Asian Cardiovasc Thorac Ann 2008;16:11-15
© 2008 Asia Publishing EXchange Ltd
Repair of Aortic Coarctation in Adults: the Fate of Hypertension
Khosro Hashemzadeh, MD,
Shahriar Hashemzadeh, MD,
Farzad Kakaei, MD
Department of Cardiovascular Surgery, Shahid Madani Heart Center, Tabriz University of Medical Sciences, Tabriz, Iran
For reprint information contact: Farzad Kakaei, MD Tel: 98 915 311 8095 Fax: 98 411 334 1317 Email: fkakaei{at}yahoo.com, Department of Surgery, Imam Khomeini’s Hospital, Daneshgah Street, Tabriz, Iran.
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ABSTRACT
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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.
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INTRODUCTION
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Coarctation of the aorta accounts for 5%–8% of patients treated for congenital heart disease.1 Isolated coarctation is slightly more than twice as common in males as in females.2 Owing to rapid advances in early diagnosis and management, coarctation of the aorta is now rarely encountered in adults. Unrepaired coarctation of the aorta results in high morbidity and mortality from hypertension and associated problems including myocardial infarction, heart failure, intracranial hemorrhage, aortic rupture, infective endocarditis and coronary disease.3,4 Without correction, most patients die before the age of 50 years.5 There is less agreement about the benefits of surgery for those discovered to have coarctation as adults, because several reports indicated poor resolution of hypertension postoperatively in older patients.6 But other authors suggest that "surgical repair, even in adults, is safe and improves systemic hypertension".7 This retrospective study was undertaken to evaluate the fate of hypertension after surgical intervention in adults with coarctation of the aorta, in the Northwestern Iranian population.
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PATIENTS AND METHODS
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Between 1996 and 2006, 38 adults (
16-years old) underwent repair of coarctation of the aorta at Tabriz University of Medical Sciences. There were 22 (58%) males and 16 (42%) females, with a mean age of 25.6 ± 6.9 years (range, 16 to 39 years). Preoperative blood pressure (BP) was measured in the right arm. Aortic pressures proximal and distal to the coarctation were measured by preoperative catheterization in 28 patients. In accordance with guidelines established by the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure,8 systolic hypertension was defined as: mild, 140 to 159 mm Hg; moderate, 160 to 179 mm Hg; severe, 180 to 210 mm Hg; and very severe 210 mm Hg. The patients were divided into groups according to the number of antihypertensive agents taken before surgery and at the time of the last follow-up. The drugs included diuretics, vasodilators, beta blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin II receptor inhibitors. The number of antihypertensive drugs each patient was taking before surgery was compared with drug intake at the last follow-up.
All operations were performed through a left posterolateral thoracotomy. A simple clamp-and-sew technique was employed for coarctation repair which comprised resection and end-to-end anastomosis in 11 patients, patch aortoplasty in 24 with Dacron (in 16) or Gore-Tex (in 8; one of whom had concurrent patent ductus arteriosus closure), and resection with interposition of a Dacron tube graft (size 22) in 3. One patient had undergone a Bentall operation one year earlier. Follow-up of all patients was achieved during an office visit or review of office records, and by telephone interview. The patients were followed up for 2 to 90 months (mean, 37 ± 23 months).
Data are presented as mean ± standard deviation. Systolic BP gradients across the coarctation before and after repair were evaluated using the paired Student’s t test. A p value < 0.05 was considered significant. In addition, the age difference between patients receiving no drugs and those with at least one drug was assessed with an unpaired t test.
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RESULTS
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Thirty (79%) patients had systolic hypertension at the time of admission, and 8 (21%) were normotensive (< 140 mm Hg). Systolic BP in hypertensive patients ranged from 140 to 200 mm Hg, with a mean of 158.3 ± 18.6 mm Hg. The mean diastolic BP was 93.1 ± 14 mm Hg (range, 70 to 140 mm Hg). Hypertension was severe in 7 patients, moderate in 6 and mild in 17. The peak systolic gradient across the coarctation in 28 patients was 70.6 ± 21.2 mm Hg (range, 38 to 120 mm Hg); the gradient across the coarctation segment could not be assessed in the other 10 patients who had very little forward flow in the aorta. Most patients (28/38, 74%) were on a regimen of at least one antihypertensive drug (Figure 1
). Of the 10 patients who were not on any medication at the time of operation, 9 were hypertensive (systolic BP, 140–200 mm Hg) with a mean systolic BP of 160 ± 19 mm Hg, and a mean diastolic BP of 98 ± 13 mm Hg. The BP status of all patients is given in Table 1. Eight (21%) patients had a bicuspid aortic valve with (4/8) or without (4/8) mild aortic insufficiency. Other co-existing cardiac anomalies were mitral regurgitation, subvalvular aortic stenosis and severe aortic insufficiency in 2 patients each.
The patients were followed up after coarctation repair for 2 to 90 months (mean, 37 ± 23 months). There was no death. One patient had paraplegia after surgery. Two patients who were taking anticoagulants had a hemorrhage after hospital discharge; one of them underwent re-operation for clotted hemothorax. There were 3 other re-interventions during follow-up: 2 patients were found to have aortic valve disease (treated by valve replacement in one, and a Bentall procedure in the other); the third had discrete subvalvular aortic stenosis that was treated by resection.
One of the 8 patients who were normotensive before the operation was lost to follow-up. Of the 30 patients with preoperative hypertension, one was lost to follow-up, and 25 (83%) were normotensive (systolic BP < 140 mm Hg) at the most recent follow-up. The other 4 patients showed no substantial improvement over their preoperative status (preoperative BP, 151 ± 14 mm Hg; postoperative BP, 147 ± 10 mm Hg). The mean systolic BP after the operation in the 29 hypertensive patients (who were followed up completely) was 126.9 ± 14.7 mm Hg (range, 100–160 mm Hg); compared to the preoperative values, the difference was significant (t = 6.7, df = 28, p = 0.000). Mean diastolic BP (75 ± 13 mm Hg) was also significantly reduced (t = 4.9, df = 28, p = 0.000). The postoperative gradient across the repaired segment was trivial (
10 mm Hg) in 26 patients, mild ( 20 mm Hg) in 11, and moderate (> 20 mm Hg) in one. The mean postoperative gradient across the repaired segment was 7.0 ± 6.8 mm Hg.
Fifteen (42%) patients were taking no medication at the last follow-up. Ten of the 21 other patients required only a single agent, 9 required 2 drugs, and 2 required 3 drugs (Figure 2). Among those still needing medication, fewer drugs were required to maintain BP. The mean age of those still taking medication was 27 ± 7 vs 24 ± 6 years for those with no need of antihypertensive drugs; this difference was not significant ( p = 0.274). The mean age at surgery of all patients was 25.6 ± 6.9 years (range, 16–39 years), and all were classified as adults. We used age limits of 18, 20, 25 and 30 years as cut-off points in our analysis, but there was no significant difference in perioperative BP data according to age.
Table 2 shows the perioperative BP data according to the type of operation in the 30 patients with preoperative hypertension. All types of operation significantly reduced BP as well as the pressure gradient across the coarctation segment, except for the interposition graft which was carried out in only 3 patients and insufficient data were available.
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DISCUSSION
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Hypertension is an established major risk factor for cardiovascular disease leading to premature death.3,9 Some patients who are normotensive at rest show hypertensive reactions on exercise.10 Several factors have been implicated in the persistence of hypertension after successful repair of coarctation; these include endocrine factors, poor compliance of the arterial tree proximal to the coarctation site, geometry of the aortic arch, age at the time of repair and residual descending aortic narrowing.11–14 Despite a satisfactory reduction in BP soon after operation, studies with longer follow-up have demonstrated that approximately one-third of patients develop late hypertension, even when surgery is performed in the neonatal period.15,16,17 Clarkson and colleagues18 showed that the prevalence of late hypertension increased with the duration of follow-up.
Age at the time of initial repair of coarctation is the most important predictor of late hypertension.1,4,7,9 For this reason, there has been some reluctance to refer older adults for coarctation repair, and it has been suggested that patients with repaired coarctation of the aorta, may be "fixed but not cured".19 Most long-term follow-up series lack information about antihypertensive medications; in addition, patients with 20–25 years of follow-up were operated on and followed up in a period when there were fewer drugs to control BP. However, Wells and colleagues20 described 26 adults with follow-up of 1–7 years after coarctation repair who had a significant improvement in systolic hypertension.
In this study, 30 (79%) patients had preoperative systolic hypertension. Of these, one was lost to follow-up and 25 (83%) were normotensive at the most recent follow-up. The mean systolic BP postoperatively was significantly less than the preoperative value. This result is in agreement with Wells’ study that found hypertensive patients had significantly improved systolic BP postoperatively, and the majority (88%) were normotensive.20 In this series, the mean postoperative gradient across the repaired segment was significantly reduced. Another finding was that 15 (42%) patients were taking no medication at the last follow-up. The age of the patients and the type of operation had no effect on postoperative results. Of the patients still needing medication, the number of drugs required to control BP was less. On the basis of this experience, repair of aortic coarctation can be recommended in adults with a low risk of surgery.
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REFERENCES
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- Waldhausen JA, Myers JL, Campbell DB. Coarctation of the aorta and interrupted aortic arch. In: Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS. Glenn’s thoracic and cardiovascular surgery. 5th ed. Norwalk, Appleton&Lange 1991;1107–22.
- Shinebourne EA, Tam AS, Elseed AM, Paneth M, Lennox SC, Cleland WP. Coarctation of the aorta in infancy and childhood. Br Heart J 1976;38:375–80.[Abstract/Free Full Text]
- Maron BJ, Humphries JO, Rowe RD, Mellits ED. Prognosis of surgically corrected coarctation of the aorta. A 20-year postoperative appraisal. Circulation 1973;47:119–26.[Medline]
- Cohen M, Fuster V, Steele PM, Driscoll D, McGoon DC. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction. Circulation 1989;80:840–5.[Medline]
- Campbell M. Natural history of coarctation of the aorta. Br Heart J 1970;32:633–40.[Abstract/Free Full Text]
- Nanton MA, Olley PM. Residual hypertension after coarctectomy in children. Am J Cardiol 1976;37:769–72.[Medline]
- Daniels SR. Repair of coarctation of the aorta and hypertension: does age matter? Lancet 2001;358(9276):89.[Medline]
- The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med 1993;153:154–83.[Medline]
- Brouwer RM, Erasmus ME, Ebels T, Eijgelaar A. Influence of age on survival, late hypertension, and recoarctation in elective aortic coarctation repair. Including long-term results after elective aortic coarctation repair with a follow-up from 25 to 44 years. J Thorac Cardiovasc Surg 1994;108:525–31.[Abstract/Free Full Text]
- Vriend JW, van Montfrans GA, Romkes HH, Vliegen HW, Veen G, Tijssen JG, et al. Relation between exercise-induced hypertension and sustained hypertension in adult patients after successful repair of aortic coarctation. J Hypertens 2004;22:501–9.[Medline]
- Kirklin JW, Barratt-Boyes BG. Cardiac Surgery. New York: Churchill Livingstone, 1993:1263–325.
- Ou P, Bonnet D, Auriacombe L, Pedroni E, Balleux F, Sidi D, et al. Late systemic hypertension and aortic arch geometry after successful repair of coarctation of the aorta. Eur Heart J 2004;25:1853–9.[Abstract/Free Full Text]
- Vriend JW, Zwinderman AH, de Groot E, Kastelein JJ, Bouma BJ, Mulder BJ. Predictive value of mild, residual descending aortic narrowing for blood pressure and vascular damage in patients after repair of aortic coarctation. Eur Heart J 2005;26:84–90.[Abstract/Free Full Text]
- O’Sullivan JJ, Derrick G, Darnell R. Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement. Heart 2002;88:163–6.[Abstract/Free Full Text]
- Burchell HB, Clagett OT, Hines EA Jr, Wood EH, Wright JL. Hemodynamic and clinical appraisal of coarctation four to seven years after resection and end-to-end anastomosis of the aorta. Circulation 1956;14:806–14.[Abstract]
- Rathi L, Keith JD. Post-operative blood pressures in coarctation of the aorta. Br Heart J 1964;26:671–8.[Free Full Text]
- Maia MM, Aiello VD, Barbero-Marcial M, Ebaid M. Coarctation of the aorta corrected during childhood. Clinical aspects during follow-up. Arq Bras Cardiol 2000;74(2):167–80.[Medline]
- Clarkson PM, Nicholson MR, Barratt-Boyes BG, Neutze JM, Whitlock RM. Results after repair of coarctation of the aorta beyond infancy: a 10 to 28 year follow-up with particular reference to late systemic hypertension. Am J Cardiol 1983;51:1481–8.[Medline]
- Celermajer DS, Greaves K. Survivors of coarctation repair: fixed but not cured. Heart 2002;88:113–4.[Free Full Text]
- Wells WJ, Prendergast TW, Berdjis F, Brandl D, Lange PE, Hetzer R, et al. Repair of coarctation of the aorta in adults: the fate of systolic hypertension. Ann Thorac Surg 1996;61:1168–71.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
