Renal sympathetic denervation for resistant hypertension in a child after aortic coarctation surgery

Abstract

Canniffe et al. report that the current prevalence of hypertension lateafter successful coarctation repair is 32.5% (range 25 –68%) [1].Ahigherage at the time of surgery, a longer time of follow up and a better de fini-tion of hypertension are factors that increase the prevalence. There areinsufficient long term data to adequately compare catheter based inter-vention to surgical procedures for native coarctation in terms of the lateprevalence of hypertension. A causative role of the autonomic nervoussystemresultinginarterialhypertensionmaybeoverlooked.Wepresentthe first paediatric patient in whom successful interventional renalsympathetic denervation improved postcoarctation repair hypertension.A 16 yearold boy wasoperated at the age of 13 years. Hypertensionandaorticcoarctationwere firstnoticedduringsurgeryforsportsinjury.Arm/leg pressure gradient was 90 mm HG (194/103 vs 104/69). MRimaging showed severe coarctation and hypoplastic isthmus (Fig. 1).Surgery comprised of proximal descending aorta replacement with an18 mm Dacron tube (Uni-Graft™, B. Braun, Berlin, Germany). Longterm postoperative hypertension with average blood pressures of upto 171/92 mm Hg occurred in circadian monitoring despite fourfoldmedication (Fig. 2). A careful examination of his autonomic nervoussystem showed a highly reduced heart rate variability indicatingsympathetic predominance. Adding carvedilol improved heart rate var-iabilityonly.Maximal Doppler flow was2.8 m/sin the aorticgraft with-outarm/legpressuregradient.Theboysufferedfromchronicfatigueandheadache. He was also found to have an intracranial aneurysm, wasobese (BMI 28.6 kg/m