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

Role of Computed Tomography Angiography in the Short-Term Follow-up of Aortic Coarctation Repair

INTRODUCTION

Coarctation of the aorta (CoA) is a narrowing of the thoracic aorta that often manifests as discrete stenosis but may be tortuous or in long segment. The study aimed to evaluate pre and post-surgical aspects of pediatric patients submitted to CoA surgical correction and to identify possible predisposing factors for aortic recoarctation.

METHODS

Twenty-five patients were divided into groups according to presence (N=8) or absence (N=17) of recoarctation after surgical correction of CoA and evaluated according to clinical-demographic profile, vascular characteristics via computed angiotomography (CAT), and other pathological conditions.

RESULTS

Majority of males (64%), ≥ 15 days old (76%), ≥ 2.5 kg (80%). There was similarity between groups with and without recoarctation regarding sex (male: 87% vs. 53%; P=0.277), age (≥ 15 days: 62.5 vs. 82%; P=0.505), and weight (≥ 2.5 kg: 87.5 vs. 76.5; P=0,492). Altered values of aortic root/Valsalva diameter, proximal transverse arch, and distal isthmus, and normal values for aorta prevailed in preoperative CAT. Normal values for the aortic root/Valsalva sinus diameter were observed with and without recoarctation, the same for both groups regarding ascending and descending aorta in postoperative CAT. No significant difference for altered values of proximal transverse arch and alteration in distal isthmus was observed.

CONCLUSION

No predictive risk for recoarctation was observed. CTA proved to be important in CoA diagnosis and management, since CoA is mainly related with altered diameter of aortic root/sinus of Valsalva and proximal and distal aortic arch/isthmus, however, it failed to show predictive risk for recoarctation.

Anatomical/Physiological Correlates of Functional Capacity in Adults With Repaired and Nonsevere Coarctation of the Aorta

Background

There is limited data regarding the interplay of anatomic and physiologic parameters with exercise capacity in adults with native or recurrent nonsevere coarctation of the aorta (CoA).

Objectives

The objective of this study was to use exercise stress echocardiography and cardiac magnetic resonance imaging to identify anatomic and physiologic correlates of exercise capacity in these patients.

Methods

We conducted a single-center retrospective analysis of 54 adults with nonsevere CoA (repaired or unrepaired) followed at our institution between 2015 and 2020. Resting coarctation gradients were obtained using echocardiography. Exercise gradients and functional capacity were assessed using exercise stress echocardiography. Aorta anatomy was obtained using magnetic resonance imaging.

Results

Coarctation-to-diaphragm ratio correlated with minutes of exercise (r = 0.56, P < 0.01) and metabolic equivalents (r = 0.49, P < 0.01). These relationships remained significant after controlling for use of beta-blockers, valvular disease, and type of coarctation repair. Minutes of exercise correlated with mean resting gradients (r = -0.39, P < 0.05). Coarctation-to-diaphragm ratio correlated with peak and mean resting gradients (r = -0.34, P < 0.05; r = -0.48, P < 0.01). Patients with coarctation-to-diaphragm ratio ≤0.7 achieved fewer metabolic equivalents (11.1 ± 1.9 vs 12.8 ± 2.2, P < 0.05) and minutes of exercise (10.3 ± 2.0 vs 12.6 ± 2.7, P < 0.05).

Conclusions

In patients with nonsevere native or recurrent CoA, reduced exercise capacity is correlated with coarctation severity by anatomic size and gradients. Those with a coarctation-to-diaphragm ratio ≤0.7 may represent a subset of patients with nonsevere CoA whose clinical symptoms are only elicited with exercise stress testing. Exercise stress testing and cross-sectional imaging may help identify those who could be considered for earlier coarctation intervention.

Infants With Congenital Heart Disease at Risk of Early Atherosclerotic Disease

Background

Aortic intima‐media thickness (aIMT) measurement is an established indicator of preclinical atherosclerosis. We aimed to describe the aIMT in infants with congenital heart disease undergoing cardiac surgery over the first year of life and explore its association with cardiopulmonary bypass, growth velocity, and a diagnosis of left heart obstruction.

Methods and Results

A prospective cohort study measuring mean and maximum aIMT preoperatively, at 3 months, and 1 year of age in neonates with congenital heart disease undergoing cardiac surgery. Twenty‐four infants with a median gestation of 39 weeks and a median birth weight of 3184 g were included. Sixteen (67%) infants had left outflow tract obstruction. Gestation correlated inversely with baseline mean aIMT (β=−0.027, P =0.018) and positively with the percentage of increase in mean and maximum aIMT between baseline and 3 months (β=17%, P =0.027 and β=15%, P =0.023). The presence of left outflow obstruction was significantly associated with increasing mean and maximum aIMT between baseline and 1 year (mean aIMT change: β=34%, P =0.017 and maximum aIMT change β=43%, P =0.001). Both subgroups of left heart obstruction and non‐left heart obstruction significantly changed over time ( P =0.001 and P <0.001) but trends were not statistically different between both subgroups ( P =0.21). Growth velocity and cardiopulmonary bypass were not associated with baseline or change in aIMT over the first year of life.

Conclusions

AIMT significantly increased over the first 3 months in our cohort of infants with repaired congenital heart disease. Increasing gestation was associated with decreasing aIMT at 3 months. Growth velocity and cardiopulmonary bypass were not associated with aIMT changes over the first year. Left heart obstruction was associated with a trend toward increased aIMT.

Hypertension after coarctation repair-a systematic review

BACKGROUND

Coarctation of the Aorta (CoA) leads to increased morbidity and mortality later in life despite early surgical or percutaneous treatment. Many long-term complications are related to hypertension (HT) which is a common finding late after coarctation repair.

METHODS

A systematic Review was performed including articles published between February 2012 to December 2020. Systematic searches were conducted on PubMed and the Cochrane Controlled Trials Register to look for studies on HT after aortic CoA-repair. PRISMA guidelines were used.

RESULTS

In this systematic review on HT after CoA Repair the mean prevalence of HT was 47.3% (20-70%). A progressive character was of the HT was found, furthermore if only studies are included with 24 h blood pressure (BP) recording in addition to standard BP measurements, the incidence of HT rose to 57.8%.

DISCUSSION

Most clinical studies look at complications, mortality rate and residual pressure gradient rather than correlating hemodynamic indices with long-term outcome. Although HT is commonly based in measurement of peripheral BP, it has been shown that peripheral BP in CoA patients has a poor correlation with central aortic pressure. Central aortic hemodynamics are significantly altered in patients with repaired CoA, which can now adequately be investigated non-invasively. At the present time there are no studies linking long-term outcome with abnormal central hemodynamics.