Abnormalities of Aortic Arch Shape,Central Aortic Flow Dynamics,and Distensibility Predispose to Hypertension After Successful Repair of Aortic Coarctation

Abstract

Background:

Systemic hypertension (HT) is a major long-term complication even after successful repair of aortic coarctation (CoA), and many factors are involved in this pathophysiology.

Objective:

To investigate the role of abnormalities in the aortic arch shape, central aortic flow dynamics, and distensibility in developing HT after successful repair of CoA.

Methods:

We selected a group of 26 normotensive patients (mean age 16.9 ± 7.3 years, range 9-32 years) with anatomically successful repair of CoA among 140 patients regularly followed after repair of CoA and analyzed their last clinical and echocardiographic data. Bicycle exercise test and ambulatory blood pressure monitoring (ABPM) were also obtained. Mean age at surgical repair was 3.2 ± 3.9 years (range 10 days-15 years); 12 patients underwent surgical correction during the first year of life. Repair of CoA was performed by end-to-end anastomosis (TT) in 23 patients (extended TT in 6 patients with arch hypoplasia), patch aortoplasty in 2, and subcalvian flap aortoplasty in 1. The postsurgical follow-up was 13.8 ± 7.2 years (range 3.5-29.4 years). The shape of the aortic arch was defined by magnetic resonance imaging (MRI) on this global geometry (normal–gothic–crenel), ratio of the height–transverse diameter (A/T), percentage of residual stenosis, and growth index of the transverse arch segments. Flow mapping by phase-contrast imaging in the ascending and descending aorta was performed in order to measure the systolic waveforms and central aortic distensibility. Twenty normal age-matched patients submitted to the same MRI protocol were used as controls.

Results:

Six patients were found to have a gothic and 20 a normal aortic arch shape. Patients with gothic aortic arch shape had an increased A/T ratio (0.80 ± 0.07 vs 0.58 ± 0.05, P < .001), a greater loss of systolic wave amplitude across the aortic arch (43% ± 2% vs 34% ± 5%, P < .001), and a lower distensibility of the ascending aorta compared to those with normal shape (4.87 ± 1.06 mm Hg⁻¹×10⁻³ vs 7.20 ± 1.73 mm Hg⁻ ¹ × 10⁻ ³; P = .005) and controls (4.87 ± 1.06 mm Hg⁻¹×10⁻³ vs 8.57 ± 1.71 mm Hg⁻¹×10⁻³; P < .001). The maximal systolic blood pressure (SBP) on exercise as well as SBP, diastolic blood pressure, and percentage of >135 mm Hg on ABPM were higher in the gothic than in the normal arch group. There was a correlation between nocturnal SBP, 24 hours pulse pressure on ABPM in the whole group, and different MRI variables (A/T, distensibility of the ascending aorta, and percentage of loss of systolic wave amplitude).

Conclusions:

In the long-term follow-up after CoA repair, a gothic arch shape is associated with a decreased ascending aorta distensibility with an increased loss of systolic wave amplitude across the aortic arch. These findings explain at least in part the association between this abnormal arch geometry and late HT at rest and on exercise, left ventricular hypertrophy, and adverse cardiovascular outcome in this group of young adults with successful repair of CoA.

Keywords

aortic arch aortic operation coarctation congenital heart disease (CHD)

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References

Celermajer

Greaves

. Survivors of coarctation repair: fixed but not cured. Heart. 2002;88 (2):113–114.

O’Sullivan

Derrick

Darnell

. Prevallence 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 (2):163–166.

Bonnet

Auriacombe

Pedroni

. Late systemic hypertension and aortic arch geometry after successful repair of coarctation of the aorta. Eur Heart J. 2004;25 (20):1853–1859.

de Divitiis

Rubba

Calabrò

. Arterial hypertension and cardiovascular prognosis after successful repair of aortic coarctation: a clinical model for the study of vascular function. Nutr Metab Cardiovasc Dis. 2005;15 (5):384–392.

Mousseaux

Celermajer

. Aortic arch deformation following coarctation surgery: effect on blood pressure response. J Thorac Cardiovasc Surg. 2006;132 (5):1105–1111.

Celermajer

Raisky

. Angular (gothic) aortic arch leads to enhanced systolic wave reflection, central aortic stiffness, and increased left ventricular mass late after aortic coarctation repair: evalutation with magnetic resonance flow mapping. J Thorac Cardiovasc Surg. 2008;135 (1):62–68.

Willum-Hansen

Staessen

Torp-Pedersen

. Prognostic value of aortic pulse wave velocity as index of arterial stiffness in the general population. Circulation. 2006;113 (5):664–670.

Dernellis

Panaretou

. Aortic stiffness is an independent predictor of progression to hypertension in nonhypertensive subjects. Hypertension. 2005;45 (3):426–431.

National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 task force report on high blood pressure in children and adolescents: a working group report from National High Blood Pressure Education Program. Pediatrics. 1996;98 (4 PT 1):649–658.

10.

Gunthard

Buser

Miettunen

Hagmann

Wyler

. Effects of morphologic restenosis, defined by MRI after coarctation repair, on blood pressure and arm-leg and Doppler gradients. Angiology. 1996;47 (11):1073–1080.

11.

Vouhe

Trinquet

Lecompte

. Aortic coarctation with hypoplastic aortic arch. Results of extended end-to-end aortic arch anastomosis. J Thorac Cardiovasc Surg. 1988;96 (4):557–563.

12.

Manolio

Burke

Savage

Sidney

Gardin

Oberman

. Exercise blood pressure response and 5-year risk of elevated blood pressure in a cohort of young adults: the CARDIA study. Am J Hypertens. 1994;7 (3):234–241.

13.

Ellestad

MH.

Stress Testing: Principles and Practice. 3rd ed. Philadelphia, PA: FA Davis;1986.

14.

Lauer

Levy

Anderson

Plehn

. Ist her a relationship between and left ventricular mass? The Framingham Heart study. Ann Intern Med. 1992;116 (3):203–210.

15.

Second Task Force on Blood Pressure Control in Children: Report of the Second Task Force on Blood Pressure Control in Children – 1987. Pediatrics. 1987;79 (1):1–25.

16.

Ernst

Bergus

. Noninvasive 24-hour ambulatory blood pressure monitoring. Overview of technology and clinical applications. Pharmacotherapy. 2002;22 (5):597–612.

17.

Stern

Locher

Wallnoefer

. Nonivasive assessment of coarctation of the aorta: comparison measurements by two-dimensional echocardiography, magnetic resonance and angiography. Ped Cardiol. 1991;12(1):1–5

18.

O’Rourke

. Arterial stiffening and vascular/ventricular interaction. J Hum Hypertens. 1994;8 (suppl):S9–S15.

19.

London

. Role of arterial wall properties in the pathogenesis of systolic hypertension. Am J Hypertens. 2005;18(suppl):19S–22 S.

20.

Celermajer

Mousseaux

. Vascular remodeling after successful repair of coarctation: impact of aortic arch geometry. J Am Coll Cardiol. 2007;49 (8):883–890.

21.

Shiota

Omoto

. Intravascular ultrasound assessment of regional aortic wall stiffness, distensibility and compliance in patients with coarctation of the aorta. Am Heart J. 1997;134 (1):93–98.

22.

Brili

Dernellis

Aggeli

. Aotic elastic properties in patients with repaired coarctation of aorta. Am J Cardiol. 1998;82 (9):1140–1143.

23.

Vriend

de Groot

de Waal

Zijta

Kastelein

Mulder

. Increased carotid and femoral intima-media thickness in patients after repair of aortic coarctation: influence of early repair. Am Heart J. 2006;151 (1):242–247.

24.

Clarkson

Nicholson

Barrat-Boyes

Neutze

Whitlock

. Results after repair of coarctation of the aorta beyond infancy: 10 to 28 years follow-up with particular reference to late systemic hypertension. Am J Cardiol. 1983;51 (9):1481–1488.

25.

Heger

Willfort

Neunteufl

. Vascular dysfunction after coarctation repair is related to the age at surgery. Int J Cardiol. 2005;99:295–299.

26.

de Divitiis

Pilla

Kattenhorn

. Vascular dysfunction after repair of coarctation of the aorta: impact of early surgery. Circulation. 2001;104 (suppl 1):I165–I170.

27.

Vogt

Kuhn

Baumgartner

. Impaired elastic properties of the ascending aorta in newborns before and early after successful coarctation repair: proof of a systemic vascular disease of the prestenotic arteries? Circulation. 2005;111 (24):3269–3273.

28.

Laurent

Boutouyrie

Asmar

. Aotic stiffness is an independent predictor of all-cause and cardiovascular mortality in hypertensive patients. Hypertension. 2001;37 (5):1236–1241.

29.

Simsolo

grunfeld

Gimenez

. Long-term systemic hypertension in children after successful repair of coarctation of the aorta. Am Heart J. 1988;115 (6):1268–1273.

30.

Antikainen

Jousilahti

Toumilehto

. Systolic blood pressure, isolated systolic hypertension and risk of coronary heart disease, strokes, cardiovascular disease and all-cause mortality in the middle-aged population. J Hypertens. 1998;16 (5):577–583.

31.

Siewers

Ettedgui

Pahl

Tallman

del Nido

. Coarctation and hypoplasia of the aortic arch: wil the arch grow. Ann Thorac Surg. 1991;52 (3):608–613.

32.

Williams

Lacy

Thom

. Differential impact of blood pressure-lowering drugs on central aortic pressure and clinical outcomes: principal results of the Conduit Artery Function Evaluation (CAFE) study. Circulation. 2006;113 (9):1213–1225.