Exercise systolic blood pressures are of questionable value in the assessment of the adult with a previous coarctation repair

Hypertensive response to exercise in adult patients with repaired aortic coarctation

OBJECTIVE

The clinical and prognostic implications of a hypertensive response to exercise after repair of coarctation of the aorta (CoA) remain controversial. We aimed to determine the prevalence of a hypertensive response to exercise, identify factors associated with peak exercise systolic blood pressure (SBP) and explore the association of peak exercise SBP with resting blood pressure and cardiovascular events during follow-up.

METHODS

From the Dutch national CONgenital CORvitia (CONCOR) registry, adults with repaired CoA who underwent exercise stress testing were included. A hypertensive response to exercise was defined as a peak exercise SBP ≥210 mm Hg in men and ≥190 mm Hg in women. Cardiovascular events consisted of coronary artery disease, stroke, aortic complications and cardiovascular death.

RESULTS

Of the original cohort of 920 adults with repaired CoA, 675 patients (median age 24 years (range 16-72 years)) underwent exercise stress testing. Of these, 299 patients (44%) had a hypertensive response to exercise. Mean follow-up duration was 10.1 years. Male sex, absence of a bicuspid aortic valve and elevated resting SBP were independently associated with increased peak exercise SBP. Peak exercise SBP was positively predictive of office SBP (β=0.11, p<0.001) and 24-hour SBP (β=0.05, p=0.03) at follow-up, despite correction for baseline SBP. During follow-up, 100 patients (15%) developed at least 1 cardiovascular event. Peak exercise SBP was not significantly associated with the occurrence of cardiovascular events (HR 0.994 (95% CI 0.987 to 1.001), p=0.11).

CONCLUSIONS

A hypertensive response to exercise was present in nearly half of the patients in this large, prospective cohort of adults with repaired CoA. Risk factors for increased peak exercise SBP were male sex, absence of a bicuspid aortic valve and elevated resting SBP. Increased peak exercise SBP independently predicted hypertension at follow-up. These results support close follow-up of patients with a hypertensive response to exercise to ensure timely diagnosis and treatment of future hypertension.

Assessment of hemodynamic responses to exercise in aortic coarctation using MRI-ergometry in combination with computational fluid dynamics

In patients with aortic coarctation it would be desirable to assess pressure gradients as well as information about blood flow profiles at rest and during exercise. We aimed to assess the hemodynamic responses to physical exercise by combining MRI-ergometry with computational fluid dynamics (CFD). MRI was performed on 20 patients with aortic coarctation (13 men, 7 women, mean age 21.5 ± 13.7 years) at rest and during ergometry. Peak systolic pressure gradients, wall shear stress (WSS), secondary flow degree (SFD) and normalized flow displacement (NFD) were calculated using CFD. Stroke volume was determined based on MRI. On average, the pressure gradient was 18.0 ± 16.6 mmHg at rest and increased to 28.5 ± 22.6 mmHg (p < 0.001) during exercise. A significant increase in cardiac index was observed (p < 0.001), which was mainly driven by an increase in heart rate (p < 0.001). WSS significantly increased during exercise (p = 0.006), whereas SFD and NFD remained unchanged. The combination of MRI-ergometry with CFD allows assessing pressure gradients as well as flow profiles during physical exercise. This concept has the potential to serve as an alternative to cardiac catheterization with pharmacological stress testing and provides hemodynamic information valuable for studying the pathophysiology of aortic coarctation.

Defining the relationship between arm and leg blood pressure readings: a systematic review and meta-analysis

OBJECTIVES

To define the relationship between arm and leg blood pressure (BP) to inform the interpretation of leg BP readings in routine clinical practice where arm readings are not available.

METHODS

Systematic review of all existing studies comparing arm and leg BP measurements. A search strategy was designed in MEDLINE and adapted to be run across six further databases. Articles were deemed eligible for inclusion if they measured and reported arm and leg BP taken in the supine position and/or the difference between the two. Mean values for arm-leg BP difference and measures of precision [95% confidence intervals (CIs) or SD] were extracted and entered into a random-effects meta-analysis.

RESULTS

A total of 887 articles were screened and 44 were included in the descriptive analyses, including 9771 patients. In the general population, ankle SBP was 17.0 mmHg (95% CI 15.4-21.3 mmHg) higher than arm BP in the supine position. For DBP, there was no difference between arm and ankle BP (-0.3 mmHg, 95% CI -1.5-1.0 mmHg). In patients with vascular disease, SBP was -33.3 mmHg (95% CI -59.1 to -7.6 mmHg) lower in the ankle compared with the arm.

CONCLUSION

This is the first review to provide empirical data defining the difference between BP in the arm and leg in the general population. Findings suggest a diagnostic threshold of 155/90 mmHg could be used for diagnosing hypertension when only ankle measurements are available in routine practice.

Long-term observation of adults after successful repair of aortic coarctation

Introduction

Despite successful repair of aortic coarctation, cardiovascular complications occur.

Aim

To analyse type and frequency of late complications and their impact on exercise capacity in adults after aortic coarctation repair.

Material and methods

Fifty-eight adults after aortic coarctation repair, 36 male, median age 27.46 ±10.57, were compared to 30 healthy volunteers. Physical examination, transthoracic echocardiography, carotid intima-media thickness measurement, cardiopulmonary exercise test and 24-hour ambulatory blood pressure monitoring were performed.

Results

The main complications were: arterial hypertension 48.3%, myocardial hypertrophy in echocardiography 29.34%, recoarctation 25.86%, aortic dilation 13.79% and coronary artery disease 6.89%. Exercise tolerance was reduced in the cardiopulmonary exercise test. The VO₂/kg peak was lower, 29.01 ±8.79 vs. 49.16 ±7.38 ml/kg/min, p < 0.001, VE/VCO₂ peak higher 28.18 ±4.69 vs. 26.78 ±3.13, p = 0.017. The peak heart rate was reduced, 157.28 ±22.22 vs. 177.93 ±23.08 bpm, p < 0.001, peak systolic blood pressure was higher, 174.79 ±17.62 vs. 153.33 ±4.79 mm Hg, p < 0.001. Systolic blood pressure in 24-hour ambulatory monitoring correlated with left ventricle mass index, r = 0.29, p = 0.025, wall thickness, r = 0.31, p = 0.039. Age at operation was related to left ventricle wall thickness, r = 0.27, p = 0.041, and carotid intima-media thickness, r = 0.26, p = 0.046. There was no association of any cardio-pulmonary parameters with time from surgery, type of operation or echocardiography results.

Conclusions

Adults after aortic coarctation repair suffer from arterial hypertension, recurrent aortic stenosis, aortic aneurysms, and coronary artery disease. Reduced exercise capacity in cardio-pulmonary exercise test is related to hypertensive reaction and chronotropic incompetence.

Echocardiography during submaximal isometric exercise in children with repaired coarctation of the aorta compared with controls

Objective

Patients with repaired coarctation (RCoA) remain at higher risk of cardiac dysfunction, initially often only detected during exercise. In this study, haemodynamics of isometric handgrip (HG) and bicycle ergometry (BE) were compared in patients with RCoA and matched controls (MCs).

Methods

Case–control study of 19 children with RCoA (mean age 12.9±2.3 years; mean age of repair 7 months) compared with 20 MC. HG with echocardiography followed by BE was performed in both groups.

Results

During HG (blood pressure) BP increased from 114±11/64±4 mm Hg to 132±14/79±7 mm Hg, without significant differences. During HG as well as BE, HR increased less in patients with RCoA. There were no significant differences in (left ventricle) LV dimensions or LV mass.

The RCoA group had diastolic dysfunction: both at rest and during HG they had significantly higher transmitral E and A velocities and lower tissue Doppler E′ and A′ velocities. E/E′ was higher, reaching statistical significance during HG (p<0001).

Conventional parameters of systolic function (FS and EF) were similar at rest and HG. More sensitive tissue Doppler S′ was significantly lower at rest in CoA subjects (5.1±1.5 cm/s vs 6.5±1±1 cm/s; p<0.01), decreasing further during HG by 5% in the CoA group (NS) while unchanged in controls.

Conclusions

We provide first evidence that HG with echocardiography is feasible, easy and patient-friendly. A decreased systolic (tissue Doppler) and impaired diastolic LV function was measured in the RCoA group, a difference that tended to increase during HG.

Late hypertension in patients with repaired aortic coarctation

Coarctation of the aorta represents more than a simple obstructive lesion, as there is often evidence of hypertension and vascular dysfunction despite successful surgery at an early age. There are ample data showing that a large proportion of patients develop arterial hypertension, and this appears to increase with age. Our understanding of the pathogenesis of late hypertension is incomplete, and there is limited information on which drugs are most appropriate. Increased arterial rigidity is now well described in this patient group, although it is not known how this should influence therapy. The increase in afterload associated with this increased rigidity has been found to have an impact on the left ventricle at an early stage, and the interaction between the vascular dysfunction and the ventricle is an area of interest and active research. This article reviews some recent studies and highlights areas where research questions remain.

Correlation of exercise response in repaired coarctation of the aorta to left ventricular mass and geometry

The role of exercise testing to risk stratify patients with repaired coarctation of the aorta (CoA) is controversial. Concentric left ventricular (LV) hypertrophy, defined as an increase in the LV mass-to-volume ratio (MVR), is associated with a greater incidence of adverse cardiovascular events. The objective of the present study was to determine whether a hypertensive response to exercise (HRE) is associated with increased LVMVR in patients with repaired CoA. Adults with repaired CoA who had a symptom-limited exercise test and cardiac magnetic resonance imaging examination within 2 years were identified. A hypertensive response to exercise was defined as a peak systolic blood pressure >220 mm Hg during a symptom-limited exercise test. The LV mass and volume were measured using cardiac magnetic resonance by an investigator who was unaware of patient status. We included 47 patients (median age 27.3 years, interquartile range 19.8 to 37.3), who had undergone CoA repair at a median age of 4.6 years (interquartile range 0.4 to 15.7). Those with (n = 11) and without (n = 36) HRE did not differ in age, age at repair, body surface area, arm-to-leg systolic blood pressure gradient, gender, or peak oxygen uptake with exercise. Those with a HRE had a greater mean systolic blood pressure at rest (146 ± 18 vs 137 ± 18 mm Hg, p = 0.04) and greater median LVMVR (0.85, interquartile range 0.7 to 1, vs 0.66, interquartile range 0.6 to 0.7; p = 0.04) than those without HRE. Adjusting for systolic blood pressure at rest, age, age at repair, and gender, the relation between HRE and LVMVR remained significant (p = 0.001). In conclusion, HRE was associated with increased LVMVR, even after adjusting for multiple covariates.

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.

Pulsatility index in aortic coarctation: a possible way to evaluate factors affecting stenting outcome

BACKGROUND

The pulsatility index (PI) shows continuous blood flow to the end organs and is a significant factor believed to decrease in aortic coarctation. Correction of this factor is of great importance in the treatment of stenotic lesions of the aorta. However, there are minimal data regarding the trend of changes in the PI after stent implantation. Furthermore, the association between the PI and other echocardiographic indices in patients undergoing stent implantation is unclear. This study was designed to evaluate changes in the PI following stenting and its correlation with other echocardiographic indices.

METHODS

Twenty-three patients with a diagnosis of aortic coarctation consecutively underwent two-dimensional and Doppler echocardiographic imaging modalities twice (before and after stenting). The patients were divided into two groups based on the percentage of increase in the PI after stenting (< 50% or ≥ 50%). The relation between the post-stenting PI and the baseline echocardiographic indices was assessed.

RESULTS

The PI was increased from 0.89 (SD = 0.30) to 1.75 (SD = 0.51) after stenting (p value < 0.001). Baseline diastolic/systolic velocity (D/S velocity) ratio of the abdominal aorta (p value = 0.013), mean velocity (p value = 0.033), and peak gradient of the descending aorta (p value = 0.033) were significantly higher in the patients with ≥ 50% increase in the PI after stenting.

CONCLUSION

OUR FINDINGS SHOWED THAT ELEVATION IN THE PI AFTER STENTING WAS A PREDICTABLE CRITERION IN PATIENTS WITH AORTIC COARCTATION: it was predicted by some baseline clinical and echocardiographic indices. Baseline D/S ratio velocity of the abdominal aorta, mean velocity and peak gradient of the descending aorta, and baseline systolic blood pressure were the statistically significant indices to predict ≥ 50% increase in the PI in our patients.

Usefulness of exercise-induced hypertension as predictor of chronic hypertension in adults after operative therapy for aortic isthmic coarctation in childhood

Chronic hypertension is a major concern in adults who have undergone resection of coarctation of the aorta (CoA) in childhood. In otherwise healthy subjects, exercise-induced hypertension is prognostic for chronic hypertension; however, the prognostic value in patients with CoA remains unknown. The aim of the present study was to evaluate the predictive value of exercise-induced hypertension for chronic hypertension in these patients. In the present prospective follow-up study, 74 patients with CoA (58% men, age 30.9 ± 9.5 years) underwent ambulatory blood pressure (BP) monitoring and exercise testing twice from 2001 to 2009 with a follow-up period of 6.3 ± 0.8 years. Hypertension was defined as a mean systolic BP ≥140 mm Hg and/or mean diastolic BP ≥90 mm Hg or the need for antihypertensive treatment. Exercise-induced hypertension was defined as a mean systolic BP of <140 mm Hg and peak exercise systolic BP of ≥200 mm Hg. At baseline, 27 patients (36%) were hypertensive, 11 (15%) had exercise-induced hypertension, and 36 (49%) were normotensive. At follow-up, all 27 hypertensive patients remained hypertensive. Of the 11 with exercise-induced hypertension, 7 (64%) had developed chronic hypertension, and 4 (36%) continued to have exercise-induced hypertension. Of the 36 normotensive patients, 7 (19%) had developed hypertension, 12 (33%) had developed exercise-induced hypertension, and 17 (47%) remained normotensive. On multivariate analysis, baseline maximum exercise systolic BP was independently associated with the mean systolic BP at follow-up (β = 0.13, p = 0.005). In conclusion, the maximum exercise systolic BP was a predictor for chronic hypertension in patients with CoA. These findings demonstrate the clinical importance of exercise-induced hypertension and warrant additional study into the long-term consequences of exercise-induced hypertension and the potential beneficial role of early antihypertensive treatment in adult patients after CoA repair with exercise-induced hypertension.

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.

Coarctation of the aorta: evaluation and management

PURPOSE OF REVIEW

Coarctation of the aorta is the discrete narrowing of the proximal descending aorta and is the sixth most common lesion in congenital heart disease. Repair of the coarctation can relieve the obstruction, but recurrent coarctation and future aneurysm formation can occur, and a heightened risk of vascular disease is present. This review focuses on advances in the management of native and previously treated coarctation and provides insights into future vascular risk.

RECENT FINDINGS

Coarctation of the aorta is associated with other left heart obstructive lesions, and advances in the genetic basis of these conditions have been made. Recurrent coarctation and aneurysm formation are common after surgical and endovascular repair of coarctation of the aorta. Endovascular treatment is an acceptable alternative to surgical repair of native and recurrent coarctation. Covered stents and stent grafts can be used to treat arch complications with a low risk of complications. In spite of repair of the obstruction, hypertension persists and appears to be multifactorial due to a variety of factors, including endothelial dysfunction, aortic stiffness, altered arch morphology and increased ventricular stiffness.

SUMMARY

People with previously repaired coarctation of the aorta require long-term surveillance for local complications with aortic imaging and surveillance and management of hypertension to prevent vascular disease.

Covered stents in the management of coarctation of the aorta in the adult: initial results and 1-year angiographic and hemodynamic follow-up

BACKGROUND

The purpose of this study was to determine the safety and efficacy of the Cheatham Platinum covered stent in adults with coarctation of the aorta.

METHODS

Adults with native coarctations (n=14); previous coarctation surgery (n=4), stenting (n=1) or both surgery and endovascular therapy (n=3) underwent percutaneous intervention with a covered stent. Indications for stenting in those with previous intervention were recurrent coarctation (n=4), aneurysm formation at the site of previous intervention (n=2) or both recurrent coarctation and aneurysm formation (n=2).

RESULTS

Twenty-three covered stents were placed in 22 patients (mean age 39+/-14 years, n=11 males). Successful device deployment was achieved in all patients, although one patient required a second covered stent for aortic wall rupture. Peak systolic gradient across the coarctation site decreased from 29+/-17 to 3+/-5 mm Hg (p<0.001) immediately following implant and this was maintained (6+/-9 mm Hg, p=0.001) at invasive assessment, 12 months after the initial procedure. Right arm systolic blood pressure significantly declined (p=0.02), as did the number of antihypertensive medications per patient (p=0.03). At angiographic follow-up, post-stenotic dilatation of the aorta decreased from 32+/-8 mm to 30+/-8 mm (p=0.001), however, no stent recoil was observed.

CONCLUSIONS

Covered stents are safe, durable and efficacious in the management of coarctation of the aorta. Angiography and hemodynamic assessment is an effective method of screening for recurrent coarctation, and arch and vascular complications after stenting in adults.

Exercise capacity and exercise hypertension after surgical repair of isolated aortic coarctation

There are contradictory reports whether exercise capacity is reduced in patients on long-term follow-up after coarctation repair. Data from unselected patient groups are missing. In a cross-sectional, long-term follow-up study of a tertiary congenital cardiology referral center, 260 patients (30.2+/-11.4 years old, 84 women), after surgical repair for isolated aortic coarctation (age at surgery 11.5+/-11.2 years), underwent a symptom-limited exercise test. Peak workload was 180+/-52 W, significantly less than the age- and height-related reference values (p<0.0005). A peak workload under 80% of expected was found in 200 patients (77%). Exercise performance of the patients was independent from age at surgery, type of surgery, or the systolic brachial-ankle blood pressure difference. The only exercise-limiting factor found was the chronic administration of diuretics to treat hypertension (p=0.005). Exercise hypertension, defined as a systolic blood pressure >2 SD above the load-dependent reference value, was found in 73 patients (28%). It was independently related to the systolic brachial-ankle blood pressure difference (p<0.0005) and diuretics administration (p=0.037). In conclusion, most patients after coarctation repair have a reduced exercise performance. This reduction is not related to the surgical results. Particularly, as these patients are at risk of early atherosclerosis, exercise should be promoted as primary prevention after restenosis, aortic or cerebral aneurysms, and severe exercise hypertension are ruled out.

Coarctation Long-term Assessment (COALA): Significance of arterial hypertension in a cohort of 404 patients up to 27 years after surgical repair of isolated coarctation of the aorta, even in the absence of restenosis and prosthetic material

OBJECTIVE

Recent studies have demonstrated that there is a loss of aortic compliance in patients after coarctation repair. The clinical effect of this and other mechanisms apart from restenosis on the rate of arterial hypertension is unknown.

METHODS

From 1974 through 2000, 404 patients born before January 1, 1985, underwent surgical intervention for isolated aortic coarctation. From those 382 who are still alive, 273 patients aged 16 to 73 years (1-27 years after surgical intervention) underwent a structured clinical investigation according to a prospective protocol, including blood pressure measurement at all limbs, ambulatory blood pressure measurement, and symptom-limited exercise testing.

RESULTS

Sixty-seven (25%) patients were already taking antihypertensive drugs, and another 63 (23%) patients had an increased ambulatory blood pressure. Still another 26 (10%) patients had a blood pressure during exercise exceeding 2 standard deviations of reference values. Only 117 (43%) patients had a normal blood pressure reaction. From those 156 patients with hypertension, only 21 (13%) had a systolic brachial-ankle blood pressure difference of greater than 20 mm Hg, suggesting restenosis. In the patient group without restenosis (n = 245), independent risk factors for hypertension were repair with prosthetic material, male sex, a residual brachial-ankle blood pressure difference, and older age at follow-up.

CONCLUSIONS

The majority of patients were hypertensive at long-term follow-up after coarctation repair. This is caused by restenosis, defined by a gradient of greater than 20 mm Hg, in only a few patients. Even in those without prosthetic material or minimal-grade restenosis, there is a substantial incidence of arterial hypertension.

The adult with repaired coarctation of the aorta

Coarctation of the aorta is a common congenital lesion that may often be repaired or intervened upon early in life. The management of patients with this disorder revolves around the concept that although the coarctation may be treated, what remains is a diffuse systemic cardiovascular disorder. Careful clinical care and investigation is required to reduce morbidity from recurrent disease and residual lesions. The natural and modified history of the disorder is reviewed. This article focuses on the clinical care of adults with repaired coarctation and includes a review of clinical goals and investigation as well as indications for reintervention.

Impact of transverse aortic arch hypoplasia after surgical repair of aortic coarctation: An exercise echo and magnetic resonance imaging study

BACKGROUND

We sought to assess the impact of persistent hypoplasia of the transverse aortic arch (TAA) after repair of aortic coarctation (AoC), on blood pressure response to exercise, left ventricular (LV) hypertrophy and presence of collateral circulation.

METHODS

34 consecutive patients with end-to-end repair of AoC (age at repair 3.2+/-2.5 years) underwent exercise echocardiography and magnetic resonance imaging (MRI) at 24+/-7 years of age (range 11.3 to 44.6 years). Systolic Doppler pressure gradient (SPG) across the descending aorta and blood pressure at the right arm were measured at baseline and every minute throughout all exercise. Magnetic resonance imaging was used to measure LV mass index, presence and amount of collateral flow, and the diameters of the aortic isthmus and TAA indexed to the diameter of the diaphragmatic.

RESULTS

Aortic isthmus index was higher than that of the TAA (p=0.006). We observed LV hypertrophy in 15 patients (45%) and presence of collateral circulation in 14 (41%). Eighteen patients (53%) had an abnormal blood pressure response to exercise. Patients with abnormal pressure response to exercise had smaller TAA index (p=0.0005), but similar aortic isthmus index (p=0.09). They also had higher exercise SPG (p<0.0001), higher LV mass index (p<0.0001) and prevalence of LV hypertrophy (p=0.007), higher prevalence of collateral circulation (p<0.0001) and a higher amount of collateral flow (p<0.0001). TAA index, but not aortic isthmus index, correlated with exercise blood pressure (r=-0.59, p=0.003), exercise SPG (r=-0.70, p=0.0005), amount of collateral flow (r=-0.74, p=0.0002) and LV mass index (r=-0.68, p=0.0007).

CONCLUSIONS

After repair of AoC, hypoplasia of the TAA may be responsible for abnormal blood pressure response to exercise, persistence of collateral circulation and LV hypertrophy.

Exercise testing in adults after repair of aortic coarctation: evaluation of cardiopulmonary exercise capacity and B-type natriuretic protein levels

The aim of the study was to investigate, in adult patients after successful repair of aortic coarctation, potential relationships between B-type natriuretic peptide levels and exercise capacity and the following factors: arterial hypertension, residual stenosis of the ascending aorta, and age at the time of surgery. The study group comprised 74 patients (45 men) aged 19 to 61 years (mean, 31.2 +/- 9.8 yr), who had undergone surgery at the age of 0.5 to 34 years (mean, 10.4 +/- 6.8 yr). The surgery was performed between 5 and 34 years earlier (mean, 21.4 +/- 6.2 yr). A subgroup with residual aortic stenosis (significant when > or =25 mmHg) comprised 32 patients; a subgroup without residual stenosis comprised 42 patients. Patients were also divided into subgroups without arterial hypertension (n=32), with exercise-induced arterial hypertension (n=10), and with persistent arterial hypertension (n=32). All patients were in New York Heart Association functional class I. The control group comprised 30 healthy subjects (18 men) aged 26 to 46 years (mean, 32.2 +/- 6.6 yr). After testing exercise capacity in accordance with a modified Bruce protocol, we concluded that the exercise capacity of adults is reduced after surgical repair of aortic coarctation. This reduction is more pronounced in patients who have arterial hypertension, but it is unaffected by residual stenosis of the descending aorta. Serum B-natriuretic peptide concentrations, as determined by immunoradiometric assay, are significantly elevated, which may result from pressure overload of the left ventricle or from residual myocardial lesions due to coarctation repair at an older age.

Aortic arch shape deformation after coarctation surgery: Effect on blood pressure response

OBJECTIVE

We sought to investigate the effect of particular deformations of aortic arch shape on blood pressure response in children who had undergone successful repair of coarctation of the aorta.

METHODS

We studied normotensive patients (aged 15.1 +/- 5.8 years) who had undergone coarctation surgery by means of simple (n = 43) or extended (n = 32) end-to-end anastomosis. All patients underwent systematic exercise testing during follow-up, as well as magnetic resonance imaging. Three types of aortic arch geometry were evident on magnetic resonance imaging: gothic arch with angular geometry and an increased height/width ratio of the arch, crenel arch with a rectangular shape, and normal arch with a smooth rounded shape. For each subject's arch, the continuous variable height/width ratio was calculated.

RESULTS

Exercise-induced hypertension was more frequent in patients with gothic arch, with a prevalence of 83% at 15 years after surgical intervention (95% confidence interval, 69%-97%) versus 25% (95% confidence interval, 0%-50%) in those with crenel and 21% (95% confidence interval, 10%-46%) in those with normal arch geometry (P < .001). The cumulative incidence of exercise-induced hypertension as a function of aortic arch geometry was significantly higher in patients with gothic arch geometry throughout follow-up. On multivariate analysis, both gothic arch geometry and higher height/width ratio were significantly correlated with exercise-induced hypertension.

CONCLUSION

An angulated gothic arch is independently associated with abnormal blood pressure response. This deformation of the aortic arch identifies a subgroup of subjects with postoperative coarctation at high risk of hypertension in young adult life.

Endovascular stenting for aortic coarctation

Surgery had been the traditional treatment for native coarctation of the aorta, one of the most common cardiovascular congenital malformations. As a less invasive mode of treatment, balloon angioplasty has emerged as an alternative to surgery but has not gained universal acceptance due to its rates of restenosis secondary to vessel recoil and concerns over aortic wall injury resulting in aneurysm formation. To overcome these problems, endovascular stents were introduced in the management of this condition. The early- and intermediate-term results are encouraging, with low rates of restenosis and complications. In this article, the authors review the current evidence on coarctation stenting and discuss future trends in this area.

Results and mid–long-term follow-up of stent implantation for native and recurrent coarctation of the aorta

AIMS

Since the late 1980s, endovascular stents have been used in the treatment of several vascular lesions. In the last decades, stent implantation has been proposed as a reliable option for the treatment of coarctation of the aorta. In this setting, it seems to have some advantages, rendering it superior to angioplasty alone.

METHODS AND RESULTS

Between December 1997 and December 2004, 71 consecutive patients (44 males and 27 females) underwent cardiac catheterization for native or recurrent coarctation of the aorta. Seventy-four stents were implanted. All discharged patients were enrolled in a follow-up programme. Every patient underwent clinical evaluation, echo-colour Doppler studies, and exercise ECG at 1 and 6 months after the stent implantation. Peak systolic gradient dropped from 39.3 +/- 15.3 to 3.6 +/- 5.5 mmHg (P = 0.0041). The diameter of the coarcted segment increased from 8.3 +/- 2.9 to 16.4 +/- 3.8 mm (P = 0.037). In our series, one death occurred in a 22-year-old girl with a recurrent coarctation of the aorta, just after stent implantation. The rate of minor complications was <2%. Re-dilatation of a previously implanted stent was performed in three patients.

CONCLUSION

In our experience (the largest reported to the best of our knowledge), stenting of a coarctation/re-coarctation of the aorta represents a safe alternative treatment without a significant mid-long-term complication.

Stenting vs. balloon angioplasty for discrete unoperated coarctation of the aorta in adolescents and adults

More information is needed to clarify whether stenting is superior to balloon angioplasty (BA) for unoperated coarctation of the aorta (CoA). From September 1997, 21 consecutive adolescents and adults (24 +/- 11 years) with discrete CoA underwent stenting (G1). The results were compared to those achieved by BA performed in historical group of 15 patients (18 +/- 10 years; P = 0.103; G2). After the procedure, systolic gradient reduction was higher (99% +/- 2% vs. 87% +/- 17%; P = 0.015), residual gradients lower (0.4 +/- 1.4 vs. 5.9 +/- 7.9 mm Hg; P = 0.019), gain at the CoA site higher (333% +/- 172% vs. 190% +/- 104%; P = 0.007), and CoA diameter larger (16.9 +/- 2.9 vs. 12.9 +/- 3.2 mm; P < 0.001) in G1. Aortic wall abnormalities were found in eight patients in G2 (53%) and in one in G1 (7%; P < 0.001). There was no major complication. Repeat catheterization (n = 33) and/or MRI (n = 2) was performed at a median follow-up of 1.0 year for G1 and 1.5 for G2 (P = 0.005). Gradient reduction persisted in both groups, although higher late gradients were seen in G2 (median of 0 mm Hg for G1 vs. 3 for G2; P = 0.014). CoA diameter showed no late loss in G1 and a late gain in G2 with a trend to being larger in G1 (16.7 +/- 2.9 vs. 14.6 +/- 3.9 mm; P = 0.075). Two patients required late stenting due to aneurysm formation or stent fracture in G1. Aortic wall abnormalities did not progress and one patient required redilation in G2. Blood pressure was similar in both groups at follow-up (126 +/- 12/81 +/- 11 for G1 vs. 120 +/- 15/80 +/- 10 mm Hg for G2; P = 0.149 and 0.975, respectively). Although satisfactory and similar clinical outcomes were observed with both techniques, stenting was a better means to relieve the stenosis and minimize the risk of developing immediate aortic wall abnormalities.

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.

Mid-term effects of implanting stents for relief of aortic recoarctation on systemic hypertension, carotid mechanical properties, intimal medial thickness and reflection of the pulse wave

OBJECTIVE

Primary implantation of stents is an accepted technique for treating aortic recoarctation, albeit that the effects of stenting on pressure profiles, carotid mechanical properties, intimal medial thickness, and reflection of the pulse wave have not been systematically investigated.

METHODS

Over the period from 1 January, 1999, to 31 December, 2002, we implanted stents to relieve aortic recoarctation in 15 patients, with a median age of 17 years, and a range from 7 to 29 years, with a median weight of 56 kilograms, ranging from 20 to 96 kilograms. Indications were a gradient of 20 millimetres of mercury or more measured in all, systemic hypertension at rest in 8, and systemic hypertension at exercise in all. Of the patients, 5 were receiving anti-hypertensive treatment. Before implantation of the stents, and after a mean follow-up of 22 months, all patients underwent an exercise test, vascular echography, and examination of the common carotid artery so as to determine its cross sectional compliance and distensibility, and the augmentation index. results: The stents were implanted successfully in all patients. The mean gradient was reduced from 27 to 4 millimetres of mercury (p < 0.001). Systolic blood pressure at rest diminished from 140 to 131 millimetres of mercury (p = 0.04), while hypertension at rest regressed in 4 patients. Systolic blood pressure at exercise diminished from 245 to 222 millimetres of mercury (p = 0.018), and hypertension at exercise regressed in 1 patient. Anti-hypertensive treatment is still required for 4 patients. A correlation was found between systolic blood pressure at rest and initial peak-to-peak gradient (r = 0.8), and between initial gradient and percentage reduction of systolic blood pressure at rest at follow-up (r = -0.73). Compliance and distensibility of the common carotid artery were not significantly modified, albeit that the intimal medial thickness diminished from 0.64 to 0.57 millimetres (p = 0.04), and the augmentation index decreased from 5 to -1 (p = 0.012).

CONCLUSIONS

Primary implantation of stents is effective in mid-term repair of aortic recoarctation. Although there is an improvement in systemic hypertension, the tensional profile and vascular sonography are not normalized. At long term follow-up, the suppression of an early reflection site of the pulse wave could decrease the wall stress of the great elastic vessels, reducing the thickness of the arterial walls.

Relation between exercise-induced hypertension and sustained hypertension in adult patients after successful repair of aortic coarctation

OBJECTIVES

To investigate whether exercise-induced hypertension in successfully repaired adult post-coarctectomy patients is associated with hypertension on 24-h blood pressure measurement and increased left ventricular mass.

METHODS

One hundred and forty-four consecutive post-coarctectomy patients (mean age 31.5 years, range 17-74 years; mean age at repair 7.9 years, range 0-45 years) from three tertiary referral centres were studied using ambulatory blood pressure monitoring, treadmill exercise testing and echocardiography.

RESULTS

Of the 144 patients, 27 (19%) were known to have sustained hypertension, based on their history, and all were on antihypertensive medication. However, 32 (27%) of the remaining 117 patients showed elevated mean daytime systolic blood pressure readings at 24-h ambulatory blood pressure monitoring (systolic blood pressure > or = 140 mmHg). Of the remaining 85 patients with normal mean daytime systolic blood pressure, 18 patients (21%) had exercise-induced hypertension (maximal exercise systolic blood pressure > 200 mmHg). Mean daytime systolic blood pressure was higher in the exercise-induced hypertensive patients compared to the normotensive patients with normal exercise blood pressure (134 +/- 5 versus 129 +/- 7 mmHg, P = 0.008). By multivariate analysis, both maximal exercise systolic blood pressure (P = 0.007) and resting systolic blood pressure (P < 0.0001) were independently associated with mean daytime systolic blood pressure. Maximal exercise systolic blood pressure had no independent predictive value for left ventricular mass (P = 0.132).

CONCLUSIONS

In adult post-coarctectomy patients, maximal exercise systolic blood pressure is independently associated with mean daytime systolic blood pressure at ambulatory blood pressure monitoring. In this study no independent predictive value of maximal exercise systolic blood pressure for left ventricular mass could be demonstrated.

Aortic coarctation: the need for lifelong surveillance

Survival of patients with aortic coarctation improved dramatically after surgical repair became available and the number of patients who undergo surgery 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 into five categories: recoarctation, endocarditis, stenotic and/or incompetent coexisting bicuspid aortic valve, aortic aneurysm formation and systemic hypertension. In this review, these complications, with particular reference to late hypertension, are discussed and strategies for the clinical management of postcoarctectomy patients are described.

Exercise blood pressure in congenital heart disease and in patients after coarctation repair

Cardiologists have often described aortic coarctation as "simple" rather than "complex" congenital heart disease; nothing could be further from the truth.