Immediate and remote effects of resection on the hypertension in coarctation of the aorta

Juxtaductal aortic coarctation. Analysis of 84 patients studied hemodynamically, angiographically, and morphologically after age 1 year

Although many studies of juxtaductal coarctation of the aorta have been reported, none has correlated clinical, hemodynamic, angiographic, anatomic, and operative findings. Of 84 patients (62 male and 22 female; age range, 1 to 49 years [mean 17]), all had murmurs; 76 had absent, diminished, or delayed femoral pulsations; 50 had cuff systolic blood pressures in the arm greater than 140 mm Hg, and 30 had diastolic pressures greater than 90 mm Hg. The average pressure gradients (mm Hg) by direct measurements above and below the coarctation in 35 patients were peak systolic, 45; mean, 17; and diastolic, 5. Rib notching, visible in chest roentgenograms in 43 patients, correlated directly with age and inversely with the diameter of the coarctation. Moderate or marked cardiomegaly by radiograph was present in only 1 of 48 patients with isolated coarctation and in 17 of 36 with associated cardiovascular malformations. Electrocardiograms were abnormal in more than two thirds of patients with associated anomalies, but were normal in more than three fourths of those with isolated coarctation. In 70 excised, serially sectioned coarctations the aortic lumens were completely occluded in 4 patients, up to 0.5 mm in internal diameter in 22 patients, from 0.6 to 2 mm in 26 patients, from 2.1 to 5 mm in 14, and greater than 5 mm in 4, and correlated directly with lumens measured angiographically. The most significant anatomic factor causing the coarctation was invagination of the media from the posterior aortic wall, but intimal proliferation (jet lesion) at and immediately distal to the invagination contributed to the narrowing. Three (each with associated anomalies) of 70 patients died early after coarctation repair. Systolic or diastolic blood pressures decreased early postoperatively in 58 (87%) of 67 surviving patients, and both pressures decreased in 42 (63%). Late postoperatively (mean follow-up, 4.7 years), the systolic blood pressure remained elevated in 25% of patients.

Evaluation of persistent coarctation of aorta after surgery with blood pressure measurement and exercise testing

In 16 patients with coarctation of the aorta blood pressure in the arms and legs was measured before and after exercise using a treadmill and the Bruce protocol to achieve a standardized level of exercise. Three patients had had no previous operation; 13 had had a previous surgical repair of the coarctation. Three patients were studied both before and after operation. Two of the 13 patients studied postoperatively were found to have significant residual coarctation on the basis of a postexercise arm to leg pressure gradient that had not been appreciated on routine postoperative examination, and one of these patients was found to have residual coarctation after his second operation. One patient not operated on was believed to have mild coarctation of no clinical significance. Eleven of the 13 patients previously operated on (85%) were found to have had a satisfactory repair. A postexercise arm to leg systolic blood pressure gradient of more than 35 mm Hg after repair of coarctation of the aorta is suggested as an indication for recatheterization.

Coarctation of the aorta

Coarctation of the aorta is a cause of hypertension that can present dramatically in the severely ill infant or appear incidentally in the asymptomatic young adult. Coarctation is easily detected and there is good evidence that the extremely poor natural history can be altered favorably by surgical correction. The elevated blood pressure can be lowered in the majority of patients, and there is every expectation that the incidence of known complications of coarctation can be decreased. However, in about three fourths of the patients, significant residual cardiovascular defects persist, with their potential for future problems as yet incompletely defined. For this reason, patients who have undergone surgery for coarctation will need to be followed carefully for an indefinite period.

Coarctation of the aorta in adults

Thirty-six patients, 19 men and 17 women, presented at age 18 or older between 1952 and 1974 with coarctation of the aorta. Of the 14 (39%) who had associated cardiovascular disease, 12 had aortic stenosis or insufficiency or both. Three patients had infections-two, endocarditis (aortic valve) and one, endarteritis. Three of the seven patients who did not undergo an operation are alive, two at more than 50 years of age. Five patients had myocardial infarctions, two at 35 years of age. Twenty-nine (80%) had operations; in eight instances the patient was over age 40. All 18 patients undergoing repair of isolated coarctation survived, while only 7 of the 11 patients with associated cardiovascular lesions who underwent repair recovered. Aortic valvular disease and myocardial infarction are serious complicating factors in coarctation of the aorta.

Residual hypertension after coarctectomy in children

Coarctectomy in 190 children aged over 1 year to 15 years at operation produced a significant reduction in blood pressure for the group as a whole. Forty-nine patients (24 percent) remained hypertensive. Postoperative hypertension was unexplained in 29 (15 percent) of the 190 patients, and coarctation persisted or recurred in 20 (11 percent). For patients operated on between the ages of 4 and 15 years the earlier the age of operation, the greater the reduction in the blood pressure index: (measured blood pressure/normal mean systolic [or diastolic] blood pressure for age) X 100.

Coarctation of the aorta. Longitudinal assessment of operated patients

One hundred and ninety patients over the age of two operated upon for coarctation of the aorta from 1957 to 1972 at one institution were followed for one to 15.5 years (mean, 6.6 years). There were eleven cardiovascular deaths in the follow-up period. The mean age at death was 32.5 years. Two-thirds of the patients had an associated cardiovascular anomaly; 74 had coexistent aortic valve disease, and 19 had mitral stenosis or insufficiency. Five patients had a significant central nervous system event in the late postoperative period. Left ventricular hypertrophy by electrocardiogram was noted in 45, and 72 had radiographic left ventricular hypertrophy. A significant persistent or residual hemodynamic abnormality, either congenital heart disease, residual coarctation or persistent diastolic hypertension, could account for the residual electrocardiographic or radiographic abnormality. The data indicate that this population requires continuing care despite correction of the coarctation.

Prognosis of surgically corrected coarctation of the aorta. A 20-year postoperative appraisal

A long-term retrospective analysis of 248 patients, 11-25 years after surgical correction of coarctation of the aorta, revealed a high incidence of premature cardiovascular disease. Twelve percent of patients with follow-up have died. It is suggested that premature death in patients with adequate surgical repair may be related to the duration of preoperative hypertension. Fifty-nine patients were evaluated on a standard hospital protocol. Seventy-eight percent had evidence of cardiovascular disease and over 40% had no change or had increased blood pressure over the preoperative value.

These data emphasize the importance of early diagnosis and treatment for patients with coarctation of the aorta as well as the need for close postoperative follow-up.

PARADOXICAL HYPERTENSION AND THE ABDOMINAL PAIN SYNDROME FOLLOWING RESECTION OF COARCTATION OF THE AORTA

Sixteen children with coarctation of the aorta were studied in respect of the incidence of paradoxical hypertension and the abdominal pain syndrome after repair of the coarctation. These postoperative complications were investigated in relation to vanillylmandelic acid (VMA) excretion and extent of operative repair. The results, compared to those in a control group, indicated no evident causal relationship between these complications and catecholamine production. The severity of coarctation, the degree of correction and the operative increase in luminal surface area, however, appeared to be significant factors.