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Ann Thorac Surg 1996;61:1168-1171
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Repair of Coarctation of the Aorta in Adults: The Fate of Systolic Hypertension

German Heart Institute, Berlin, Germany, and University of Southern California, Los Angeles, California

Accepted for publication December 6, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 
Background. The benefit of coarctation repair in adults has been questioned by suggesting that hypertension may not be relieved by the operation and that surgical intervention may have no impact on the natural history of the disease.

Methods. To delineate the impact of surgical intervention on systolic hypertension, we conducted a retrospective review of 26 adults with a mean age of 32 ± 10 years who underwent coarctation repair between 1987 and 1993. All patients were hypertensive (mean systolic blood pressure, 174 ± 21 mm Hg; range, 140 to 220 mm Hg), and 18 patients (69%) were on a regimen of at least one hypertensive medication at the time of surgical admission. All patients underwent catheterization, and the mean peak systolic gradient across the coarctation was 61 ± 25 mm Hg (range, 25 to 120 mm Hg). Operation included resection and end-to-end anastomosis (3 patients), resection with an interposition tube graft (6 patients), a bypass graft (11 patients), and patch angioplasty (6 patients). There was no hospital mortality or late morbidity.

Results. Intermediate follow-up was available at a mean of 2.3 ± 2 years (range, 1 to 7 years). At last follow-up, the peak systolic gradient between the upper and lower body was trivial (10 mm Hg) in 23 patients (88%) and mild (11 to 20 mm Hg) in 3 (12%). All patients had significant improvement in systolic blood pressure (p < 0.001) compared with preoperative values, and the majority (23, 88%) were normotensive. More than half of the patients (14, 54%) were still on a regimen of antihypertensive medication at last follow-up, with a trend (p = 0.06) toward older patients requiring medication.

Conclusions. Surgical repair of coarctation in adults is an effective, low-risk procedure, which results in a significant improvement in systolic hypertension and a decreased requirement of antihypertensive medications.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 
Unrepaired coarctation of the aorta results in high morbidity and mortality from hypertension and associated problems, including myocardial infarction, heart failure, intracranial hemorrhage, aortic rupture, and infective endocarditis. Without correction, most patients die before the age of 50 years [1]. It is generally agreed that the optimal timing for surgical intervention is in infancy or early childhood, unless heart failure and decrease in systemic perfusion necessitate earlier intervention [2–5]. There is less agreement about the benefits of operation for those discovered to have coarctation as adults, because several authors [6–8] report poor resolution of systolic hypertension postoperatively in older patients. Olley [6] suggested that data are insufficient to predict with certainty that operation in adults alters the natural history of the disease. This retrospective study is intended to clarify the impact of adult coarctation repair on systolic blood pressure (SBP).

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 
Between 1987 and 1993, 26 consecutive adult patients (21 years old) underwent repair of coarctation either at the German Heart Institute (15 patients) or the University of Southern California (11 patients). There were 20 men (77%) and 6 women (23%) with a mean age of 32 ± 10 years (range, 21 to 60 years). All patients seen for surgical intervention had critical systolic hypertension (SPB 140 mm Hg). Recent discovery of systolic hypertension was the most common reason for surgical referral. Among the patients with symptoms, the most common were headache, fatigue, heart failure, and intermittent claudication.

Blood Pressure Measurements
Both preoperative and postoperative blood pressure values were obtained by simultaneous cuff pressure measurements in the right arm and lower extremities. Aortic pressures proximal and distal to the coarctation were measured at preoperative catheterization in most patients. In accordance with guidelines established by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure [9], systolic hypertension was defined as follows: mild = 140 to 159 mm Hg, moderate = 160 to 179 mm Hg, severe = 180 to 210 mm Hg, and very severe = >210 mm Hg. For this study, SBP is reported, as systolic hypertension is equivalent to mean or diastolic hypertension in regard to cardiovascular sequelae and longevity [10].

Antihypertensive Medications
Patients were separated into groups according to the number of antihypertensive medicines prescribed preoperatively and at the time of last follow-up. These medications included diuretics, vasodilators, ß-blocking agents, calcium-channel blockers, and angiotensin-converting enzyme inhibitors. In some instances, there were combinations of agents.

Operative Procedure
All operations were done through a left thoracotomy. In 23 (88%) of the 26 patients, a simple clamp-and-sew technique for coarctation repair was employed. Two of the remaining 3 patients had left heart bypass (left atrium to femoral artery using a centrifugal pump), and 1 had placement of a heparinized shunt between the proximal and distal aorta. Patients were separated into groups according to the type of coarctation repair performed: resection and end-to-end anastomosis (3 patients), resection and interposition Dacron tube graft (size 14 to 18 mm) (6 patients), patch angioplasty with Gore-Tex (W. L. Gore & Assoc, Flagstaff, AZ) (6 patients), and a bypass Dacron tube graft from the proximal (either left subclavian or distal transverse arch) to the descending thoracic aorta (size 14 to 22 mm) (11 patients).

Follow-up
Follow-up of all patients was achieved during an office visit with one of us (23 patients) or by telephone interview and review of office records from a referring physician (3 patients).

Statistical Analysis
Data are presented as the mean ± the standard deviation. Systolic blood pressure gradients across the coarctation before and after repair were evaluated using the paired t test. A p value of less than 0.05 was considered significant. In addition, the age difference between patients receiving no medications and patients with at least one medication was assessed with a nonpaired Student's t test.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 
Preoperative Status
All patients had systolic hypertension at the time of admission for operation (Fig 1). Systolic blood pressure ranged from 140 to 220 mm Hg with a mean pressure of 174 ± 21 mm Hg. The hypertensive status of all patients is depicted in Table 1. The mean diastolic pressure was 94 ± 15 mm Hg (range, 69 to 112 mm Hg). The peak systolic gradient across the coarctation was 61 ± 25 mm Hg (range, 25 to 120 mm Hg). The majority of patients (18/26, 69%) were on a regimen of at least one antihypertensive medication (Fig 2). The remaining 8 were immediately referred for operation after discovery of the coarctation and associated hypertension and thus were not on a regimen of medication at the time of operation.

View larger version (25K): [in this window] [in a new window]   Fig 1. . Preoperative hypertensive status (as defined by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure [9]). (BP = blood pressure.)

View larger version (21K): [in this window] [in a new window]   Fig 2. . Preoperative antihypertensive medications. (ACE = angiotensin converting enzyme.)

Blood Pressure
Of the 26 patients with preoperative hypertension, 23 (88%) were normotensive (SBP < 140 mm Hg) at the most recent follow-up visit. The remaining 3 patients showed substantial improvement versus the preoperative status (preoperatively, 183 ± 23 mm Hg, versus postoperatively, 152 ± 7 mm Hg). The mean SBP after operation for the group was 125 ± 14 mm Hg (range, 100 to 160 mm Hg); compared with the preoperative values, the difference was significant (p 0.001) (Fig 3). Mean diastolic blood pressure was 76 ± 13 mm Hg. The gradient from upper to lower body was trivial (10 mm Hg) in 23 patients and mild (20 mm Hg) in 3.

View larger version (25K): [in this window] [in a new window]   Fig 3. . Systolic blood pressure (BP) preoperatively versus most recent follow-up visit.

View larger version (20K): [in this window] [in a new window]   Fig 4. . Postoperative hypertensive status and medications.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

Natural History
Age at coarctation repair is reported as the most significant risk factor for premature death after operation. This may be linked with the increased incidence of postoperative hypertension, and therefore it will be important to observe whether improved control of hypertension in the older coarctectomy patients will translate into improved long-term survival. Preexisting cardiac and vascular damage from years of exposure to elevated blood pressure related to the coarctation may play a major role in the problem of premature death. Still, improved blood pressure control after operation may be beneficial.

Technique of Repair
In this series, we found no difference in outcome on the basis of the type of repair. Each of the four techniques provided excellent relief of the coarctation gradient. Compared with the aorta of infants and children, the aorta of the adult patient with coarctation is relatively immobile, and there are frequently large collaterals immediately adjacent to the narrow segment. This makes bypass grafting from the left subclavian or distal aortic arch to the descending aorta, which can be performed with a partially occluding clamp, an attractive option. This is the likely explanation for its frequent (11/26 or 42%) use in this series.

The technique of repair was left entirely to the preference of the operating surgeon, but there were institutional differences in the frequency with which various procedures were performed. All 11 patients operated on at the University of Southern California had a Dacron tube graft (interposition, 3; bypass graft, 8). In Berlin, there were three resection and end-to-end anastomoses, six patch angioplasties (Gore-Tex), and six bypass grafts. The results were equally good, and there were no differences between institutions in the incidence of complications or postoperative hypertension. The use of left heart bypass or a shunt between the proximal and distal aorta was also by preference of the surgeon and appeared to reflect the anticipation of a longer clamp time or compromise of major collaterals by the aortic clamp.

	Conclusions

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 
On the basis of the experience reflected in this series, we recommend repair for adult patients with coarctation of the aorta. In our series, patients up to the age of 60 years appear to have benefited from the operation as indicated by improved control of systolic hypertension. This experience suggests that adult patients with coarctation, some of whom fail medical treatment for hypertension prior to operation, become normotensive after operation. Though roughly half of our patients still require antihypertensive medications, nearly all can achieve a resting SBP of less than 140 mm Hg.

Because the risk of operation is extremely low, we recommend operation even for patients with mild preoperative hypertension. Future study of this patient population will focus on long-term control of hypertension and the incidence of late cardiovascular complications.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 
Address reprint requests to Dr Wells, Division of Cardiothoracic Surgery, Children's Hospital of Los Angeles, 4650 Sunset Blvd, MS 66, Los Angeles, CA 90027.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Conclusions References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Winfield J. Wells Roland Hetzer Vaughn A. Starnes Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wells, W. J. Articles by Starnes, V. A. Search for Related Content PubMed PubMed Citation Articles by Wells, W. J. Articles by Starnes, V. A.