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Ann Thorac Surg 2001;72:2060-2064
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
b Department of Congenital Heart Diseases, Deutsches Herzzentrum Berlin, Berlin, Germany
Accepted for publication July 16, 2001.
* Address reprint requests to Dr Matthias Bauer, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
e-mail: mbauer{at}dhzb.de
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Abstract |
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Methods. At follow-up investigation from 0.5 to 11.5 years (mean, 4 years) after primary surgical correction of coarctation in 15 patients aged 50 to 63 years (mean, 54 years), we analyzed the preoperative and postoperative complications, symptoms, need for antihypertensive drugs, and blood pressure at rest and during exercise.
Results. Preoperatively no patient had normal blood pressure at rest despite combined antihypertensive medication. There was no significant mortality or morbidity after repair. At follow-up examination only 3 patients had at rest mild hypertension, the other 12 patients were normotensive. Of the 11 tested patients, 8 displayed systolic arterial hypertension during exercise.
Conclusions. Surgical correction of coarctation can be performed after the age of 50 years with low surgical risk. Operation reduces systolic hypertension at rest and permits more effective medical treatment. Despite persistence of the hypertension during exercise, symptomatic improvement occurs in most patients.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Although operation for coarctation of the aorta has been successfully performed for 55 years [3], many questions with regard to long-term survival, fate of arterial hypertension, and relief of symptoms remain unanswered, especially in older patients. There are only a few reports that deal with patients who were operated on at more than 50 years of age [4–6].
In this report we analyzed the long-term results of surgical repair of coarctation of the aorta in 15 patients older than 50 years of age.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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All 15 patients underwent follow-up examination in our institution 0.5 to 11.5 years (mean, 4 years) after operation. The recent follow-up data, which included clinical examination, interview about symptoms, and the need for antihypertensive medication, as well as blood pressure measurement at rest and during bicycle exercise testing, were analyzed. The oldest patient at follow-up examination was 71 years old.
Systemic hypertension was defined when the right arm blood pressure exceeded 140/90 mm Hg. A residual gradient was defined as a systolic blood pressure gradient between the right arm and either leg of more than 20 mm Hg at rest.
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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In 9 patients (69%), systolic hypertension was severe (systolic blood pressure > 180 mm Hg). An invasively measured pressure gradient at the coarctation (30 to 116 mm Hg, mean 67.7 mm Hg) was observed preoperatively in all 15 patients (Table 1).
The following complications occurred preoperatively in 7 patients (46%): 1 patient experienced aortic valve endocarditis, 2 patients had a cerebrovascular insult (in both cases without residual defects), and 4 patients had congestive heart failure (Table 1).
There was no early or late mortality or neurologic complications after coarctation repair.
Twelve patients (80%) exhibited paradoxical hypertension early after the operation, which was controlled in all instances with sodium nitroprusside infusion and ß-adrenergic blockers. Other complications were not observed. Blood pressure before discharge was normal in 13 patients. Only 2 patients had mild hypertension (systolic blood pressure measured at right arm was 150/80 and 155/80 mm Hg).
During the follow-up period there were no complications related to the operation or hypertension in any of the 15 patients. After operation there was no pressure gradient between upper and lower extremities at rest in 3 patients, whereas a mild gradient of less than 20 mm Hg was found in 12 patients (Table 2).
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At the last follow-up examination after 0.5 to 11.5 years (mean, 4 years), only 3 patients had mild hypertension; the other 12 patients (80%) were normotensive. Only 1 patient was postoperatively without the need for antihypertensive medication (Table 2).
The extent of antihypertensive therapy was postoperatively reduced in all patients. Nine patients (60%) needed only one antihypertensive drug, such as a ß-adrenergic blocker, an angiotensin-converting enzyme inhibitor, or a diuretic for the control of blood pressure (Table 2).
Follow-up bicycle exercise testing was possible in 11 patients. In 3 patients exercise testing was not performed because of aortic valve stenosis, and 1 patient had undergone a leg amputation after an accident. Eight of the 11 patients (72.7%) showed a pathologic blood pressure increase at low exercise levels (50 W) or developed severe arterial hypertension at higher exercise levels (systolic blood pressure > 195 mm Hg), which led to cessation of the exercise testing. In the other 2 patients the exercise testing was stopped because of dyspnea (patient 10) and muscle weakness (patient 11).
The symptomatic state of the patients postoperatively significantly improved. Incidence of headache, palpitations, dyspnea, and angina pectoris significantly diminished. Claudication, which was observed preoperatively in 3 patients (age 50, 53, and 60 years), disappeared after the operation (Fig 1).
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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In our patients the preoperative pressure gradients varied from 25 to 118 mm Hg, but the pressure gradient was not decisive as an indication for operation. The goal of operation in this group of patients was to decrease the left ventricular afterload and to increase the possibility of more effective medical treatment of hypertension after relief of coarctation. The surgical approach by means of extraanatomic bypass techniques was first described by Blalock and Park in 1944 [14]. They performed an end-to-side anastomosis of the left subclavian artery with the aorta distal to the stenosis.
Subclavian artery to descending aorta prosthetic bypass (Fig 3) completely relieves aortic obstruction, can be performed without cardiopulmonary bypass, provides stable long-term results, and seems to be a life-long solution for this group of patients, as also reported in other studies [8, 15].
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After operation using the subclavian artery to descending aorta prosthetic bypass, there was a distinct improvement in the clinical status of our patients. This supports the beneficial effect of coarctation repair in patients older than 50 years.
Cohen and associates [18] found postoperative systolic blood pressure to be an independent predictor of late survival: there was a direct correlation between severity of postoperative systolic hypertension and the probability of premature death.
According to published studies, the prevalence of late hypertension after correction of aortic coarctation in adults varies from 12% [7] to 50% [19, 20]. The percentage of patients with systemic hypertension increases with time after surgical repair of coarctation in adults. Presbitero and colleagues [21] reported that blood pressure was normal in most of the patients seen 10 years after operation, but later hypertension gradually became more frequent. Thirty years after coarctation repair only 32% of the patients are expected to be normotensive, which is much lower than the incidence in the normal population.
Aris and coworkers [6] showed that all 8 patients in their study older than 50 years who underwent coarctation repair were normotensive after a mean interval of 4 years, and 5 patients did not need antihypertensive medication. Exercise testing was not performed because the authors showed in a previous study [22] that a hypertensive response to exercise only occurs if a residual gradient is present.
Twelve of our 15 patients had normal blood pressure at rest postoperatively, and only 3 patients had mild hypertension (systolic pressure, 140 to 160 mm Hg). Exercise tests disclosed that in 8 of 11 patients tested, a pathologic blood pressure profile and exercise hypertension were found, despite the absence of a pressure gradient at the prosthesis. Therefore, residual stenosis may be excluded as a reason for the development of exercise hypertension. Exercise testing is mandatory in every patient after correction of coarctation to reveal latent hypertension and to optimize antihypertensive treatment. Postoperatively the need for antihypertensive drug treatment was significantly reduced in our patients.
The study by Kaemmerer and associates [23], which included 41 patients aged 25.0 ± 13.7 years at the time of operation with a mean interval between operation and the study of 11 ± 4.9 years, showed that during exercise testing 20% exhibited pathologic blood pressure behavior, but that no patient with normal blood pressure at rest was hypertensive during exercise. These findings are contrary to ours in the older patients.
Postoperatively most of our patients are in NYHA class II. Even 7 preoperatively severely compromised (NYHA classes III and IV) patients improved (Fig 2).
Similarly to other groups [7], we found a high incidence of bicuspid aortic valves and coronary artery disease. One patient needed coronary artery bypass grafting, and 1 patient prosthetic aortic valve replacement during the follow-up period.
In conclusion, our experience shows that correction of coarctation of the aorta can be performed safely and effectively in patients older than 50 years of age. Despite persistence of hypertension during exercise, symptomatic improvement occurs in most of the patients, and surgical correction of coarctation allowed a more effective medical treatment of residual hypertension. Correction of coarctation may therefore be performed in the older patient to prevent the complications of chronic arterial hypertension in the further course of the patient’s life.
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Acknowledgments |
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References |
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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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 H. Laks, D. Marelli, M. Plunkett, and J. Myers Adult Congenital Heart Disease Card. Surg. Adult, January 1, 2008; 3(2008): 1431 - 1464. [Full Text]
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 P. F. Ford and M. A. Farber Role of Endovascular Therapies in the Management of Diverse Thoracic Aortic Pathology Perspectives in Vascular Surgery and Endovascular Therapy, June 1, 2007; 19(2): 134 - 143. [Abstract] [PDF]
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 J. A. Carr The Results of Catheter-Based Therapy Compared With Surgical Repair of Adult Aortic Coarctation J. Am. Coll. Cardiol., March 21, 2006; 47(6): 1101 - 1107. [Abstract] [Full Text] [PDF]
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H. Laks, D. Marelli, M. Plunkett, J. Odim, and J. Myers Adult Congenital Heart Disease Card. Surg. Adult, January 1, 2003; 2(2003): 1329 - 1358. [Full Text]
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