Department of Cardiovascular Surgery, Children's National Medical Center, Washington, DC 20010, USA.
J Thorac Cardiovasc Surg. 2011 Nov;142(5):1130-6, 1136.e1. doi: 10.1016/j.jtcvs.2011.02.048. Epub 2011 Jul 7.
Blood pressure gradients that are noted early after repair of coarctation in neonates and infants are often attributed to proximal arch hypoplasia. Rapid growth of the hypoplastic proximal arch is usually observed, although in some individuals an early gradient predicts the subsequent need for reintervention. To define the predictive reliability of blood pressure gradients between arms and legs and to identify predictors of arch growth, we undertook a retrospective study.
Between January 2000 and June 2008, 77 infants underwent surgical repair of coarctation. Data collected included preoperative dimensions of aortic segments. Blood pressure gradients between arms and legs determined by cuff were compared intraoperatively and postoperatively, as well as 2-dimensional echocardiographic dimensions of the aorta between those who did not require reintervention for recoarctation (group A) and those who did (group B). Receiver operating characteristic curve analysis was applied to evaluate discrimination of the systolic gradient in differentiating the 2 groups of patients.
At surgery, patients' median age was 10 days and weight was 3.3 kg. There was 1 early death. Median follow-up was 40 months (interquartile range, 24-63 months). Recoarctation developed in 11 patients (14.3%), defined as a resting blood pressure gradient of greater than 20 mm Hg with a corresponding decrease in the diameter of the aorta by 50%. Freedom from recoarctation was 87% at 1 year and 85% at 5 years. Multivariable logistic regression analysis identified the size of the ascending aorta as a risk factor for recoarctation. Blood pressure gradient at the end of surgery was not predictive of recoarctation. The ascending aorta and transverse arch showed rapid growth in group A, and this was associated with a decrease in blood pressure gradient over time. In comparison, the growth of the ascending aorta and arch in group B was significantly less than in group A and associated with worsening of gradients. Receiver operating characteristic curve analysis revealed that gradients at the time of hospital discharge (>13 mm Hg) had excellent discriminative accuracy in identifying patients in whom subsequent recoarctation developed.
Small size of the ascending aorta is a risk factor for recoarctation. Limb gradient in the operating room at completion of surgery is not a reliable tool to assess repair of coarctation, although the gradient at the time of hospital discharge can be used to accurately predict recoarctation. Rapid growth of both the ascending and the transverse aorta is frequently observed and associated with improvement in gradients over time.
新生儿和婴儿主动脉缩窄修复术后早期发现的血压梯度通常归因于近端弓发育不良。尽管在某些情况下，早期梯度预测随后需要再次介入，但通常会观察到发育不良的近端弓快速生长。为了定义手臂和腿部之间血压梯度的预测可靠性，并确定弓生长的预测因素，我们进行了一项回顾性研究。
2000 年 1 月至 2008 年 6 月，77 名婴儿接受了主动脉缩窄修复手术。收集的数据包括主动脉各段术前尺寸。通过袖带比较手术室内和手术后手臂和腿部之间的血压梯度，以及未因再狭窄而需要再次介入的患者（A 组）和需要再次介入的患者（B 组）之间的二维超声心动图主动脉尺寸。应用受试者工作特征曲线分析评估收缩期梯度在区分两组患者中的区分能力。
手术时，患者的中位年龄为 10 天，体重为 3.3kg。有 1 例早期死亡。中位随访时间为 40 个月（四分位距，24-63 个月）。11 名患者（14.3%）发生再狭窄，定义为静息血压梯度大于 20mmHg，同时主动脉直径缩小 50%。1 年和 5 年时无再狭窄率分别为 87%和 85%。多变量逻辑回归分析确定升主动脉大小为再狭窄的危险因素。手术结束时的血压梯度不能预测再狭窄。A 组的升主动脉和横弓生长迅速，随着时间的推移，血压梯度逐渐降低。相比之下，B 组的升主动脉和弓的生长明显小于 A 组，并且与梯度恶化相关。受试者工作特征曲线分析显示，出院时的梯度（>13mmHg）在识别随后发生再狭窄的患者中具有出色的判别准确性。
升主动脉较小是再狭窄的危险因素。手术结束时手术室中的肢体梯度不是评估主动脉缩窄修复的可靠工具，尽管出院时的梯度可以准确预测再狭窄。升主动脉和横弓的快速生长经常被观察到，并与随着时间的推移梯度的改善相关。
