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Ann Thorac Surg 1997;63:1827-1828
© 1997 The Society of Thoracic Surgeons
Cardiac Surgery, University of Pavia, IRCCS Policlinico San Matteo, P.le Golgi 4, I-27100 Pavia, Italy
To the Editor:
In the article "Repair of Coarctation in Adults: the Fate of Systolic Hypertension," Wells and colleagues [1] report the successful impact of surgical intervention on the natural history of aortic coarctation. They describe normalization of systolic blood pressure, recorded at rest during a follow-up visit in the majority of their patients. We think that the article has a lack of information regarding the fate of systolic blood pressure during exercise testing.
Experience reported in the literature suggests that the persistence of systolic hypertension in patients operated on because of aortic coarctation is a multifactorial phenomenon. One factor to consider is an altered renin-angiotensin system [2] with sodium and water retention and neural reflex [3]. Furthermore, patients who are normotensive at rest may have a hypertensive response to exercise in the absence of residual coarctaction, and their life expectancy could be affected by the incidence of premature coronary and cerebrovascular disease. The reasons for this altered control in systemic blood pressure are unclear; mechanical factors have been demonstrated related to the baroreflex set to a high level and less sensitive to any change in blood pressure [3]. Postcoarctectomy patients have an augmented sympathetic discharge at peak exercise, which leads to increased peripheral vascular resistances and greater stimulation of ß1-subtype adrenoceptors that mediate the release of renin during exercise. Gardiner and colleagues [4] also documented an exercise-related hypertension in postcoarctectomy patients caused by significant impairment of arterial dilatation in the precoarctation vascular bed of healthy young adults. The abnormal arterial stiffness in the precoarctation segment may be due to an increased content of scleroprotein and a decrease in smooth muscle in the arterial wall. Abnormal vascular responses were not related to age at operation, being also present in subjects operated on in the neonatal period.
On this ground we think that persistence of structural and functional abnormalities of vessels after repair of aortic coarctation should be investigated by monitoring systolic blood pressure during exercise.
Our experience consists of 14 adults (Table 1
) operated on in our unit because of isthmic coartaction of the aorta, with a mean follow-up of 9 years (range, 2 to 14 years). All patients in this cohort had a good surgical result as demonstrated by either digital angiography or nuclear magnetic resonance imaging of the aorta; all of them were normotensive at rest and without medication. All subjects underwent an exercise test using a modified Bruce protocol until 90% of predicted heart rate was achieved. Pressure increments were compared with data regarding normal adult subjects reported in the literature [5, 6]. Although in good general condition, 4 patients evidenced hypertensive response to exercise. We think that the therapeutic goal in patients affected by aortic coarctation should be not only a good anatomic result but also long-term vigilance on the status of arterial reactivity. Accurate follow-up is mandatory and should include an exercise test to identify patients at risk of having hidden hypertension and requiring close surveillance.
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References
Division of Cardiothoracic Surgery, University of Southern California, Mail Stop #66, 4650 Sunset Blvd, Los Angeles, CA 90027
To the Editor:
The points brought out by Dr Viganò and his co-authors are appropriate and pertinent to the follow-up of postcoarctectomy patients. My colleagues and I would agree that exercise testing should be done on all patients after coarctation repair to identify those who may benefit from antihypertensive therapy, even if the baseline blood pressure is normal. We have been collecting exercise data on the adult patients from our series to include in a future correspondence providing longer term follow-up of the series. We congratulate Dr Viganò and his co-authors on their fine results and the valuable information that they bring to the topic. The only minor exception we would take to their report is that by standardized definition 4 of their patients had hypertension on the baseline measurement after operation.
The important message, however, is that exercise testing should be included in postcoarctectomy patients, regardless of age. In our experience, cardiologists (who tend to do the long-term follow-up of postcoarctectomy patients) rarely include this in their evaluation. Hopefully, the issues raised by Dr Viganò and his co-authors will carry over to our cardiology colleagues.
This article has been cited by other articles:
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  H. A. Vohra, L. Adamson, and M. P. Haw Does surgical correction of coarctation of the aorta in adults reduce established hypertension? Interactive CardioVascular and Thoracic Surgery, January 1, 2009; 8(1): 123 - 127. [Abstract] [Full Text] [PDF]
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 M. Bauer, V. V. Alexi-Meskishvili, U. Bauer, D. Alfaouri, P. E. Lange, and R. Hetzer Benefits of surgical repair of coarctation of the aorta in patients older than 50 years Ann. Thorac. Surg., December 1, 2001; 72(6): 2060 - 2064. [Abstract] [Full Text] [PDF]
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F. Bouchart, A. Dubar, A. Tabley, P. Y. Litzler, C. Haas-Hubscher, M. Redonnet, J. P. Bessou, and R. Soyer Coarctation of the aorta in adults: surgical results and long-term follow-up Ann. Thorac. Surg., November 1, 2000; 70(5): 1483 - 1488. [Abstract] [Full Text] [PDF]
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A. Aris, M. T. Subirana, P. Ferres, and M. Torner-Soler Repair of aortic coarctation in patients more than 50 years of age Ann. Thorac. Surg., May 1, 1999; 67(5): 1376 - 1379. [Abstract] [Full Text] [PDF]
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