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Aortic Pressure Wave Reflection in Patients After Successful Aortic Arch

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Aortic Pressure Wave Reflection in Patients After Successful Aortic Arch Hypertension Research (2013) 36, 603–607 & 2013 The Japanese Society of Hypertension All rights reserved 0916-9636/13 www.nature.com/hr ORIGINAL ARTICLE Aortic pressure wave reflection in patients after successful aortic arch repair in early infancy Tomoaki Murakami1,2, Atsuhito Takeda1, Hirokuni Yamazawa1, Shigeru Tateno2, Yasutaka Kawasoe2 and Koichiro Niwa2,3 Despite the apparently successful surgical repair of aortic coarctation, subsequent cardiovascular complications have sometimes been encountered. Aortic pressure wave reflection is one of the risk factors for developing cardiovascular diseases, and an enhancement of the pressure wave reflection has been reported in patients after aortic arch repair. To clarify this issue, the increase in pressure wave reflection was evaluated in patients o15 years old who underwent aortic arch repair. This study enrolled 35 patients after aortic arch repair in early infancy. All patients underwent cardiac catheterization, and in 20 patients, there was no pressure difference within the repaired aortic arch. The aortic pressure waveforms in patients after successful aortic arch repair were recorded using a pressure sensor-mounted catheter, and the augmentation index in the ascending aorta was calculated. The augmentation index in patients after an aortic arch repair was increased compared with control subjects, although there was no pressure difference between the ascending and descending aorta (Po0.0001). The increase in the augmentation index was correlated with the patient’s age (r ¼ 0.8932, Po0.0001) and with the left ventricular posterior wall thickness (r ¼ 0.4075, P ¼ 0.0373). In patients who undergo aortic arch repair, the pressure wave reflection is accelerated, even when the aortic arch repair is ‘successful’. This increase is one of the possible causes of left ventricular hypertrophy. Hypertension Research (2013) 36, 603–607; doi:10.1038/hr.2013.1; published online 14 February 2013 Keywords: aortic arch; aortic coarctation; hypertrophy; pressure wave reflection INTRODUCTION was that the augmentation index of the patients was compared with Aortic pressure augmentation caused by pressure wave reflection is a age-matched, one-to-one controls in the report. The aortic physiologically important phenomenon. It keeps the arterial blood augmentation index in children correlates with body height, not flow constant while enhancing the coronary blood supply. However, age.17 To resolve these problems and perform a quantitative analysis excessive aortic pressure wave reflection contributes to an increase in of enhanced pressure wave reflection, the augmentation index was cardiovascular diseases.1,2 To evaluate the degree of aortic pressure calculated in patients who underwent aortic arch repair without a reflection, the augmentation index, which is obtained from the central pressure gradient in their aortas and compared with reference data on arterial pressure waveform as the ratio of augmentation pressure to the basis of height in this study. The purpose of this study was to the total pulse pressure, is one of the most popular tools.3 In adults, prove the enhancement of aortic pressure wave reflection in patients significant evidence supports a correlation between the value of the after aortic arch repair was compared with normal patients on the augmentation index and the occurrence of cardiovascular diseases.4–6 basis of their height and quantify the increase in pressure wave Despite apparently successful aortic arch repair, defined as no reflection. Moreover, to clarify the influence of enhanced pressure residual pressure gradient after the surgical repair of aortic coarcta- wave reflection, the correlation between the increase in the pressure tion, subsequent cardiovascular complications have been encoun- wave reflection and left ventricular wall thickness was also examined. tered.7–12 One such complication is the early onset of cardiovascular diseases, such as hypertension, myocardial infarction, cardiac failure, PATIENTS AND METHODS stroke and sudden death. Problems have been reported to occur even Study subjects when the aortic arch repair is successful.13–15 In total, 35 patients who were o15 years old who had undergone an aortic We previously reported the enhancement of the aortic pressure arch repair for coarctation of the aorta (24 patients) or interrupted aortic arch 16 wave reflection in patients with aortic coarctation after repair. How- (11 patients) in early infancy were enrolled. Although no patient had any ever, the study had two limitations. One was that some patients in the subjective sign of cardiovascular dysfunction, cardiac catheterization proved study had a small pressure gradient in their aortic arch, and the other small pressure differences between the ascending and descending aorta 1Department of Pediatrics, Hokkaido University, Graduate School of Medicine, Sapporo, Japan; 2Department of Adult Congenital Heart Disease and Pediatric Cardiology, Chiba Cardiovascular Center, Ichihara, Japan and 3Department of Cardiology, St Luke’s International Hospital, Tokyo, Japan Correspondence: Dr T Murakami, Department of Cardiology, Chiba Children’s Hospital, 579-1 Heta-cho, Midori-ku, Chiba 266-0007, Japan. E-mail: [email protected] Received 28 June 2012; revised 25 November 2012; accepted 26 November 2012; published online 14 February 2013 Pressure wave reflection after aortic arch repair TMurakamiet al 604 Table 1 Patients’ characteristics (n ¼ 20) 60 Characteristics Value 40 Male/female 14/6 Age (years) 8.0±3.6 Height (cm) 122.3±22.7 20 Weight (kg) 26.1±13.3 Brachial SBP (mm Hg) 107.3±15.6 0 Hypertension ( þ ) 2 (10%) Heart rate (b.p.m.) 86.4±21.2 CoA/IAA 14/6 –20 Period after arch repair (years) 7.9±3.6 VSD ( þ ) 14 (70%) Period after VSD repair (years) 6.8±3.8 [%] The corrected augmentation index –40 Arch repair method Extended end-to-end anastomosis 13 (65%) –60 Subclavian flap 6 (30%) 0 50 100 150 200 Blalock–Park 1 (5%) Height [cm] Abbreviations: CoA, coarctation of aorta; IAA, interruption of the aortic arch; SBP, systolic Figure 1 The relationship between the body height and the heart rate- blood pressure; VSD, ventricular septal defect. corrected augmentation index of reference data (open circle)17 and in Values are mean±s.d. or number (%). children o15 years of age after an aortic arch repair (closed circle). The index was significantly higher in the aortic arch repair group (Po0.0001). (o20 mm Hg) in 15 patients, and they were excluded from this study. Corrected augmentation index (%) ¼ augmentation index (%) þ (heart Therefore, 20 patients (14 males and 6 females, 14 coarctation of the aorta rate (b.p.m.) À75) Â 0.39. and 6 interrupted aortic arch) aged 1–13 (8.0±3.6) years were included in the The corrected augmentation index in patients who underwent aortic arch analysis (Table 1). No patients had any significant leakage at the aortic level, repair was compared with reference data in children, which were analyzed in including the patent ductus arteriosus and aortic regurgitation. The methods the same way.17 of aortic arch repair were extended end-to-end anastomosis in 13 patients, subclavian flap in 6 and Blalock–Park operation in 1. Aortic arch repair was performed at 24.0±23.7 days after birth (3 days 3 months), and the period Morphological analysis of the left ventricle after aortic arch repair was 7.9±3.6 years. Three patients had undergone To evaluate the degree of left ventricular hypertrophy, the end-diastolic left balloon dilatation of the aortic arch after surgical arch repair. Fourteen patients ventricular posterior wall thickness (LVPWTd) was measured using echocar- had ventricular septal defect, which was closed at 0.8±0.5 years old. Seven diography.20 The value was converted to the percentage of normal LVPWTd patients were diagnosed with a bicuspid aortic valve. None of them were taking (%LVPWTd) using the known relationship between body surface area and any medication or diagnosed to be suffering from Turner syndrome. Their LVPWTd in healthy Japanese children. right brachial systolic blood pressure was 107.3±15.6 mm Hg, and the %LVPWTd (%) ¼ (LVPWTd (mm)/(4.1 Â log (body surface area (m2)) diastolic blood pressure was 59.1±15.6 mm Hg. Only two patients were þ 6.1)) Â 100. diagnosed with hypertension based on Japanese guidelines for the management of hypertension (JSH 2009). One was diagnosed with systolic hypertension, Statistical analysis and the other was diagnosed with systolic and diastolic hypertension. Their Continuous values are expressed as the mean value±s.d. Categorical measures parents and siblings did not suffer from hypertension or diabetes. All subjects are presented as frequencies with percentages. The continuous variables were gave their written informed consent, and the Chiba Cardiovascular Center compared between groups using the Mann–Whitney test. The corrected ethics committee approved the study protocol (No.945, 2011.12.16). augmentation index–body height relationship between the aortic arch repair group and the reference data was compared using analysis of covariance, with the corrected augmentation index as the dependent variable, arch repair as the Study protocol factor and body height as the covariate. The strength of the correlation Left heart catheterization was performed by femoral arterial puncture. The between the two groups was analyzed by Spearman’s test. PRISM software ascending aortic pressure was measured using a pressure sensor-mounted version 4.0c (Graph Pad Software, La Jolla, CA, USA) was used for all statistical catheter (model SPC-464D, Millar Instrument, Houston, TX, USA) before the analyses without analysis of covariance, which was performed with SPSS injection of any contrast material. The ascending aortic pressure waveform was (Statistical Package for the Social Sciences) software version 16.0 (SPSS, recorded at one vertebral body thickness higher than the aortic valve. The Chicago, IL, USA). A P value o0.05 was considered to be statistically waveform was recorded on a hard disk through an analog-digital converter, significant. and it was also simultaneously recorded with an electrocardiogram.
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