Repair of coarctation of the aorta in adults and hypertension

doi:10.1016/S0967-2109(03)00107-8

Cardiovascular Surgery, Vol. 11, No. 5, pp. 353–357, 2003  2003 The International Society for Cardiovascular Surgery Published by Elsevier Ltd. All rights reserved. 0967-2109 $30.00

www.elsevier.com/locate/cardiosur

Repair of coarctation of the aorta in adults and hypertension Ahmet O¨zyazıcıog˘lu∗, Azman Ates¸∗, I˙brahim Yekeler∗, Ahmet Yavuz Balcı∗ and Engin Bozkurt† ∗

Department of Cardiovascular Surgery, Atatu¨rk University Aziziye Hospital, Erzurum, Turkey and Department of Cardiology, Atatu¨rk University Aziziye Hospital, Erzurum, Turkey

†

The aim of this study is to determine if surgical repair of coarctation in adults improves systemic hypertension. The charts of 23 consecutive patients (age range 13–36 years, mean 23.6 ± 7) who underwent repair of aortic coarctation at the Atatu¨rk University, Aziziye Hospital, between 1986 and 2000 were reviewed. There were 16 (70%) men and seven (30%) women. All patients had preoperative hypertension. Systolic blood pressure (BP) ranged between 150 and 200 mmHg, with a mean of 176 ± 15 mmHg. Peak systolic gradient across the coarctation was 52 ± 20 mmHg (range from 30 to 112 mmHg). There were no early or late deaths. Mean systolic BP values at the first postoperative evaluation were 176 ± 15 mmHg (p ⬍ 0.001 from preoperative values). Exercise testing revealed hypertensive response to exercise in three of 10 patients who had borderline hypertension at rest and without medication. Repair of coarctation of aorta even in adults is safe and improves systemic hypertension. To identify patients with potential hypertension, exercise testing should be performed. Impaired arterial dilatation may be an important contributor to exercise-related hypertension and late morbidity or mortality.  2003 The International Society for Cardiovascular Surgery. Published by Elsevier Ltd. All rights reserved. Keywords: Coarctation, Hypertension, Adults

Introduction Patients with coarctation of the aorta should be diagnosed at a young age before hypertension develops. However, the diagnosis of coarctation may be missed and the patient may present with hypertension in later childhood. Rarely will adults present with undiagnosed coarctation of the aorta. Despite the successful repair of coarctation of aorta in adults, survivors often have hypertension at

¨ zyazıcıog˘lu. Gez Mah. Yasemin Sok., Correspondence to: Ahmet O Atmaca Ap., A-Block, No:5, Erzurum, Turkey. Tel.: +90-442-3166333x2142; fax: +90-442-3166-340; e-mail: [email protected]

CARDIOVASCULAR SURGERY

OCTOBER 2003 VOL 11 NO 5

rest or on exercise, and their life expectancy is shorter than normal because of coronary and cerebrovascular diseases [1,2]. The aim of this study was to determine the impact of surgical repair of coarctation of the aorta in later childhood and adulthood (more than 13 years of age) on patients’ blood pressure (BP).

Methods The charts of 23 consecutive Turkish patients (age range 13–36, mean 23 ± 7 years) who underwent repair of aortic coarctation at Atatu¨rk University Aziziye Hospital between May 1986 and September 2000 were reviewed. There were 16 (70%) males and seven (30%) females. All patients had critical 353

Repair of coarctation of the aorta in adults and hypertension: Ahmet O¨zyazıcıog˘lu et al. Table 1

Preoperative data of patients No. of patients

Systemic hypertension Rib notching Left ventricular hypertrophy (EKG) Dyspnea Vertigo Fatigue Palpitation Angina Headache Claudication Other symptoms No symptoms

23 19 14 11 11 10 10 8 7 7 5 2

systolic hypertension (systolic BP: SBPⱖ140 mmHg). Preoperative clinical findings are summarized in Table 1. Preoperative and postoperative BP measurements were obtained in the left and right arms and lower limbs. Preoperatively, systolic BP ranged between 150 and 200 mmHg with a mean of 176 ± 15 mmHg and diastolic BP between 85 and 110 mmHg with a mean pressure of 97±8 mmHg (Table 2). Hypertension was defined as a systolic BP of more than 140 mmHg and/or a diastolic BP of more than 90 mmHg at rest. Preoperative systolic hypertension was defined as follows: mild = 140 to 159 mmHg,

moderate = 160 to 179 mmHg, severe = 180 to 210 mmHg and very severe = ⬎210 mmHg [3]. According to those criteria, 12 patients had mild, and 11 patients had severe hypertension. Aortic pressures proximal and distal to the coarctation were measured at preoperative catheterization in all patients. The peak systolic gradient across the coarctation was 52 ± 20 mmHg (range 30–112 mmHg). The majority of patients (70%) were on a regimen of at least one antihypertensive medication. The remaining seven (30%) patients were operated on soon after the discovery of the aortic coarctation and thus had not received antihypertensive medication. Antihypertensive medication included diuretics, βblocking agents, calcium-channel blockers and angiotensin-converting enzyme inhibitors. In some instances, there were combinations of agents. One patient who was diagnosed as having coarctation had a descending aortic dissection. This patient died before being operated upon and was therefore removed from this study. Coarctation repair was carried out through a left thoracotomy. Resection of the coarctation with endto-end anastomosis was performed in eight patients (35%). In 12 of the 23 patients (52%), patch graft aortoplasty was performed. In two patients (9%), resection of the coarctation and reconstruction of the aorta with a tubular graft were performed. In one patient with aortic arch hypoplasia, coarctation was

Table 2

The evolution of blood pressure and other data before operation, after operation and at follow-up

Patient no.

Sex

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

M M F M F M M M M M F M F M F F M M M F M M M

Age at operation

16 21 24 13 18 32 35 31 28 18 36 15 21 24 24 16 18 28 32 34 15 21 23

Blood pressure (mmHg)

Exercise testing

Preoperative

First postoperative

At follow-up

165/90 185/100 200/110 190/100 160/100 175/95 195/100 180/90 190/105 165/90 200/105 170/90 180/100 170/95 160/85 155/80 180/85 170/90 195/105 195/110 160/100 150/100 160/95

140/85 150/90 150/95 140/90 130/80 145/95 150/95 140/90 140/90 130/90 160/100 140/90 140/90 130/90 140/90 130/80 120/85 130/90 155/100 155/105 135/90 130/85 130/85

140/85 150/95 155/95 140/90 130/80 145/95 160/95 140/90 140/90 140/95 160/100 140/90 150/95 130/90 140/95 130/80 130/85 140/90 145/90 160/110 145/90 130/85 140/90

⫺ ⫺ ⫺ 180/100 ⫺ ⫺ 200/110 ⫺ 195/95 185/100 ⫺ 200/100 215/110 ⫺ 225/110 ⫺ ⫺ ⫺ 210/105 ⫺ 190/100 ⫺ 200/105

Medications

Preoperative

At follow-up

C C B+ B B B+ C C C (⫺) B+ A A B (⫺) B B+ C A A (⫺) A A

(⫺) (⫺) B (⫺) B B (⫺) C (⫺) (⫺) B+D (⫺) (⫺) (⫺) (⫺) (⫺) A (⫺) (⫺) A (⫺) (⫺) (⫺)

D D

D

D

A: Angiotensin-converting enzyme inhibitors; B: β-blockers; C: calcium-channel blockers; D: diuretics.

354

CARDIOVASCULAR SURGERY

OCTOBER 2003 VOL 11 NO 5

Repair of coarctation of the aorta in adults and hypertension: Ahmet O¨zyazıcıog˘lu et al.

reconstructed by a Dacron patch graft along the ascending and descending aorta. Mean postoperative follow-up was 8 years (range 1–14 years). Follow-up of 20 patients was achieved during outpatient clinic visits. For three patients, interviews were carried out by telephone. On the majority of the patients, the quality of the repair was evaluated by Doppler echocardiography. Computed tomography was performed in six patients and angiography was done in five patients early in our experiment. Postoperatively, the patients who had upper to lower body pressure gradients higher than 10 mmHg were removed from this series. Ten patients underwent an exercise stress test using the Bruce protocol until 90% of predicted heart rate was achieved (Table 3). Pressure increments were compared with the data regarding normal adult subjects. These patients were considered to have borderline hypertension (BH) according to the World Health Organization criteria (BP between 140/90 and 160/95 mmHg as measured by a conventional mercury sphygmomanometer) [4,5]. None of these patients was receiving antihypertensive medication. An abnormal BP response was considered to be present when systolic BP exceeded 220 mmHg and/or diastolic BP exceeded 105 mmHg at maximal exertion [6]. Statistical analysis Data are presented as the mean ± standard deviation. Paired comparisons were performed using the paired t test, and a p value ⬍0.05 was considered statistically significant.

Results There were no early or late deaths. One of the patients had spinal cord ischemia. The patient, a 13year-old child with hypertension, had rib notching on the chest roentgenogram and large collateral circulation on the angiogram. The coarctate segment was long and aortic cross clamp time was 55 min. Distal aortic pressure after cross clamping was 55– 60 mmHg. No other major complications occurred. Table 3

There were no repeated interventions during followup. No patient showed a BP gradient between upper and lower extremities. At clinical examination, all the patients had palpable femoral pulses. Mean systolic BP values at the first postoperative evaluation were 140 ± 9 mmHg (p ⬍ 0.001 from preoperative values). The mean systolic BP value at the follow-up evaluation was 143 ± 10 mmHg. Compared with the first postoperative values, the difference was not significant (p ⬎ 0.05). The other BP values and comparisons are summarized in Tables 4 and 5. At follow-up, nine (40%) patients were normotensive at rest without any antihypertensive medication, and four patients were normotensive with only one antihypertensive medication. Ten patients were considered to have BH. All the patients in this group underwent an exercise test [5]. Only three of them (30%), however, manifested hypertensive response to exercise (Table 2]. Sixteen (70%) patients were not receiving medication at follow-up. Six patients required only a single agent, and only one patient required two drugs (Table 2).

Discussion Follow-up of surgically treated patients with aortic coarctation indicates that they are not rendered entirely normal. Some patients who have a technically excellent repair may not have a complete resolution of hypertension. The cause of persistent hypertension following repair is unclear but is related to the age at repair and the duration of preoperative hypertension. Cohen et al. [7], reporting on the long term follow-up of 571 patients following repair of coarctation, found that age at the time of surgery was the most important predictor of survival and the most important predictor of persistent hypertension. The incidence of late postoperative hypertension has been reported to be higher as age at operation increases [8]. For this reason, there has been some reluctance to refer older adult patients for coarctation repair [9]. Vigano et al. [10] reported 14 adult patients treated for isthmic coarctation of aorta. All their patients had good surgical results and were normot-

Treadmill protocols of Bruce testing Table 4 Evolution of blood pressure

Test phase

1 2 3 4 5 6 7

Duration (min)

Speed (mph) Grade (%) Approximate METS

3 3 3 3 3 3 3

1.7 2.5 3.4 4.2 5.0 5.5 6.0

CARDIOVASCULAR SURGERY

10 12 14 16 18 20 22

5 7 10 13 16 19 22

OCTOBER 2003 VOL 11 NO 5

Preoperative systolic BP Preoperative diastolic BP First postoperative systolic BP First postoperative diastolic BP Follow-up systolic BP Follow-up diastolic BP

Mean

Standard deviation

176.08 96.52 140.43 90.43 142.60 91.52 23.60

15.44 8.03 9.28 6.01 9.63 6.47 7.12

355

Repair of coarctation of the aorta in adults and hypertension: Ahmet O¨zyazıcıog˘lu et al. Table 5

The difference of blood pressure 95% confidence interval of the difference

Preop systolic–first postop systolic Preop diastolic–first postop diastolic Preop systolic–follow-up systolic Preop diastolic–follow-up diastolic First postop systolic–follow-up systolic First postop diastolic–follow-up diastolic

Lower

Upper

31.72 3.32 28.84 1.87 ⫺4.68 ⫺2.53

39.58 8.84 38.10 8.12 0.33 0.36

ensive at rest. However, in spite of their good general condition, four patients manifested a hypertensive response to exercise. In our study, we noted a series of 23 adult patients followed after coarctation repair. Our patients had a mean age of 23.6 ± 7 years at the time of operation. At the follow-up, only 12 (52%) patients were normotensive (systolic BP equal to or less than 140 mmHg or a diastolic BP equal to or less than 90 mmHg). Our series revealed a high number of patients presenting residual hypertension after repair who required an increase in their medications. Ten patients who had BH underwent maximal exercise testing. This testing was designed and undertaken to assess the relevance of an abnormal BP response to exercise. All patients had BH or normal BP at rest and without medication. In spite of good conditions in general, three patients evidenced hypertensive response to exercise (Table 2). Our experiences demonstrated that persistence of vessel abnormal reactivity after coarctation repair should be investigated by exercise test. In patients with hypertension at rest or during exercise, on about yearly basis, it could be useful to carry out repeated exercise stress tests to be able to implement antihypertensive medications. Preexisting cardiac and vascular damage from years of exposure to elevated BP related to the coarctation might play a role in the problem of death. However, improved BP control after operation may be beneficial. In our study, mean systolic BP values at the first postoperative evaluation were 140 ± 9 mmHg (p ⬍ 0.001 from preoperative values). The difference was significant. Although the majority of patients (20/23) had hypertension with one or two antihypertensive medication(s) at the time of admission, 12 patients were normotensive without or with only one antihypertensive medication. Additionally, nine (40%) patients who had failed medical treatment for hypertension prior to operation became normotensive at rest without any antihypertensive medication after operation. On this ground, we agree that even though the incidence of residual hypertension approaches 50% in adult coarctation repair, patients up to the age of 36 years appear to benefit from oper356

t

Significance

18.82 4.57 14.99 3.31 ⫺1.79 ⫺1.55

0.000 0.000 0.000 0.003 0.086 0.135

ation, as indicated by the improved control of hypertension. In summary, we recommend coarctation repair in childhood in order to prevent persistent hypertension. Surgical repair of aortic coarctation in adult patients may reduce hypertension, and these patients may not need any antihypertensive medication postoperatively [11]. The therapeutic aim in these patients should not only be a good anatomic result but also a long term follow-up on the status of arterial reactivity. Impaired arterial dilatation may be an important contributor to exercise-related hypertension and late morbidity or mortality. To identify patients with potential postoperative hypertension, exercise testing should be done [12].

References 1. Gardiner, H. M., Celermajer, D. S., Sorensen, K. E. et al. Arterial reactivity is significantly impaired in normotensive young adults after successful repair of aortic coarctation in childhood. Circulation, 1994, 89, 1745–1750. 2. Daniels, S. R. Repair of coarctation of the aorta and hypertension: does age matter? Lancet, 2001, 358, 89–92. 3. Gifford, R. W. The fifth report of the Joint National Committee on detection, evaluation and treatment of high blood pressure. Arch Intern Med, 1993, 153, 154–183. 4. Singh, J. P., Larson, M. G. and Manolio, T. A. Blood pressure response during treadmill testing as a risk factor for new onset hypertension: The Framingham Heart Study. Circulation, 1999, 99, 1831–1836. 5. Guerrera, G., Melina, D., Colivicchi, F. et al. Abnormal blood pressure response to exercise in borderline hypertension. A two year follow-up study. Am J Hypertens, 1991, 4, 271–273. 6. Lollgen, H., Ulmer, H. V. and Crean, P. Recommendations and standard guidelines for exercise testing: a report of the Task Force Conference on Ergometry. Eur Heart J, 1988, 9, 3–37. 7. Cohen, M., Fuster, V., Steele, P. M. et al. Coarctation of the aorta. Long-term follow-up and prediction of outcome after surgical correction. Circulation, 1989, 80, 840–845. 8. Clarkson, P. M., Nicholson, M. R., Barrat-Boyes, B. G. et al. Results after repair of coarctation of the aorta beyond infancy: a 10–28 year follow-up with particular reference to late systemic hypertension. Am J Cardiol, 1983, 51, 1481–1488. 9. Wells, W. J., Prendergast, T. W., Berdjist, F. et al. Repair of coarctation of the aorta in adults: the fate of systemic hypertension. Ann Thorac Surg, 1996, 61, 1168–1171. 10. Vigano, M., Ressia, L. and Gaeta, R. Long-term follow-up after repair of coarctation of the aorta in adults. Ann Thorac Surg, 1997, 63, 1827–1828.

CARDIOVASCULAR SURGERY

OCTOBER 2003 VOL 11 NO 5

Repair of coarctation of the aorta in adults and hypertension: Ahmet O¨zyazıcıog˘lu et al. 11. Aris, A., Subirana, T., Ferres, P. et al. Repair of aortic coarctation in patients more than 50 years of age. Ann Thorac Surg, 1999, 67, 1379–1379. 12. Bouchart, F., Dubar, A., Tabley, A. et al. Coarctation of the

CARDIOVASCULAR SURGERY

OCTOBER 2003 VOL 11 NO 5

aorta in adults: surgical results and long-term follow-up. Ann Thorac Surg, 2000, 70, 1483–1489.

357