J Thorac Cardiovasc Surg 2008;135:1406
© 2008 The American Association for Thoracic Surgery
Reply to the Editor
Alfred Hager, MD,
John Hess, MD
Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
Robicsek outlined in his letter to the Editor in response to our article1
that arterial hypertension exists distal the coarctation even before coarctation repair. Hypertension in the long-term follow-up is simply the continuation of this neurosympathetic process.
Previously published data from our group2 on blood pressure and aortic distensibility in neonates with coarctation before and after surgical repair did not show poststenotic hypertension before repair in general. However, we totally agree with Robicsek and other authors3,4 that inborn processes not touched by current modes of repair are also responsible for hypertension in the long-term follow-up after successful repair. We believe that the starting point of the pathophysiologic chain is the inborn alteration of the arterial wall with elastic fiber fragmentation, fibrosis, and cystic medial necrosis, which are later exaggerated by existing hypertension. This causes the increased stiffness most pronounced in the central elastic arteries, the blunted baroreceptor reflex, and the neurosympathetic activation. However, the novelty of our study was the extent of this phenomenon. Our relation to age showed that arterial hypertension has to be expected in almost all patients after coarctation repair in older ages. Close surveillance and aggressive treatment of arterial hypertension might prevent further cardiovascular disease.
References
- Hager A, Kanz S, Kaemmerer H, Schreiber C, Hess J. Coarctation Long-term Assessment (COALA): Significance of arterial hypertension in a cohort of 404 patients up to 27 years after surgical repair of isolated coarctation of the aorta, even in the absence of restenosis and prosthetic material. J Thorac Cardiovasc Surg 2007;134:738-745.[Abstract/Free Full Text]
- Vogt M, Kuhn A, Baumgartner D, Baumgartner C, Busch R, Kostolny M, et al. Impaired Elastic Properties of the Ascending Aorta in Newborns Before and Early After Successful Coarctation Repair: Proof of a Systemic Vascular Disease of the Prestenotic Arteries?. Circulation 2005;111:3269-3273.[Abstract/Free Full Text]
- Isner JM, Donaldson RF, Fulton D, Bhan I, Payne DD, Cleveland RJ. Cystic medial necrosis in coarctation of the aorta: a potential factor contributing to adverse consequences observed after percutaneous balloon angioplasty of coarctation sites. Circulation 1987;75:689-695.[Abstract/Free Full Text]
- Niwa K, Perloff JK, Bhuta SM, Laks H, Drinkwater DC, Child JS, et al. Structural abnormalities of great arterial walls in congenital heart disease: light and electron microscopic analyses. Circulation 2001;103:393-400.[Abstract/Free Full Text]
