Ann Thorac Surg 1999;67:1376-1379
© 1999 The Society of Thoracic Surgeons
Original Articles
Repair of aortic coarctation in patients more than 50 years of age
Alejandro Aris, MD, PhDa,
M. Teresa Subirana, MDa,
Pere Ferrés, MDa,
Miguel Torner-Soler, MDa
a Department of Cardiology and Cardiac Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
Accepted for publication December 3, 1998.
Address reprint requests to Dr Aris, Cardiac Surgery Service, Hospital de la Santa Creu I Sant Pau, Avenida S. Antonio M. Claret 167, 08025 Barcelona, Spain
e-mail: aaris{at}hsp.santpau.es
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Abstract
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Background. Most patients with uncorrected coarctation of the aorta die before reaching age 50 years. In those who survive, the beneficial effect of surgical repair on systolic hypertension has been questioned.
Methods. Surgical repair of aortic coarctation was performed in 8 patients aged 51 to 73 years (mean, 58 ± 9 years). Preoperative mean systolic pressure was 185 ± 34 mm Hg and systolic gradient, 70 ± 11 mm Hg. In addition, 3 patients had significant coronary artery disease. Severe calcification of the aortic arch and left subclavian artery was found in 3 patients. The surgical technique involved bypass of the coarctation with a Dacron tube graft (16 or 18 mm) in all patients. One patient underwent concomitant coronary artery bypass grafting.
Results. There were no operative or late deaths during a mean follow-up of 4.3 years. Mean systolic blood pressure decreased significantly in the postoperative period to 128 ± 16 mm Hg (p < 0.001). At the last visit, systolic blood pressure was a mean of 127 ± 9 mm Hg. Five patients were not taking antihypertensive medication.
Conclusions. Surgical repair of aortic coarctation in patients more than 50 years of age with a Dacron tube bypass graft reduces systolic hypertension and the need of antihypertensive medication.
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Introduction
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Most patients with uncorrected coarctation of the aorta die before the age of 50 years [1]. Myocardial infarction, intracranial hemorrhage, congestive heart failure, and aortic dissection or rupture are the most common causes of death. Concomitant bicuspid aortic valve may be a source of morbidity and mortality. Patients who survive may be denied the benefits of operation because regression of systolic hypertension has been questioned in this age group [2, 3]. Wells and colleagues [4] demonstrated that systolic hypertension is relieved by coarctation repair in adults but, in their series, only 2 patients were older than 50 years. In the present study, we report our results with coarctation repair in 8 patients with ages between 51 and 73 years who had regression of their hypertension at the latest follow-up.
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Patients and methods
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Eight patients aged 51 to 73 years (mean, 58 ± 9 years) underwent surgical correction of aortic coarctation at our institution. This group of patients represents 7.7% of the total of 103 coarctation repairs performed during the past 20 years, 67 of them in adult patients. Sex, age, preoperative blood pressure, and medication, symptoms, and length of follow-up are shown in Table 1.
The diagnosis of aortic coarctation was made after study for hypertension in all patients, but no surgical treatment had been suggested in most cases. Patients 7 and 8, the oldest of the group, had the diagnosis made 30 years before operation, but they had consistently refused operation. When arrhythmias and progressive blindness, respectively, developed, they accepted to undergo surgical repair of the coarctation. Preoperative antihypertensive medication was effective only in 2 patients (nos. 2 and 4). Two patients were in atrial fibrillation. Systolic gradient across the coarctation was 70 ± 11 mm Hg. All patients underwent coronary cineangiography before operation. Significant coronary artery stenoses were found in 3 patients.
Operative findings included severe calcification of the left subclavian artery and aortic arch in 3 patients and aneurysms of the intercostal arteries in 2 patients.
Surgical technique was the use of a Dacron tube graft (sized 16 or 18 mm) to bypass the coarctation in all patients. In 5 patients, the graft was anastomosed, proximally to the left subclavian artery, which had an adequate size. In the other 3 patients, the proximal anastomosis was placed in the aortic arch. In 1 patient with severe calcification of the subclavian artery and the distal aortic arch, the dissection was carried to the proximal arch and the graft was placed at this level, anteriorly.
One patient with severe symptomatic coronary artery disease underwent triple saphenous vein coronary bypass grafting to the right coronary artery and to the first diagonal and left anterior descending coronary arteries in a sequential fashion. After heparin neutralization, the sternotomy was closed, the patient turned to his side and repair of the coarctation accomplished through a left posterior thoracotomy. The other 2 patients with significant lesions in the coronary arteries were not considered suitable candidates for myocardial revascularization. One had diffuse disease with poor distal vessels and low left ventricular ejection fraction, whereas the other had an asymptomatic single lesion in the distal circumflex artery. An intercostal artery with a large aneurysm was ligated in 1 patient.
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Results
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There was no hospital or late mortality. All patients developed paradoxic hypertension in the immediate postoperative period, which was controlled by sodium nitroprusside infusion and ß-blockers. The patient who underwent associated myocardial revascularization developed bilateral postperfusion lung edema, which was treated with mechanical ventilatory support and diuretics. One patient with a previous episode of atrial fibrillation had recurrence of her arrhythmia. She had also an old calcified tuberculous pleuritis that made the surgical procedure very difficult. A pleural effusion developed, which was drained. All patients but 2 required maintenance with ß-blockers during their hospital stay to control blood pressure within normal range. Mean values before discharge were 128 ± 16 mm Hg (p < 0.001 from preoperative values). The patient with low ejection fraction showed hypertension (systolic blood pressure, 155 mm Hg) at hospital discharge. An echocardiogram performed 3 years after operation showed that his ventricular function and diameters remained unchanged, but he was normotensive and asymptomatic. Patients have been followed at regular intervals by their cardiologist. At the last visit, a mean of 4.3 years after the operation (range, 1 to 12 years), mean systolic pressure was 127 ± 9 mm Hg (Fig 1). No patient showed hypertension (systolic blood pressure > 140 mm Hg) or external gradient between upper and lower extremities. Three patients were taking antihypertensive medication. The patient with low ejection fraction was on diuretics and angiotensin-converting enzyme inhibitors. A second patient was on angiotensin-converting enzyme inhibitors and antiarrhythmic drugs because of persistent atrial fibrillation and the oldest patient was controlled with ß-blockers. The remaining 5 patients maintain a normal blood pressure without medication.
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Fig 1. Evolution of systolic blood pressure from preoperative to early postoperative and to the latest follow-up (mean, 4.3 years). The thick line and numbers indicate mean ± standard deviation values.
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Comment
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Coarctation of the aorta is a congenital malformation that can lead to premature death if it remains uncorrected. According to Campbell [1], 50% of the patients die by the age of 30 years, 75% at 46 years, and 90% at 58 years. Age at operation is the most important factor to determine control of hypertension and long-term survival [3, 5–10]. For these reasons, some investigators question the efficacy of surgical repair to control hypertension in older patients. Wells and colleagues [4] reported a series of 26 adult patients followed after coarctation repair. Only 2 patients were older than 50 years and only 1 was normotensive (systolic blood pressure, < 140 mm Hg) at 1-year follow-up. Cayenne and associates [11] reported asymptomatic coarctation in a 59-year-old patient. Hypertension regressed after surgical repair with an interposition graft. Other series [5, 10, 12, 13] report long-term results after coarctation repair, including patients older than 50 years, but no details are given as far as number or degree of hypertension in these older patients. Our patients had a mean age of 58 years at the time of operation. At this age, only 10% of patients with coarctation are alive, according to Campbell [1]. Although the number of patients is limited, we believe that it represents a unique group of patients with special characteristics. Three of these patients had significant coronary lesions. We routinely perform preoperative coronary angiograms on all patients undergoing cardiac operation and coarctation of the aorta is no exception. The occurrence of coronary artery disease in patients after coarctation repair was observed by Cokkinos and colleagues [13]. In patients older than 35 years, they found that nearly half of hospital and late deaths were attributable to myocardial infarction. Similarly, two-thirds of the patients followed by Lawrie and associates [6] and between one-third and one-fourth in other studies [3, 5, 7] died of myocardial infarction. We elected to perform concomitant myocardial revascularization at the time of coarctation repair in 1 patient with very symptomatic triple-vessel disease. The other 2 patients were not considered good candidates, although coarctation repair decreased afterload significantly in the patient with left ventricular impairment. Patients undergoing coarctation repair with myocardial revascularization and aortic valve replacement have been reported recently [14–16]. These researchers have performed the cardiac procedure first, correcting the coarctation through the same incision by means of an extraanatomic bypass from the ascending to the descending aorta. The internal mammary artery is not a good choice as conduit in these particular patients, not only because of the large size of the artery and its side branches but also as a result of the severe atherosclerosis found in the internal mammary arteries of patients subjected to a previous coarctation repair [17, 18].
Operation in these older patients differs from the standard repair of coarctation in children. Severe calcification of the distal aortic arch and left subclavian artery may be encountered. The intercostal arteries are extremely large, some with aneurysmal dilatation. For these reasons, we elected to correct the coarctation with a tube graft bypass, with partial occlusion of the aorta. The procedure is simple, requires less dissection, does not compromise arterial blood flow to the spinal chord, and is as effective as other types of repair as long as the graft has an area larger than 40% of the descending aorta [19]. Wells and colleagues [4] used this technique in 42% of adult coarctation repairs with results comparable to other techniques and Grinda and associates [20] achieved excellent results with bypass grafts, mostly 16 mm in size, to treat complex forms of aortic coarctation in 14 adult patients. Blood pressure in the lower part of the body during operation was not monitored as the aorta was not completely occluded and all patients had extensive collateral circulation.
The fact that all 8 patients are normotensive is not surprising. Systolic blood pressure tends to decrease in the first postoperative year. Clarkson and colleagues [7] found that most patients were normotensive 5 to 10 years after the operation, but 78% of their 37 patients, aged 49 to 59 years at an average follow-up of 17.5 years, were hypertensive. Only 5 of their patients were older than 50 years at the time of operation. Our mean follow-up is 4.3 years, with only 2 patients reaching the ninth postoperative year. However, most of them are without medication and are closely followed by a cardiologist. Should hypertension develop, it could be easily controlled with antihypertensive drugs. We did not perform exercise testing in our patients as suggested by Viganò and associates [21]. In a previous study we have shown that a hypertensive response to exercise correlates with the presence of a residual gradient [22], which was not present during follow-up.
In summary, surgical repair of aortic coarctation in patients older than 50 years of age can reduce systolic hypertension and the need of antihypertensive medication. Coronary angiography should be performed before repair as coronary artery disease is common in these patients. The technique of bypass with an adequately sized tube graft is simple and effective, although the procedure can be complicated by the presence of calcification of the aorta and the left subclavian artery.
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References
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Top
Abstract
Introduction
