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Does surgical correction of coarctation of the aorta in adults reduce established hypertension?

Department of Cardiothoracic Surgery, Southampton General Hospital, Southampton, UK

Received 6 June 2008; received in revised form 11 August 2008; accepted 20 August 2008

*Corresponding author. Department of Paediatric Cardiac Surgery, Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Road, Southampton, UK. Tel.: +44 2380 777222; fax: +44 2380 798508.

E-mail address: marcus.haw{at}suht.nhs.uk (M.P. Haw).

	Abstract

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether surgical correction of coarctation of the aorta in adults (>16 years) results in reduction in established hypertension. Altogether 484 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that surgical repair of coarctation of the aorta in adult patients is superior to conservative management in the reduction of established hypertension, with one meta-analysis and several retrospective reviews reporting low morbidity and low risk of re-stenosis. The reduction in blood pressure postoperatively has been demonstrated consistently, with most patients reported as normotensive without medication and the remainder having reduced requirements for antihypertensive medications. In all the papers included here (except one), there was no early mortality and no procedure-related late mortality during mean follow-up ranging from 2 to 14 years. Thus, surgical correction of aortic coarctation is a relatively safe procedure.

Key Words: Coarctation of aorta; Cardiac surgery; Hypertension; Evidence based medicine

	1. Introduction

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
A best evidence topic was constructed according to a structured protocol. This protocol is fully described in the ICVTS [1].

	2. Clinical scenario

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
A 50-year-old man is referred to your clinic by the cardiologists. He has had severe hypertension (BP 210/96 mmHg) secondary to coarctation of the aorta. He has been prescribed an antihypertensive regimen including ACE inhibitor and calcium channel blocker. The cardiologist has just attended a national conference and heard about the practice of repair of coarctation of the aorta in adult patients and how this has been shown in some cases to reduce hypertension postoperatively. He asks whether this patient might benefit from surgical repair of his coarctation of aorta. You discuss it with your consultant who has read conflicting evidence regarding repair of coarctation in adults, specifically that it does not alter the natural history of disease in a patient with already established hypertension. He asks you to review the literature.

	3. Three-part question

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
In [adult patients with coarctation of the aorta] is [surgical repair or conservative management] the best option in [reducing established hypertension]?

	4. Search strategy

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
Medline 1950–March 2008 using the OVID interface. [exp coarctation/OR coarctation.mp] AND [exp surgery/OR surgery.mp] AND [exp adult/OR adult.mp] AND [exp hypertension/OR hypertension.mp].

	5. Search outcome

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
A total of 484 papers were produced by the above search out of which 50 papers relevant to the subject were found. Out of these, 11 papers were selected as representing the best evidence on this topic (Table 1).

	6. Comments

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

In a retrospective study by Almeida de Oliveira et al. [2], 18 patients underwent extra-anatomic bypass grafting to repair coarctation of the aortic arch, and a further 81 patients underwent conventional repair of aortic coarctation. It was shown that extra-anatomic repair improved mortality and that postoperatively, blood pressure was normal in 67% of this group without the need for medication. The authors concluded that the procedure of extra-anatomic bypass grafting for repair of coarctation of the aortic arch effectively controls arterial hypertension with an acceptable long-term survival.

Connolly et al. [3] reviewed 18 patients with coarctation of the aorta undergoing ascending to descending aortic bypass graft via the posterior pericardium with regard to postoperative morbidity, hypertension and left ventricular function. The found significant complications in four patients including reexploration for control of bleeding, transient atrial fibrillation and the need for a permanent pacemaker. They demonstrated a decrease in systolic blood pressure, however, found no overall change in left ventricular function. They comment that extra-anatomic bypass is particularly useful when simultaneous intracardiac repair is required.

Carr [4] performed a meta-analysis of 22 studies of the results of treatment for coarctation in the adult and adolescent population and compared endovascular therapy to surgical therapy with regard to morbidity, restenosis, requirement for re-intervention and hypertension. It concluded that primary stenting had the lowest risk of complications, with surgery having slightly higher risk and angioplasty significantly higher risk. Rates of restenosis and need for reintervention were significantly higher following both stenting and angioplasty when compared to surgery. A cure for hypertension was seen in 61% of the endovascular group compared to 64% of the surgery group. The author comments that surgical complications which occurred were minor (e.g. vasculitis, bleeding) while endovascular complications tended to be much more serious.

Aris et al. [5] demonstrated that hypertension was significantly reduced following surgical repair of aortic coarctation, as did McKellar et al. [6] and Bauer et al. [7]. Wells et al. [8] studied 26 patients with critical systolic hypertension undergoing repair of coarctation. They studied outcome in terms of morbidity, effect on blood pressure and the need for antihypertensive medications. They reported a complication of persisted left vocal cord paralysis in one patient and no other major complications. They found a significant decrease in postoperative systemic arterial pressure and showed that requirement for antihypertensive medications was reduced following repair. They recommend operation even for patients with mild systemic hypertension.

Bouchart et al. [9] retrospectively reviewed outcomes of coarctation surgical repair in 35 adults with preoperative hypertension. They found a highly significant decrease in systolic blood pressure at both early and late follow-up, with most patients now normotensive. They report evidence of a mild stenosis in the graft in one patient and describe six patients having developed significant aortic valve disease on long-term follow-up, four of whom had bicuspid aortic valve related to their coarctation. They conclude that a reduction in systolic hypertension is evident following surgical repair of coarctation in patients older than 20 years. Hashemzadeh et al. [10] demonstrated that surgical repair of aortic coarctation in adults leads to significant regression of systolic hypertension and a decrease in antihypertensive medication in a group of 30 hypertensive patients over a mean follow-up of 37 months. A similar study by Bhat and colleagues [11] in 84 patients made the same conclusion. On the contrary, Hager et al. [12] are the only study to have reported in 273 patients that the majority of patients are hypertensive at long-term follow-up after coarctation repair. They add that even in patients without restenosis, there is a substantial incidence of arterial hypertension and in these patients the independent risk factors for hypertension are repair with prosthetic material, male sex, residual brachial-ankle blood pressure difference and older age at follow-up.

	7. Clinical bottom line

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 
Surgical repair of coarctation of the aorta in adult patients is superior to conservative management in the reduction of established hypertension, with one meta-analysis and several retrospective reviews finding low morbidity and low risk of re-stenosis. It has been shown that 90% of patients with coarctation of aorta die by the age of 58 [13]. Only the study with the longest follow-up (up to 27 years) [12] reports a 5.1% overall mortality from all causes. In all the other reports included in this paper, there was no early mortality and no procedure-related late mortality during mean follow-up ranging from 2 to 14 years in these studies. Hence, with surgery, these patients have a much better chance of survival. The reduction in blood pressure post-operatively has been demonstrated consistently (except for Hager et al. [12]), with most patients reported as normotensive without medication and the remainder having reduced requirements for anti-hypertensive medications.

	References

Top Abstract 1. Introduction 2. Clinical scenario 3. Three-part question 4. Search strategy 5. Search outcome 6. Comments 7. Clinical bottom line References

 

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This Article Abstract Full Text (PDF) 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): Hunaid A. Vohra Marcus P. Haw Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vohra, H. A. Articles by Haw, M. P. Search for Related Content PubMed PubMed Citation Articles by Vohra, H. A. Articles by Haw, M. P. Related Collections Related Article