Impact of Telehealth on Failure to Attend Rates and Patient Re-Engagement in Adult Congenital Heart Disease Clinic

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic paved the way for telehealth consultations. We aimed to determine the impact of telehealth on rates of failure to attend (FTA) in adult congenital heart disease (ACHD) clinics and whether telehealth could re-engage patients with previous FTA face-to-face appointments.

METHODS

This was a retrospective audit of a tertiary ACHD clinic over a 12-month pre-telehealth (26 March 2019-17 March 2020) and 12-month post-telehealth implementation period (24 March 2020-16 March 2021). Patients with one or more FTAs during the 24-month study period were included. Our ACHD clinic is run three times per month. Patients with ACHD are offered lifelong follow-up and reviewed annually on average. Re-engagement was defined as two or more consecutive face-to-face FTAs immediately before the telehealth period with subsequent attendance of their telehealth appointment.

RESULTS

A total of 359 patients with a total of 623 FTAs were included. Complexity of congenital heart disease was moderate in 56% (202/359) and severe in 19% (69/359) of patients. Overall FTA rate was 18% (623/3,452). FTA rate was significantly lower in the post-telehealth period (15%, 257/1,664) compared with the pre-telehealth period (20%, 366/1,788) (p<0.00001). At study conclusion, 1% of patients had died (5/359). Of the 354 remaining patients, 42% (150/354) were considered lost to follow-up (two or more FTAs including telehealth), 37% (132/354) missed only one clinic appointment, and 20% (72/354) previously considered lost to follow-up had re-engaged in the telehealth period.

CONCLUSIONS

Rates of FTA in a tertiary ACHD clinic significantly reduced after the introduction of telehealth consultation. A fifth of patients considered lost to follow-up were re-engaged with telehealth. Additional strategies to further reduce FTA should be explored.

Poorer Self-Reported Physical Health and Higher Anxiety Trait in Young Adults With Previous Coarctation Repair

BACKGROUND

Little is known about the impact of a coarctation repair on the functional outcomes of young adults. This study aimed to determine (1) the functional and mental health status in young adults with previous coarctation repair, and (2) the impact of late hypertension on their quality of life.

METHODS

A cross-sectional study using validated self-reported questionnaires (Short Form 36 version 2 [SF-36v2], Beck Depression Inventory [BDI], and State-Trait Anxiety Inventory [STAI]) was performed in 54 patients aged 15-47 years with previous paediatric coarctation repair. Questionnaire scores were compared to healthy age- and gender-matched controls. Patients' previously published 24-hour blood pressure monitoring results were included.

RESULTS

Late hypertension was present in 64% (34/54) at a mean of 29±8 years after coarctation repair. SF-36v2 mean physical component summary score was significantly lower in coarctation patients compared with controls (53.1±6.8 vs 56.0±4.7, p=0.02), but there was no significant difference in mean mental component summary score (p=0.2). SF-36v2 mean role emotional score tended to be associated with 10 mmHg increases in mean 24-hour systolic blood pressure (regression coefficient 4.3 p=0.06). STAI mean trait anxiety score tended to be higher in coarctation patients compared with controls (36.6±9.0 vs 33.5±7.8, p=0.06). There was no significant difference in BDI scores between patients and controls.

CONCLUSIONS

Young adults with previous coarctation repair report poorer physical health and tended towards higher anxiety trait compared to healthy controls. Strategies to improve self-reported physical health and anxiety should be explored. Long-term assessment of quality of life outcomes in coarctation patients is warranted.

Long-term outcomes following repair of truncus arteriosus and interrupted aortic arch

OBJECTIVES

We aim to evaluate the long-term outcomes following repair of truncus arteriosus with an interrupted aortic arch.

METHODS

We reviewed all children (n = 24) who underwent repair of truncus arteriosus and an interrupted aortic arch between 1979 and 2018 in a single institution. The morphology of the interrupted aortic arch was type A in 5, type B in 18 and type C in 1.

RESULTS

The median age at repair was 10 days and the median weight was 3.1 kg. Direct end-to-side anastomosis of the ascending and descending aorta was performed in 16 patients (67%, 16/24), patch augmentation in 5 patients (21%, 5/24) and direct anastomosis with the use of an interposition graft to the descending aorta in 2 patients (8%, 2/24). One patient, the first in the series, underwent interrupted aortic arch repair via subclavian flap aortoplasty prior to truncus repair. A period of deep hypothermic circulatory arrest was used in 16 patients, and isolated cerebral perfusion was used in 8 patients. The early mortality rate was 17% (4 out of 24 patients). There were no late deaths and overall survival was 83 ± 8% [95% confidence interval (CI) 61-93] at 20 years. Freedom from any reoperation was 33 ± 11% (95% CI 14-54) at 5 years and 13 ± 9% (95% CI 2-34) at 10 years. Six patients underwent 10 aortic reoperations. Freedom from aortic arch reoperation was 69 ± 11% (95% CI 42-85) at 10 and 20 years. Follow-up was 95% complete (19/20), with a median follow-up time of 20 years. At last follow-up, no clinically significant aortic arch obstruction was identified in any patient, and all patients were in New York Heart Association Class I/II.

CONCLUSIONS

Repair of truncus arteriosus with an interrupted aortic arch with direct end-to-side anastomosis results in good survival beyond hospital discharge. Although the long-term functional state of patients is good, reoperation rates are high.

Heart Failure in Adult Congenital Heart Disease

As the population of adult congenital heart disease patients ages and grows, so too does the burden of heart failure in this population. Despite the advances in medical and surgical therapies over the last decades, heart failure in adult congenital heart disease remains a formidable complication with high morbidity and mortality. This review focuses on the challenges in determining the true burden and management of heart failure in adult congenital heart disease. There is a particular focus on the need for developing a common language for classifying and reporting heart failure in adult congenital heart disease, the clinical presentation and prognostication of heart failure in adult congenital heart disease, the application of hemodynamic evaluation, and advanced heart failure treatment. A common case study of heart failure in adult congenital heart disease is utilized to illustrate these key concepts.

Determining Expected Research Skills of Medical Students on Graduation: a Systematic Review

BACKGROUND

Global interest in research skills in undergraduate medical education is growing. There is no consensus regarding expected research skills of medical students on graduation. We conducted a systematic review to determine the aims and intended learning outcomes (ILOs) of mandatory research components of undergraduate medical curricula incorporating the teaching, assessment, and evaluation methods of these programs.

METHODS

Using the PRISMA protocol, MEDLINE and ERIC databases were searched with keywords related to "medical student research programs" for relevant articles published up until February 2020. Thematic analysis was conducted according to student experience/reactions, mentoring/career development, and knowledge/skill development.

RESULTS

Of 4880 citations, 41 studies from 30 institutions met the inclusion criteria. Programs were project-based in 24 (80%) and coursework only-based in 6 (20%). Program aims/ILOs were stated in 24 programs (80%). Twenty-seven different aims/ILOs were identified: 19 focused on knowledge/skill development, 4 on experience/reactions, and 4 on mentoring/career development. Project-based programs aimed to provide an in-depth research experience, foster/increase research skills, and critically appraise scientific literature. Coursework-based programs aimed to foster/apply analytical skills for decision-making in healthcare and critically appraise scientific literature. Reporting of interventions was often incomplete, short term, and single institution. There was poor alignment between aims, teaching, assessment, and evaluation methods in most.

CONCLUSIONS

The diversity of teaching programs highlights challenges in defining core competencies in research skills for medical graduates. Incomplete reporting limits the evidence for effective research skills education; we recommend those designing and reporting educational interventions adopt recognized educational reporting criteria when describing their findings. Whether students learn by "doing", "proposing to do", or "critiquing", good curriculum design requires constructive alignment between teaching, assessment, and evaluation methods, aims, and outcomes. Peer-reviewed publications and presentations only evaluate one aspect of the student research experience.

The quadricuspid truncal valve: Surgical management and outcomes

OBJECTIVE

To determine the outcomes of patients with a quadricuspid truncal valve (TV) and durability of TV repair.

METHOD

We reviewed 56 patients with truncus arteriosus and a quadricuspid TV who underwent complete repair between 1979 and 2018.

RESULTS

TV insufficiency was present in 39 patients (mild, n = 22; moderate, n = 14; and severe, n = 3). Fourteen patients had concomitant TV surgery. Early mortality in patients who had concomitant TV surgery was 14% (2 out of 14 patients) and overall survival was 77.1% ± 11.7% at 15 years. Freedom from TV reoperation was 30.3% ± 14.6% at 15 years. Early mortality in patients who did not undergo concomitant TV surgery was 9.5% (4 out of 42 patients) and overall survival was 74.9% ± 6.9% at 15 years. Progression of TV insufficiency requiring TV surgery occurred in 16.7% (7 out of 42 patients). Freedom from TV reoperation was 77.1% ± 7.8% at 15 years. The most common method of repair was tricuspidization of the TV. Freedom from TV reoperation was 64.3% ± 21.0% at 10 years after tricuspidization and 0% at 6 years after other types of TV surgery. Overall follow-up was 97.6% (41 out of 42 patients) complete for survivors with median follow-up of 16.6 years. At last follow-up there was no TV insufficiency in 16 patients, mild insufficiency in 24 patients, and moderate insufficiency in 1 patient.

CONCLUSIONS

More than one-third of patients with a quadricuspid TV require TV surgery. Tricuspidization of the quadricuspid TV appears to be a durable repair option with good long-term outcomes.

High prevalence of early arch reobstruction after arch repair in patients with anomalous right subclavian artery

OBJECTIVES

Having an anomalous right subclavian artery has been quoted to be a risk factor for early and late adverse events. We wanted to determine the rate of adverse outcomes in patients who have undergone arch repair with an associated anomalous right subclavian artery.

METHODS

The follow-up of 76 patients, with an anomalous right subclavian artery, who underwent arch repair at a single institution for various indications between 1981 and 2017 was reviewed.

RESULTS

There were 12 patient deaths. Twenty-three patients required an aortic arch reintervention (17 surgeries, 2 of which were indicated for bronchial obstruction). At last follow-up, 8 of 54 surviving patients (15%) had arch reobstruction (peak gradient >25 mmHg or reintervention). Freedom from aortic arch obstruction at 10 and 15 years was 51% [95% confidence interval (CI) 36-65%] and 35% (95% CI 19-51%), respectively. Neither the complete resection of the adjacent ridge nor the detachment and reimplantation of the anomalous subclavian vessel seemed to have an impact on the rate of reobstruction [hazard ratio (HR) 1.6, 95% CI 0.77-3.5; P = 0.2 and HR 0.61, 95% CI 0.083-4.5; P = 0.6, respectively].

CONCLUSIONS

Patients with an anomalous right subclavian artery are at risk of arch reobstruction necessitating reintervention but long-term follow-up was unable to demonstrate the mechanism of this obstruction in patients with this anomaly.

Reduced Aortic Distensibility is Associated With Higher Aorto-Carotid Wave Transmission and Central Aortic Systolic Pressure in Young Adults After Coarctation Repair

Background The long-term prognosis of patients with repaired aortic coarctation is characterized by high rates of cardiovascular and cerebrovascular disease related to hypertension, the basis of which remains unclear. To define potential underlying mechanisms, we investigated aortic and carotid arterial biomechanics and wave dynamics, and determinants of aortic systolic blood pressure, in young adults after coarctation repair. Methods and Results Aortic arch and carotid biomechanics, wave intensity and wave power, and central aortic blood pressure, were derived from echocardiography and brachial blood pressure in 43 young adults after coarctation repair and 42 controls. Coarctation subjects had higher brachial and central systolic blood pressure ( P=0.04), while aortic compliance was lower and characteristic impedance (Zc) higher. Although carotid intima-media thickness was higher ( P<0.001), carotid biomechanics were no different. Carotid forward compression wave power was higher and was negatively correlated with aortic compliance ( R2=0.42, P<0.001) and distensibility ( R2=0.37, P=0.001) in coarctation subjects. Aortic wave power and wave reflection indices were no different in control and coarctation patients, but coarctation patients with elevated aortic Zc had greater aorto-carotid transmission of forward compression wave power ( P=0.006). Aortic distensibility was the only independent predictor of central aortic systolic blood pressure on multivariable analysis. Conclusions Young adults following coarctation repair had a less compliant aorta, but no change in carotid biomechanics. Reduced aortic distensibility was related to greater transmission of aortic forward wave energy into the carotid artery and higher central aortic systolic blood pressure. These findings suggest that reduced aortic distensibility may contribute to later cardiovascular and cerebrovascular disease after coarctation repair.

Long-term mortality and cardiovascular burden for adult survivors of coarctation of the aorta

OBJECTIVE

To examine the contemporary long-term outcome after coarctation repair.

METHODS

This is a retrospective cohort study of 834 patients aged ≥16 years who underwent coarctation repair under single-centre follow-up. Repair was performed at a median age of 3 years (lower-upper quartile: 1 month to 15 years) by surgery in 83% (690/834) and angioplasty/stenting in 17% (144/834). Survival was compared with an age- and gender matched normal population. Other outcomes included arch reintervention, aortic valve intervention, ascending aortic intervention, and residual/re-coarctation and resting hypertension at latest follow-up.

RESULTS

After a median follow-up of 27 years (lower-upper quartile: 18-36), there were 38 late deaths (5%, 38/834). Overall survival was 99%, 88% and 65% at 30, 50 and 70 years of age, respectively, significantly reduced compared with a matched normal population (standardised mortality ratio: 3.20, log-rank: p<0.001). Thirty per cent (246/834) required ≥1 arch reintervention, 13% (111/834) an aortic valve intervention and 5% (43/834) an ascending aortic intervention. Freedom from aortic valve and ascending aortic intervention was 83% and 92% at 50 years and 53% and 81% at 70 years of age, respectively. Residual/re-coarctation (gradient ≥25 mm Hg or repair site/diaphragm ratio ≤70%) at latest follow-up was present in 60% (282/474) and resting hypertension in 57% (379/661).

CONCLUSIONS

Long-term survival in contemporary adult survivors of coarctation repair is significantly lower than a matched normal population with accelerated decline after the third decade. Nearly 60% of patients eventually develop hypertension, whereas approximately 50% require further invasive cardiovascular treatment by 50 years of age. Our risk-stratifying data may enable personalised follow-up strategies for this common congenital heart condition.

Identifying low-grade cellular rejection after heart transplantation in children by using gene expression profiling

Endomyocardial biopsy (EMB) remains the gold standard for detecting rejection after heart transplantation but is costly and invasive. This study aims to distinguish no rejection (0R) from low-grade rejection (1R/2R) after heart transplantation in children by using global gene expression profiling in blood. A total of 106 blood samples with corresponding EMB from 18 children who underwent heart transplantation from 2011 to 2014 were analyzed (18 baseline/pretransplantation samples, 88 EMB samples). Corresponding rejection grades for each blood sample were 0R in 39% (34/88), 1R in 51% (45/88), and 2R in 10% (9/88). mRNA from each sample was sequenced. Differential expression analysis was performed at the gene level. A k-nearest neighbor (kNN) analysis was applied to the most differentially expressed (DE) genes to identify rejection after transplantation. Mean age at transplantation was 10.0 ± 5.4 yr. Expression of B cell and T cell receptor sequences was used to measure the effect of posttransplantation immunosuppression. Follow-up samples had lower levels of immunoglobulin gene families compared with pretransplantation ( P < 3E-5) (lower numbers of activated B cells). T cell receptor alpha and beta gene families had decreased expression in 0R samples compared with pretransplantation ( P < 4E-5) but recovered to near baseline levels in 1R/2R samples. kNN using the most DE gene (MKS1) and k = 9 nearest neighbors correctly identified 83% (73/88) of 1R/2R compared with 0R by leave-one-out cross validation. Using a genomic approach we can distinguish low-grade cellular allograft rejection (1R/2R) from no rejection (0R) after heart transplantation in children despite a wide age range.

Are more extensive procedures warranted at the time of aortic arch reoperation?

OBJECTIVES

To determine the early and late outcomes of patients undergoing aortic arch reoperations.

METHODS

The follow-up of 70 patients undergoing a second arch operation (excluding univentricular physiology) between 1979 and 2015 was reviewed. Median age at initial arch operation and second operation was 9 days (interquartile range: 5-35) and 10 months (interquartile range: 3-64), respectively. The most common indication for initial arch operation was coarctation in 79% (55/70). The most common indication for a second arch operation was arch reobstruction in 90% (63/70).

RESULTS

There were 2 hospital deaths (2/70, 3%) and 3 early third arch operations (3/70, 4%). Late follow-up was available in 94% (64/68) of hospital survivors. After a mean of 9 ± 7 years, there were 5 late deaths (5/64, 8%). Fifteen-year survival was 90% (95% confidence interval: 75-96). Arch reobstruction (echocardiogram gradient >25 mmHg/third operation for reobstruction) was present in 28% (18/64) and 16% (10/64) required a third arch operation. Fifteen-year freedom from arch reobstruction and third arch operation was 63% (95% confidence interval: 43-78) and 74% (95% confidence interval: 52-87), respectively. On multivariable analysis, hypoplastic arch at initial arch repair (P = 0.03) and interposition graft at second arch operation (P < 0.0001) were risk factors for third arch operation.

CONCLUSIONS

Patients undergoing a second arch operation have significant rates of arch reobstruction and reoperation. The high rates of arch reobstruction and third arch operation warrant more extensive procedures at the time of second arch operation, especially in patients with a hypoplastic arch. Regular long-term monitoring after arch reoperation is mandatory.

Early Mentoring of Medical Students and Junior Doctors on a Path to Academic Cardiothoracic Surgery

BACKGROUND

In 2005 the Department of Cardiothoracic Surgery at The Royal Children's Hospital started an early academic mentoring program for medical students and junior doctors with the aim of fostering an interest in academic surgery.

METHODS

Between 2005 and 2015, 37 medical students and junior doctors participated in research in the Department of Cardiothoracic Surgery at The Royal Children's Hospital. Each was given an initial project on which to obtain ethics approval, perform a literature review, data collection, statistical analysis, and prepare a manuscript for publication. A search of the names of these former students and doctors was conducted on PubMed to identify publications.

RESULTS

A total of 113 journal articles were published in peer-reviewed journals with an average impact factor of 4.1 (range, 1.1 to 19.9). Thirty (30 of 37, 81%) published at least one article. A mean of 4.3 journal articles was published per student or junior doctor (range, 0 to 29). Eleven (11 of 37, 30%) received scholarships for their research. Nine (9 of 37, 24%) have completed or are enrolled in higher research degrees with a cardiothoracic surgery focus. Of these 9, 2 have completed doctoral degrees while in cardiothoracic surgery training. Five will complete their cardiothoracic surgery training with a doctoral degree and the other 2 are pursuing training in cardiology.

CONCLUSIONS

A successful early academic mentoring program in a busy cardiothoracic surgery unit is feasible. Mentoring of motivated individuals in academic surgery benefits not only their medical career, but also helps maintain high academic output of the unit.

Elevated sympathetic activity, endothelial dysfunction, and late hypertension after repair of coarctation of the aorta

BACKGROUND

There is a high prevalence of late hypertension after coarctation repair. The relative contribution of elevated sympathetic tone and endothelial dysfunction to its development is unknown. This study aims to investigate the neural profile of coarctation patients including muscle sympathetic nerve activity testing to directly measure sympathetic nervous activity.

METHODS

Twenty-three patients aged ≥18years with a coarctation repair underwent measurements of clinic and 24-h blood pressures, muscle sympathetic nerve activity, sympathetic and cardiac baroreflex functions, digital endothelial function, and ambulatory arterial stiffness index. Median age at repair was 1.2months (interquartile range: 0-9months). Patients were compared to 17 healthy matched controls.

RESULTS

After 26±5years, 6% (1/18) and 44% (8/18) suffered clinic hypertension and prehypertension, respectively. On 24-h blood pressure monitoring, 15% (3/20) and 20% (4/20) had hypertension and prehypertension, respectively. Coarctation patients had elevated muscle sympathetic nerve activity compared with controls (49.6±24.9 vs. 29.9±14.0 bursts/100 heartbeats, p=0.02), dampened sympathetic baroreflex function (-2.2±2.1 vs. -7.0±5.6 bursts/100heartbeats·mm·Hg^-1, p=0.007), normal cardiac baroreflex function (41.9±30.4 vs. 35.7±21.1ms·mm·Hg^-1, p=0.6), endothelial dysfunction (pulse amplitude tonometry ratio: 0.39±0.32 vs. 0.81±0.50, p=0.004), and increased ambulatory arterial stiffness index (0.46±0.15 vs. 0.29±0.17, p=0.008).

CONCLUSION

After coarctation repair patients have increased muscle sympathetic nerve activity, dampened sympathetic baroreflex response, endothelial dysfunction, and increased ambulatory arterial stiffness index, all of which may contribute to the development of late hypertension.

High Prevalence of Hypertension and End-Organ Damage Late After Coarctation Repair in Normal Arches

BACKGROUND

To (1) determine the prevalence of hypertension late after coarctation repair in patients with normal-sized transverse arches, and (2) evaluate the potential for end-organ damage related to hypertension after coarctation repair. There are no studies specifically investigating end-organ damage and hypertension after coarctation repair using noninvasive techniques.

METHODS

Eighty-two patients aged 10 years or greater with a coarctation repair and a normal-sized arch operated on between 1978 and 2010, underwent a transthoracic echocardiogram, 24-hour blood pressure (BP) monitoring, and retinal imaging. Median age at repair was 1 year (interquartile range, 0 to 6); 45% (37 of 82) were operated in the first year of life.

RESULTS

After a follow-up of 24 ± 7 years, 27% (22 of 82) and 50% (41 of 82) suffered resting hypertension and resting prehypertension, respectively. On 24-hour BP monitoring, 61% (49 of 80) and 21% (17 of 80) suffered hypertension and prehypertension, respectively. Arch reobstruction (echo gradient > 25 mm Hg) was present in only 15% (12 of 82), and in only 15% (7 of 47) with 24-hour hypertension. Resting hypertension was associated with a smaller central retinal artery equivalent (average width of arterioles) and central retinal vein equivalent (average width of venules) (p = 0.0006 and p = 0.003, respectively). Left ventricular hypertrophy on echocardiography was present in 63% (31 of 49) with 24-hour hypertension compared with only 42% (13 of 31) with normal 24-hour BP (p = 0.06).

CONCLUSIONS

There is a high rate of hypertension late after coarctation repair, even in patients with unobstructed arches. The presence of retinal imaging abnormalities and left ventricular hypertrophy signals the presence of end-organ damage in this young adult population. Regular follow-up with 24-hour BP monitoring is warranted.

Complications of extra-anatomic aortic bypass for complex coarctation and aortic arch hypoplasia

BACKGROUND

We have adopted the extra-anatomic bypass graft as the procedure of choice for the treatment of coarctation and aortic arch hypoplasia in the adult-sized patient. However, we have experienced prolonged chest drainage and have decided to investigate this complication and the morbidity related to this procedure.

METHODS

Between 1996 and 2010, 15 extra-anatomic bypass grafts of the aorta were performed in 14 patients. Their hospital records and follow-up data were retrospectively reviewed and compared with those of 14 consecutive patients operated with other conventional techniques over the same time period.

RESULTS

There was no hospital mortality. After the extra-anatomic bypass procedure, patients had longer hospital stay because of prolonged pleural effusions. Four patients developed complications related to persistent effusions leading to reinterventions, which led to mediastinitis in 2 instances. At last follow-up, 2 of 14 patients with extra-anatomic bypass remained hypertensive, while 8 of the 14 patients who underwent other types of repair had arch obstruction, were hypertensive, or both.

CONCLUSIONS

In the adult-sized patient extra-anatomic bypass of the aortic arch relieves arch obstruction more effectively than conventional techniques. However, this technique is fraught with complications related to prolonged effusion drainage that may lead to mediastinitis and reintervention. Its indication should be weighted carefully.

Twenty-four-hour ambulatory blood pressure monitoring detects a high prevalence of hypertension late after coarctation repair in patients with hypoplastic arches

OBJECTIVES

To determine by 24-hour blood pressure monitoring the risk of hypertension late after coarctation repair in patients with arch hypoplasia.

METHODS

Sixty-two of 116 consecutive patients (age, ≥10 years) who had coarctation repair and were quoted subjectively by the surgeon or the cardiologist to have arch hypoplasia at the time of the repair underwent a transthoracic echocardiogram and 24-hour blood pressure monitoring. Median age at repair was 11 days (range, 6-48 days). Mean preoperative z score of the proximal transverse arch was -2.43 ± 0.46. Eight patients had a repair via sternotomy (6 end-to-side anastomoses, 2 patch repairs) and 54 had a conventional repair via thoracotomy.

RESULTS

After a follow-up of 18 ± 5 years, 27% of the patients (17/62) had resting hypertension and 60% (37/62) had abnormal ambulatory blood pressure. Sensitivity of high resting blood pressure in detecting an abnormal 24-hour ambulatory blood pressure was 41%. Twenty patients had arch obstruction at last follow-up. Eighteen of them (90%) had abnormal ambulatory blood pressure. None of the patients operated on with end-to-side repair via sternotomy had reobstruction compared with 33% (18/54) of those repaired via thoracotomy.

CONCLUSIONS

Patients with a hypoplastic arch operated via thoracotomy have an alarming prevalence of hypertension. Regular follow-up with 24-hour ambulatory blood pressure monitoring is warranted, especially in patients who have had a smaller aortic arch at the time of the initial operation.