularly screen for hypertension. Patients with CoA require lifelong follow-up with a congenital heart disease specialist as these patients may develop recoarctation and complications at the repair site and remain at enhanced cardiovascular risk throughout their lifetime.