Immediate and Remote Effects of Resection on the Hypertension in Coarctation of the Aorta

Abstract

Twenty-five years ago Sir Thomas Lewis summarized the state of knowledge regarding this important congenital lesion (34)* and thought that "new records of cases can have little value unless they reveal new features of interest and importance to the study of the condition." Yet hardly more than a decade later the first patients with coarctation of the aorta were to be successfully operated upon in Sweden (11) and the United States (23). A new era of progress in the treatment and understanding of the pathological physiology of this lesion began. By 1953 Gross had operated on 270 patients (24), and more recently it has been possible to collect data on 1601 patients surgically treated by 36 surgeons (52). It is apparent that operative intervention for coarctation of the aorta has become widely practised. Its broad acceptance appears to be justified not only by the demonstration that the classical pulse abnormalities can be largely reversed (5a, b), but also by the reasonable safety of the procedure and by the subjective improvement of patients (7,8, 24).The cure of the characteristic hypertension has been included among the benefits of surgical treatment in reports from a number of clinics (6,10,20, 24,27,35). Indeed a fall in blood pressure does usually follow successful intervention, but most communications have described the condition shortly after the operative procedure, and the criteria for evaluation of the blood pressure response are usually referred to an arbitrary or ideal value. With few exceptions (6, 9, 59) systematic observations at remote intervals after treatment have not been made, and in one of these (9) the conclusions appear to be at variance with the more numerous and optimistic results reported just after operation. In this latter work alone were the data given careful statistical treatment.Obviously this question is of prognostic importance since the complications of hypertension are the cause of a quarter of the deaths in coarctation (24), and since in untreated cases there is a progressive increase in systolic pressure during the first two decades of life (6). Moreover, the issue is of interest from the theoretical point of view since the mechanism of most forms of hypertension is poorly understood, and that of coarctation has evoked considerable disagreement. The classical view that it is caused by the mechanical obstruction (3, 4,34) has been challenged on a number of grounds by those who hold that it is caused by an interference with the renal arterial flow producing a generalized increase in peripheral resistance (38,44,45). Finally, there has been speculation about the mechanism and significance of the abdominal pain and the paradoxical rise of blood pressure that not infrequently follow resection of the coarctation (2,43, 47). These considerations suggested that an immediate and long-term study of the effect of operation on coarctation hypertension would be desirable. MATERIALS AND METHODSIn the ten years, [1948][1949][1950][1951][1952][1953][1954][1955][1956][1957][1958] 80 patients ...

Cerebral Blood Flow in Coarctation of the Aorta

“…These data are presented, as has been done in the past (17)(18)(19), to give information as to the severity of the coarctation.…”

“…The preoperative and postoperative differences between the femoral and the brachial pressure have been reported in detail previously (18,19) and are included in this paper only as an indication of the severity of the lesion and as evidence that surgical correction of the coarctation was adequate. This appears to be the case even though a significant residual difference (4 mm Hg) was noted between the upper and the lower extremities in the postoperative measurements.…”

Hypertension and Abdominal Pain After Resection of Aortic Coarctation

“…The persistent elevation of blood pressure for several months following successful coarctation resection has been reported in 4 to 7 per cent of the patients in longterm follow-up studies. 'll 16,17,20,21 March et al 9 reported that blood pressure fell slowly after operation; only 33 per cent of their patients were normotensive at the time of discharge.…”

Coarctation of the thoracic aorta in adults: A follow-up study after surgical treatment

“…Even though the repair of CoA has significantly reduced BP in the majority of patients (7, 106,108,149), hypertension persists in a number of them. The reported incidence of postoperative normotension is around 80 "/o in large series (7, 96,154).…”

“…Bleeding problems occur quite frequently during the operation and in the early postoperative phase. Apart from those due to surgical failures these complications are attributed to the stress changes that have developed in the aorta and collaterals and to the high aortic BP immediately after surgery (72, 106,166). Cases of the heart stopping during the operation are most often attributed to hypotension after bleeding problems (86).…”