Successful Repair Of Aortic Coarctation Research Articles

Ambulatory Blood Pressure Monitoring in Assessment of Systemic Hypertension Following Successful Aortic Coarctation Repair

Abstract Background Hypertension following primary coarctation repair affects up to a third of subjects. A number of studies suggest that future hypertension risk is reduced if primary repair is performed at a younger age. This study aims to assess prevalence of systemic hypertension after early coarctation repair (within the first two years of life) compared with late coarctation repair (after the first two years of life), including both catheter-based and surgical intervention using twenty-four hour ambulatory blood pressure monitoring. the study included 30 patients who underwent successful repair of aortic coarctation. All patients underwent complete history taking and clinical examination.All patients underwent full transthoracic echocardiographic study and ambulatory blood pressure monitoring. Results HTN had higher incidence in patients who underwent late coarctation repair than patients underwent early coarctation repair but difference was statistically insignificant. Conclusions Early intervention of aortic coarctation during infancy decreases the risk of late systemic hypertension. However, further studies are needed to evaluate increased risk of recoarctation after early intervention of aortic coarctation.

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

IntroductionDespite successful repair of aortic coarctation, cardiovascular complications occur.AimTo analyse type and frequency of late complications and their impact on exercise capacity in adults after aortic coarctation repair.Material and methodsFifty-eight adults after aortic coarctation repair, 36 male, median age 27.46 ±10.57, were compared to 30 healthy volunteers. Physical examination, transthoracic echocardiography, carotid intima-media thickness measurement, cardiopulmonary exercise test and 24-hour ambulatory blood pressure monitoring were performed.ResultsThe main complications were: arterial hypertension 48.3%, myocardial hypertrophy in echocardiography 29.34%, recoarctation 25.86%, aortic dilation 13.79% and coronary artery disease 6.89%. Exercise tolerance was reduced in the cardiopulmonary exercise test. The VO2/kg peak was lower, 29.01 ±8.79 vs. 49.16 ±7.38 ml/kg/min, p < 0.001, VE/VCO2 peak higher 28.18 ±4.69 vs. 26.78 ±3.13, p = 0.017. The peak heart rate was reduced, 157.28 ±22.22 vs. 177.93 ±23.08 bpm, p < 0.001, peak systolic blood pressure was higher, 174.79 ±17.62 vs. 153.33 ±4.79 mm Hg, p < 0.001. Systolic blood pressure in 24-hour ambulatory monitoring correlated with left ventricle mass index, r = 0.29, p = 0.025, wall thickness, r = 0.31, p = 0.039. Age at operation was related to left ventricle wall thickness, r = 0.27, p = 0.041, and carotid intima-media thickness, r = 0.26, p = 0.046. There was no association of any cardio-pulmonary parameters with time from surgery, type of operation or echocardiography results.ConclusionsAdults after aortic coarctation repair suffer from arterial hypertension, recurrent aortic stenosis, aortic aneurysms, and coronary artery disease. Reduced exercise capacity in cardio-pulmonary exercise test is related to hypertensive reaction and chronotropic incompetence.

Invited Commentary

The surgical repair of arch obstruction dates back to the first report of successful repair of aortic coarctation by Clarence Crafoord in 1944 [1Crafoord C. Nylin G. Congenital coarctation of the aorta and its surgical treatment.J Thorac Surg. 1945; 14: 347-361Abstract Full Text PDF Google Scholar]. The spectrum of aortic arch obstruction extends from the simplest form with isolated coarctation to the most complex form of obstruction, which involves complete interruption of the aorta. Although little controversy exists about the technique to repair either isolated coarctation or aortic interruption, there is a tremendous amount of controversy about the surgical management of transverse aortic arch hypoplasia. Perhaps the most controversial area is surgical management of proximal transverse arch hypoplasia, which Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] have described in their article. In dealing with arch hypoplasia, there is no commonly accepted way to describe the problem. Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] use a proximal transverse arch diameter that is less than 50% of the diameter of the ascending aorta. Surgical lore suggests that an arch size that is the patient’s weight in kilograms plus one is an acceptable standard. Z scores are probably the most common means of determining deviation from normal, but even so, there are multiple different z score programs that exist that are not identical in their measurements. A similar degree of controversy exists regarding the surgical approach to transverse arch hypoplasia. Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] champion a median sternotomy approach for their patients, but there are plenty of data to suggest that the relief of distal obstruction through a thoracotomy approach will allow for improved flow through the area of proximal hypoplasia and, ultimately, growth in this area [3Kotani Y. Anggriawan S. Chetan D. et al.Fate of the hypoplastic proximal aortic arch in infants undergoing repair for coarctation of the aorta through a left thoracotomy.Ann Thorac Surg. 2014; 98: 1386-1393Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 4Siewers R. Ettedgui J. Pawl E. TallmanT del Nido P. Coarctation and hypoplasia of the aortic arch: will the arch grow?.Ann Thorac Surg. 1991; 52: 608-613Abstract Full Text PDF PubMed Scopus (68) Google Scholar]. This controversy may be completely addressed only by a randomized controlled multiinstitutional trial. Ultimately, the ideal approach to the management of arch hypoplasia will be identified only after much longer-term follow-up. The goal of congenital heart surgery is not survival measured in months or years but in decades. The quality of that survival will also be critical in determining the best operative management, by taking into account such factors as the need for both operative and percutaneous reintervention, the need for further medical management, and detailed long-term neurodevelopmental outcomes in these patients. In particular, longitudinal neurodevelopmental outcomes are paramount to determining the success of this surgical procedure related to the consequences of the bypass technique [5Ohye R. Goldberg C. Donohue J. et al.The quest to optimized neurodevelopmental outcomes in neonatal arch reconstruction: the perfusion techniques we use and why we believe in them.J Thorac Cardiovasc Surg. 2009; 137: 803-806Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar]. In this paper, Gray and colleagues [2Gray W.H. Wells W.J. Starnes V.A. Kumar S.R. Arch augmentation via median sternotomy for coarctation of aorta with proximal arch hypoplasia.Ann Thorac Surg. 2018; 106: 1214-1219Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar] definitely present a safe and effective management strategy, but the quest to determine the ideal strategy remains elusive. Arch Augmentation via Median Sternotomy for Coarctation of Aorta With Proximal Arch HypoplasiaThe Annals of Thoracic SurgeryVol. 106Issue 4PreviewCoarctation of the aorta can be associated with hypoplasia of the proximal transverse aortic arch. One approach to manage this condition is via left thoracotomy and extended end-to-end anastomosis with the expectation that the proximal arch will grow over time. Our preferred approach is to augment the aorta via midline sternotomy. We hypothesized that this approach is safe, durable, and allows reliable growth of the aorta. Full-Text PDF

Abnormalities of aortic arch shape after successful repair of aortic coarctation and systemic arterial hypertension

Abnormalities of aortic arch shape after successful repair of aortic coarctation and systemic arterial hypertension

How successful is successful? Aortic arch shape after successful aortic coarctation repair correlates with left ventricular function

ObjectivesEven after successful aortic coarctation repair, there remains a significant incidence of late systemic hypertension and other morbidities. Independently of residual obstruction, aortic arch morphology alone may affect cardiac function and outcome. We sought to uncover the relationship of arch 3-dimensional shape features with functional data obtained from cardiac magnetic resonance scans. MethodsThree-dimensional aortic arch shape models of 53 patients (mean age, 22.3 ± 5.6 years) 12 to 38 years after aortic coarctation repair were reconstructed from cardiac magnetic resonance data. A novel validated statistical shape analysis method computed a 3-dimensional mean anatomic shape of all aortic arches and calculated deformation vectors of the mean shape toward each patient's arch anatomy. From these deformations, 3-dimensional shape features most related to left ventricular ejection fraction, indexed left ventricular end-diastolic volume, indexed left ventricular mass, and resting systolic blood pressure were extracted from the deformation vectors via partial least-squares regression. ResultsDistinct arch shape features correlated significantly with left ventricular ejection fraction (r = 0.42, P = .024), indexed left ventricular end-diastolic volume (r = 0.65, P < .001), and indexed left ventricular mass (r = 0.44, P = .014). Lower left ventricular ejection fraction, larger indexed left ventricular end-diastolic volume, and increased indexed left ventricular mass were identified with an aortic arch shape that has an elongated ascending aorta with a high arch height-to-width ratio, a relatively short proximal transverse arch, and a relatively dilated descending aorta. High blood pressure seemed to be linked to gothic arch shape features, but this did not achieve statistical significance. ConclusionsIndependently of hemodynamically important arch obstruction or residual aortic coarctation, specific aortic arch shape features late after successful aortic coarctation repair seem to be associated with worse left ventricular function. Analyzing 3-dimensional shape information via statistical shape modeling can be an adjunct to long-term risk assessment in patients after aortic coarctation repair.

Atenolol vs enalapril in young hypertensive patients after successful repair of aortic coarctation

Late arterial hypertension has been identified as a major predictor for morbidity and mortality in aortic coarctation (AoC) patients. Few data are available about efficacy and tolerability of angiotensin converting enzyme inhibitors vs beta-blockers in young AoC patients. This study aimed to evaluate the tolerability and efficacy on 24-h blood pressure (BP) and left ventricular mass/height(2.7) (LVMI), of atenolol vs enalapril. We enrolled consecutive AoC hypertensive patients with (a) no history of BP treatment or after >48 h of withdrawn, (b) aged 6-20 years, (c) body mass index (BMI) <90th percentile for age and sex, (d) >12 months from a successful AoC repair and (e) no major associated cardiovascular abnormalities. All patient were evaluated with 24-h ambulatory BP monitoring, standard echocardiography, strain-strain rate imaging, at enrolment, 3, 6 and 12 months of treatment. We studied 51 AoC patients (13±3.9 years, BMI: 21.4±4.3 kg m(-2)). Patients were randomly assigned at atenolol treatment (n=26), or enalapril treatment (n=25). The mean follow-up duration was 11±2 months. Both drugs were able to significantly reduce 24-systolic BP (SBP; atenolol: 133±11 mm Hg vs 124±16 mm Hg, P=0.016; enalapril: 135±6 mm Hg vs 127±7 mm Hg, P=0.001). Only enalapril was able to significantly reduce LVMI (47±12 vs 39.6±10 g m(-)(2.7), P=0.016). Only in atenolol group in two cases (7.7%) drug withdrawal was needed because of adverse events. Enalapril and atenolol are similarly effective in reducing SBP. However, only enalapril demonstrated a significant reduction of LVMI. In no case, enalapril was stopped because of adverse events.

Abnormalities of aortic arch shape, central aortic flow dynamics, and distensibility predispose to hypertension after successful repair of aortic coarctation.

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. 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. 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. 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). 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.

Low plasma renalase concentration in hypertensive patients after surgical repair of coarctation of aorta

The study aimed to evaluate plasma renalase level, a recently discovered kidney-derived catecholamine-metabolizing enzyme in patients after successful repair of aortic coarctation, with special consideration of arterial hypertension in the context of underlying process of arterial remodeling. This case–control study covered 50 consecutive patients after Dacron patch repair of aortic coarctation (31 men; median age 33 [26; 40]; age at surgery 10 [5; 16] years), matched in terms of age and gender with 50 controls. Both groups were stratified depending on the presence of hypertension and assessed in terms of renalase, C-reactive protein, and carotid intima-media thickness. Additionally ultrasound and tonometric markers of vascular remodeling were obtained in the study group. Hypertension was found in 21 patients (42%) in the study group and 29 (58%) in the control group (P = .11). Renalase level was significantly lower in patients in the study than control group (5825.1 vs. 6592.7 ng/mL; P = .041). Significant difference in terms of renalase concentration between hypertensive and normotensive patients was confirmed both in subjects with coarctation of aorta (P = .027) and in control group (P < .0001). Renalase level inversely correlated with serum creatinine (r = −0.36) and arterial blood pressure in the whole population, and with central systolic (r = −0.29) and diastolic pressure (r = −0.35) in study group. Multivariate regression revealed that serum creatinine and pulse pressure were independent predictors of renalase. Surgical intervention >7 years was linked to lower renalase (P = .018) and unfavorable vascular parameters. Renalase level <4958 ng/mL accurately predicted presence of hypertension in patients after coarctation of aorta repair (odds ratio, 3.8; P = .032). Renalase deficiency is associated with the presence of hypertension in both patients after surgical repair of aortic coarctation and the control group. In coarctation of aorta, its action is probably parallel to underlying arterial remodeling.

Long-term follow-up after aortic coarctation repair: The unsolved issue of exercise-induced hypertension

IntroductionDespite successful repair of aortic coarctation (AC), systemic hypertension (HTN) can persist in a significant percentage of patients. Exercise-induced HTN is also common in these patients, although its clinical significance is still unclear. In this study we aimed to assess the prevalence of exercise-induced HTN in adult patients with repaired AC. MethodsWe retrospectively reviewed the clinical records of patients aged >18 years with repaired AC followed at an adult congenital heart disease outpatient clinic in a tertiary care center. Demographic and clinical data including age at intervention, blood pressure (BP) at rest and on exercise, transthoracic echocardiogram (TTE) and treadmill exercise test results were evaluated. Exercise-induced HTN was defined as peak systolic BP ≥210 mmHg for men and ≥190 mmHg for women. ResultsWe analyzed 65 patients (40 [61.5%] male; mean age at follow-up 30±8 years). Median age at AC repair was 7 years (P25-P75: 4-20) and mean follow-up was 20±7 years. Only one patient had diabetes and 10 (15.4%) had dyslipidemia. The majority of patients had controlled BP at rest and only nine (18%) were under antihypertensive medication. Forty-nine patients performed a treadmill exercise test. The mean duration of exercise was 10.7±3.1 minutes and mean peak heart rate was 166±18 beats per minute. Eleven (22%) patients had a hypertensive response, among whom only three (33%) had uncontrolled BP at rest. In our study treatment with angiotensin-converting enzyme inhibitors (ACEI) (OR 4.0 [95% CI 1.9–18.1]) and the peak instantaneous gradient in the descending aorta by TTE (OR 8.2 [95% CI 1.8–37.0]) were predictors of a hypertensive response with exercise. Age at surgery and type of AC repair were not associated with a hypertensive response on exercise. ConclusionsIn this study we found a significant prevalence of exercise-induced HTN in adult patients after successful AC repair despite adequate BP control at rest. Exercise-induced HTN was significantly related to higher peak gradient in the descending aorta and treatment with ACEI. These results highlight the complexity of the adult AC population and show that, even after a good surgical result, several patients remain at high cardiovascular risk and require long-term follow-up.

Long-term follow-up after aortic coarctation repair: The unsolved issue of exercise-induced hypertension

IntroductionDespite successful repair of aortic coarctation (AC), systemic hypertension (HTN) can persist in a significant percentage of patients. Exercise-induced HTN is also common in these patients, although its clinical significance is still unclear. In this study we aimed to assess the prevalence of exercise-induced HTN in adult patients with repaired AC. MethodsWe retrospectively reviewed the clinical records of patients aged >18 years with repaired AC followed at an adult congenital heart disease outpatient clinic in a tertiary care center. Demographic and clinical data including age at intervention, blood pressure (BP) at rest and on exercise, transthoracic echocardiogram (TTE) and treadmill exercise test results were evaluated. Exercise-induced HTN was defined as peak systolic BP ≥210 mmHg for men and ≥190 mmHg for women. ResultsWe analyzed 65 patients (40 [61.5%] male; mean age at follow-up 30±8 years). Median age at AC repair was 7 years (P25-P75: 4-20) and mean follow-up was 20±7 years. Only one patient had diabetes and 10 (15.4%) had dyslipidemia. The majority of patients had controlled BP at rest and only nine (18%) were under antihypertensive medication. Forty-nine patients performed a treadmill exercise test. The mean duration of exercise was 10.7±3.1 minutes and mean peak heart rate was 166±18 beats per minute. Eleven (22%) patients had a hypertensive response, among whom only three (33%) had uncontrolled BP at rest. In our study treatment with angiotensin-converting enzyme inhibitors (ACEI) (OR 4.0 [95% CI 1.9–18.1]) and the peak instantaneous gradient in the descending aorta by TTE (OR 8.2 [95% CI 1.8–37.0]) were predictors of a hypertensive response with exercise. Age at surgery and type of AC repair were not associated with a hypertensive response on exercise. ConclusionsIn this study we found a significant prevalence of exercise-induced HTN in adult patients after successful AC repair despite adequate BP control at rest. Exercise-induced HTN was significantly related to higher peak gradient in the descending aorta and treatment with ACEI. These results highlight the complexity of the adult AC population and show that, even after a good surgical result, several patients remain at high cardiovascular risk and require long-term follow-up.

HYPERTENSION PATTERNS POST AORTIC COARCTATION REPAIR

Up to 55% of patients who have undergone successful aortic coarctation repair develop late systolic hypertension, however the severity and patterns of this complication have not been well characterised. All patients who had had coarctation repair and were ≥ 12 years old were eligible for

Facilitating recognition and grouping the expertise in the main fields of rare cardiovascular diseases

Facilitating recognition and grouping the expertise in the main fields of rare cardiovascular diseases

Prevalence and Long-Term Predictors of Left Ventricular Hypertrophy, Late Hypertension, and Hypertensive Response to Exercise After Successful Aortic Coarctation Repair

Controversial data exist about the long-term results of aortic coarctation (AC) repair. This study explored the prevalence and predictors of left ventricular (LV) hypertrophy, late hypertension, and hypertensive response to exercise in 48 subjects (age, 15.1±9.7years) currently followed in the authors' tertiary care hospital after successful AC repair. Data on medical history, clinical examination, rest and exercise echocardiography, and ambulatory blood pressure monitoring were collected. The time from AC repair to follow-up evaluation was 12.9±9.2years. The prevalence of LV hypertrophy ranged from 23 to 38%, based on the criteria used to identify LV hypertrophy, and that of concentric geometry was 17%. One sixth of the patients without residual hypertension experienced late-onset hypertension. One fourth of those who remained normotensive without medication showed a hypertensive response to exercise. Age at AC repair was the strongest independent predictor of LV hypertrophy, defined using indexation either for body surface area (odds ratio [OR], 1.03; p=0.0090) or for height(2.7) (OR 1.02; p=0.029), and it was the only predictor of late hypertension (OR 1.06; p=0.0023) and hypertensive response to exercise (OR 1.09; p=0.029). The risk of LV hypertrophy was 25% for repair at the age of 3.4years but rose to 50 and 75% for repair at the ages of 5.9 and 8.4years, respectively. Similar increases were found for the risk of late-onset hypertension and hypertensive response to exercise. A considerable risk of LV hypertrophy, late hypertension, and hypertensive response to exercise exists after successful AC repair. Older age at intervention is the most important predictor of these complications.

342 Assessment of systo-diastolic ventricular function using tissue Doppler imaging after successful repair of aortic coarctation

342 Assessment of systo-diastolic ventricular function using tissue Doppler imaging after successful repair of aortic coarctation

Impact of Obesity on Left Ventricular Geometry and Function in Pediatric Patients after Successful Aortic Coarctation Repair

To evaluate if obesity has an additional negative impact on left ventricular (LV) geometry and function in normotensive pediatric patients >12 months after successful treatment of aortic coarctation (CoA). We studied 40 CoA patients (mean age 14 ± 3 years, and male sex 70%), of them 10 were obese and 30 lean. Both groups were age and sex comparable. The entire studied sample underwent 24-ambulatory blood pressure (BP) monitoring, standard echocardiographic evaluation, and speckle tracking study. Both office and 24-hour diastolic BP were significantly increased in obese patients. Obese CoA patients showed increased LV mass (52 ± 13 g/m(2.7) vs. 43 ± 9 g/m(2.7) , P = 0.02), and significant reduction in E/A compared with lean CoA patients. Myocardial deformation properties were significantly reduced in obese CoA patients in all the three studied planes (longitudinal, radial, and circumferential) compared with CoA lean patients. LV twist values showed a significant reduction in the obese CoA group (9.9° ± 2.2° vs. 14.5° ± 2.3°, P < 0.0001). Our study shows that obesity in successfully treated CoA children, has an additional negative effect on BP, LV mass, and cardiac function. These findings are of particular concern, since life expectancy in CoA patients is limited mainly by atherosclerosis, and all the obesity-associated abnormalities found are harbingers of higher cardiovascular risk.

Asymmetric dimethylarginine and vascular indices of atherosclerosis in patients after coarctation of aorta repair

ObjectiveCardiovascular events are the main cause of premature death after successful repair of aortic coarctation (CoA). The aim of this study was to assess the selected biochemical markers of atherosclerosis in normotensive CoA repaired patients and to establish its relation to ultrasound indexes of vascular pathology. Methods62 patients after CoA repair (37 males, age: 34.1±1.4yrs) and 20 control individuals (10 males, age: 34.8±2.2yrs) were enrolled in the study. The serum markers: asymmetric dimethylarginine (ADMA), nitrites/nitrates (NOx), high-sensitivity C-reactive protein (hsCRP), and following vascular parameters: flow-mediated dilatation (FMD), intima-media thickness (IMT) and pulse wave velocity (PWV) were analyzed. Results33 CoA repaired patients were normotensive, and compared to controls, they presented higher serum ADMA concentrations (0.59±0.04umol/l vs. 0.46±0.03umol/l, p=0.035). An analysis of the vascular parameters revealed decreased FMD (4.75±0.5%), NMD (11.86±0.8%) and increased PWV (6.90±0.2m/s) values in the normotensive patients as compared with the control group (FMD: 8.6±0.9%, p<0.001, NMD: 20.94±1.7%, p<0.001; PWV: 5.49±0.2, p=0.023). There were no differences in the serum levels of NOx, hsCRP as well as IMT values between normotensive patients and the control group. A multivariate regression analysis revealed that serum ADMA level was a factor independently associated with the FMD value (r=−0.334; p=0.031) in normotensive CoA repaired group. ConclusionsEarly biochemical and vascular indices of atherosclerosis such as increased serum ADMA concentration as well as impaired vasodilatation and increased arterial stiffness are observed in patients after CoA repair. Serum ADMA is a strong predictor of endothelial dysfunction in patients with CoA repair.

Masked hypertension in young patients after successful aortic coarctation repair: impact on left ventricular geometry and function

Life expectancy is still reduced in aortic coarctation (AoC) patients despite a successful repair because of late arterial hypertension and atherosclerosis. Masked hypertension (MH) consists of an elevated daytime or awake ambulatory blood pressure (BP) in the presence of a normal BP on conventional measurement at the office. To assess the prevalence of MH among AoC normotensive young patients successfully treated and to evaluate the impact of MH on left ventricular (LV) geometry and function.We studied 76 AoC patients (mean age 14.5±5.7 years, male 64%). According to 24 h ambulatory BP monitoring (ABPM) our sample was divided in real normotensive patients (Group RN, n=40) and MH patients (Group MH, n=36). There was an increased pressure gradient in the aortic arch (15 mm Hg±4 vs 13 mm Hg±4.7, P<0.05), increased LV mass (51 g m(-2.7)±13 vs 46 g m(-2.7)±12, P<0.05), in MH AoC patients. Regional longitudinal deformation properties of the basal septal segment (-15%±2.4 vs -20%±5, P<0.01) and LV twist values (14°±1.6 vs 12°±1.9, P<0.0001) were reduced in the MH group. There is a high prevalence of MH in young patients with repaired AoC, which is associated with abnormal LV structure and function. Clinicians should consider 24 h ABPM measurements in apparently normotensive patients followed up for AoC repair.

317 Effect of aging at repair on Tissue Doppler imaging parameters in patients with aortic coarctation

Despite successful repair of aortic coarctation (AoC), changes in the left ventricular (LV) regional myocardial function are reported. The aim of this study was to assess the left ventricular systolic function in patients after the successful repair of aortic coarctation using tissue Doppler imaging (TDI) according to the age of aortic coarctation repair. 31 patients (mean age, 12.0 +/− 4.2 years) followed up after a successful chirurgical repair of aortic coarctation (mean follow up, 8,6 ± 7,6 years) were studied by echocardiography. The study population was divided in two groups: patients repaired at age 2 years (Group 1, n = 17) and patients repaired at age > 2 years (group 2, n = 14). The TDI parameters and the conventional echocardiographic indices of the left ventricular systolic function were analyzed and compared between the two groups. Standard echocardiographic studies revealed normal global left ventricular (LV) function. The LV dimensions, LV ejection fraction, LV shortening fraction, indexed LV mass did not differ between the examined groups. Among the studied LV filling parameters, peak early (E wave) transmitral flow velocity, as well as deceleration time DT, was similar between the two groups. The Tei index was also not affected by the age at repair of aortic coarctation. Regarding TDI measures, the early diastolic and the systolic velocities on the lateral side of the mitral annulus were significantly higher in group 1 than in group 2 (Sa: 12,7 ± 2,59 cm/s vs 10,6 ± 1,8 cm/s, p = 0,025; Ea : 20,7 ± 3,4 cm/s vs 17,3 ± 4,7 cm/s, p = 0,03). TDI velocities on the septal side of the mitral annulus and on the right ventricle (RV) free wall side of the tricuspid annulus were not different between early (before 2 years) and late (after 2 years) repair of the aortic coarctation. There were no differences of the TDI or conventional parameters between hypertensive and normotensive patients. Left ventricular systolic performance in patients after the surgical repair of aortic coarctation reveals tendency to decrease at follow-up in patients repaired at age > 2 years despite a satisfactory results after surgery.

Assessment of left ventricular diastolic function in children after successful repair of aortic coarctation

The purpose of the study was an assessment of left ventricular diastolic function in children after the successful repair of aortic coarctation (CoA). The prospective study concerned 32 pediatric patients after the CoA surgery. Tissue Doppler imaging parameters including strain and strain rate and the conventional echocardiographic indexes were analyzed in patients and healthy controls. Analysis of mitral annulus velocities, E–E′ ratio, strain, and strain rate of left ventricular mid-cavity segments and conventional indexes of mitral inflow showed the worsening of left ventricular diastolic mechanics in the study group compared to healthy controls. The E/E′ ratio was significantly higher in the study group compared to the control group (8.30 ± 3.24 vs. 6.95 ± 1.36; p < 0.05). The early diastolic strain rate to late diastolic strain rate ratio as well as early to late diastolic strain ratio of the left ventricular mid-cavity segments were significantly lower in the study group compared to healthy controls (1.81 ± 0.63 vs. 3.74 ± 1.53; p < 0.001 and 1.20 ± 0.49 vs. 3.41 ± 1.26; p < 0.001). No differences of the pulmonary venous flow parameters between those two groups were observed. The left ventricular diastolic mechanics in hypertensive patients after CoA repair did not differ from normotensive subjects. Hypertensive and normotensive children after surgical repair of CoA are found to have worsening of the left ventricular diastolic mechanics suggesting the impairment of the active myocardial relaxation.

Assessment of left ventricular systolic function using tissue Doppler imaging in children after successful repair of aortic coarctation

SUMMARY AIM: Assessment of left ventricular systolic function in children after the successful repair of aortic coarctation using tissue Doppler imaging (TDI). The study group consisted of 32 patients (mean age 12.0 +/- 4.2 years) after the aortic coarctation repair. The TDI parameters and the conventional echocardiographic endocardial and midwall indices of the left ventricular systolic function were analysed and compared with the results obtained from 34 healthy children. The systolic mitral annulus motion velocity, systolic myocardial velocity of the medial segment of the left ventricular septal wall, left ventricular strain and Strain Rate (SR) in the study group were significantly higher than in the control group, respectively: 6.92 +/- 0.75 cm s(-1) versus 6.45 +/- 0.83 cm s(-1); 5.82 +/- 1.03 cm s(-1) versus 5.08 +/- 1.11 cm s(-1); -28.67 +/- 6.04% versus -22.53 +/- 6.44% and -3.20 +/- 0.76 s(-1) versus -2.39 +/- 0.49 s(-1). Except midwall shortening fraction the conventional endocardial and midwall echocardiographic indices in the study group were significantly higher in comparison to the healthy controls. The left ventricular systolic meridional fibre stress and end-systolic circumferential wall stress did not differ between the examined groups. There were no differences of the TDI or conventional parameters between hypertensive and normotensive patients. Left ventricular systolic performance in children after the surgical repair of aortic coarctation reveals tendency to rise in late follow-up despite a satisfactory result after surgery. Higher systolic strain and SR in children treated due to coarctation of the aorta may suggest the increased preserved left ventricular performance despite normalization of afterload.