European Heart Journal Advance Access originally published online on March 10, 2005
European Heart Journal 2005 26(9):941; doi:10.1093/eurheartj/ehi213
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Aortic arch morphology and hypertension in post-coarctectomy patients
Department of Cardiology
Academic Medical Center, B2-216
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands
Tel:+31 20 5668679
Fax:+31 20 6914940
E-mail address:
j.w.vriend{at}amc.uva.nl
Department of Cardiology
Academic Medical Center, B2-216
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands
Department of Cardiothoracic Surgery
Leiden University Medical Center
Leiden
The Netherlands
Department of Cardiology
Academic Medical Center, B2-216
Meibergdreef 9
1105 AZ Amsterdam
The Netherlands
We read with great interest the paper by Ou et al.1 who report a significant association between the so-called ‘gothic’ aortic arch morphology and resting hypertension in patients after successful surgical repair of aortic coarctation. The article, however, raises several questions.
A large population of post-coarctectomy patients is followed in our tertiary referral centre and cardiac magnetic resonance (CMR) imaging is performed at regular intervals in every patient. We were not able to classify all patients based on CMR angiography images using the classification given by the authors. The figure provides an example (Figure 1). The transverse aortic arch segment in this patient is not absent, therefore excluding the classification ‘gothic arch’ morphology. The form of the aortic arch is not rectangular because the ascending aortic segment retains its curvature which excludes ‘crenel arch’ morphology. Neither can this specific morphology be classified as normal. So, we feel that the classification given by the authors does not cover all aortic arch morphologies, thus complicating the interpretation of their results.
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Data on blood pressure readings in both arms would have been useful; blood pressure differences between both arms would have provided additional information on the effect of arch geometry on blood pressure. One may expect blood pressure differences between both arms in the group of patients with gothic aortic arch morphology because the segment of interest (‘kinking’ between the ascending aorta and the transverse aorta) is located between both subclavian arteries. In the ‘crenel’ and normal types of aortic geometry, this ‘kinking’ occurs either distal to the left subclavian artery or it does not occur at all.
The authors state that the gothic arch geometry is not associated with a specific type of coarctation repair. However, the vast majority of their patients (90%) were repaired by simple resection and end-to-end anastomosis, making the analysis of type of repair on aortic arch geometry virtually impossible.
All patients after successful repair of aortic coarctation are, regardless of aortic arch geometry, at risk of sustained hypertension and should undergo regular ambulatory blood pressure monitoring.2 The authors acknowledge that reoperation for restoring aortic arch geometry is probably too dangerous, thereby automatically questioning the clinical relevance of their findings because in every hypertensive post-coarctectomy patient without significant residual aortic stenosis—regardless of aortic arch geometry—the only therapy for hypertension is anti-hypertensive medication.
References
- Ou P, Bonnet D, Auriacombe L et al. Late systemic hypertension and aortic arch geometry after successful repair of coarctation of the aorta. Eur Heart J 2004;25:1853–1859.
- Vriend JW, van Montfrans GA, Romkes HH et al. Relation between exercise-induced hypertension and sustained hypertension in adult patients after successful repair of aortic coarctation. J Hypertens 2004;22:501–509.
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