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Meijs TA, Muller SA, Minderhoud SCS, de Winter RJ, Mulder BJM, van Melle JP, Hoendermis ES, van Dijk APJ, Zuithoff NPA, Krings GJ, Doevendans PA, Spiering W, Witsenburg M, Roos-Hesselink JW, van den Bosch AE, Bouma BJ, Voskuil M. Hypertensive response to exercise in adult patients with repaired aortic coarctation. Heart 2022; 108:1121-1128. [PMID: 34987066 DOI: 10.1136/heartjnl-2021-320333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/30/2021] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Timion A Meijs
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands .,Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Steven A Muller
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Robbert J de Winter
- Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Nicolaas P A Zuithoff
- Department of Epidemiology and Biostatistics, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Gregor J Krings
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands.,Central Military Hospital, Utrecht, The Netherlands
| | - Wilko Spiering
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maarten Witsenburg
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | - Berto J Bouma
- Department of Cardiology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Mandell JG, Loke YH, Mass PN, Cleveland V, Delaney M, Opfermann J, Aslan S, Krieger A, Hibino N, Olivieri LJ. Altered hemodynamics by 4D flow cardiovascular magnetic resonance predict exercise intolerance in repaired coarctation of the aorta: an in vitro study. J Cardiovasc Magn Reson 2021; 23:99. [PMID: 34482836 PMCID: PMC8420072 DOI: 10.1186/s12968-021-00796-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/14/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Coarctation of the aorta (CoA) is associated with decreased exercise capacity despite successful repair. Altered flow patterns have been identified due to abnormal aortic arch geometry. Our previous work demonstrated aorta size mismatch to be associated with exercise intolerance in this population. In this study, we studied aortic flow patterns during simulations of exercise in repaired CoA using 4D flow cardiovascular magnetic resonance (CMR) using aortic replicas connected to an in vitro flow pump and correlated findings with exercise stress test results to identify biomarkers of exercise intolerance. METHODS Patients with CoA repair were retrospectively analyzed after CMR and exercise stress test. Each aorta was manually segmented and 3D printed. Pressure gradient measurements from ascending aorta (AAo) to descending aorta (DAo) and 4D flow CMR were performed during simulations of rest and exercise using a mock circulatory flow loop. Changes in wall shear stress (WSS) and secondary flow formation (vorticity and helicity) from rest to exercise were quantified, as well as estimated DAo Reynolds number. Parameters were correlated with percent predicted peak oxygen consumption (VO2max) and aorta size mismatch (DAAo/DDAo). RESULTS Fifteen patients were identified (VO2max 47 to 126% predicted). Pressure gradient did not correlate with VO2max at rest or exercise. VO2max correlated positively with the change in peak vorticity (R = 0.55, p = 0.03), peak helicity (R = 0.54, p = 0.04), peak WSS in the AAo (R = 0.68, p = 0.005) and negatively with peak WSS in the DAo (R = - 0.57, p = 0.03) from rest to exercise. DAAo/DDAo correlated strongly with change in vorticity (R = - 0.38, p = 0.01), helicity (R = - 0.66, p = 0.007), and WSS in the AAo (R = - 0.73, p = 0.002) and DAo (R = 0.58, p = 0.02). Estimated DAo Reynolds number negatively correlated with VO2max for exercise (R = - 0.59, p = 0.02), but not rest (R = - 0.28, p = 0.31). Visualization of streamline patterns demonstrated more secondary flow formation in aortic arches with better exercise capacity, larger DAo, and lower Reynolds number. CONCLUSIONS There are important associations between secondary flow characteristics and exercise capacity in repaired CoA that are not captured by traditional pressure gradient, likely due to increased turbulence and inefficient flow. These 4D flow CMR parameters are a target of investigation to identify optimal aortic arch geometry and improve long term clinical outcomes after CoA repair.
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Affiliation(s)
- Jason G Mandell
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
| | - Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Paige N Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Vincent Cleveland
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Marc Delaney
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Justin Opfermann
- Department of Mechanical Engineering, Johns Hopkins University, Latrobe Hall 223, 3400 North Charles St, Baltimore, MD, 21218, USA
| | - Seda Aslan
- Department of Mechanical Engineering, Johns Hopkins University, Latrobe Hall 223, 3400 North Charles St, Baltimore, MD, 21218, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Latrobe Hall 223, 3400 North Charles St, Baltimore, MD, 21218, USA
| | - Narutoshi Hibino
- Section of Cardiac Surgery, Department of Surgery, University of Chicago, 5841 S Maryland Avenue, Chicago, IL, 60637, USA
- Section of Cardiac Surgery, Department of Surgery, Advocate Children's Hospital, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Laura J Olivieri
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
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