Weber H S, Cyran S E, Grzeszczak M, Myers J L, Gleason M M, Baylen B G
Section of Pediatrics (Cardiology) and Surgery (Cardiothoracic), Pennsylvania State University, Milton S. Hershey Medical Center, Hershey 17033.
J Am Coll Cardiol. 1993 Mar 15;21(4):1002-7. doi: 10.1016/0735-1097(93)90360-d.
This study was conducted to evaluate the incidence and etiology of hypertension and aortic arch gradients during exercise in patients who have apparent good coarctation repair assessed at rest.
The reported incidence of recurrent aortic arch obstruction (rest gradient > 20 mm Hg) after previous successful surgical repair varies from 0% to 60% and usually is associated with recurrent stenosis at the site of surgical repair.
Maximal treadmill exercise with Doppler echocardiographic gradient estimation was performed in 28 patients with a good coarctation repair at rest (normal blood pressure and arch gradient < 20 mm Hg) who had isolated coarctation repair a mean of 7.8 years previously.
Eight (29%) developed systolic hypertension for age and a mean Doppler gradient of 45 +/- 13 mm Hg. At cardiac catheterization, the rest peak to peak systolic gradient (6 +/- 6 to 28 +/- 7 mm Hg, p < 0.001), peak systolic instantaneous gradient (16 +/- 11 to 48 +/- 9 mm Hg, p < 0.01) and cardiac index (3.5 +/- 0.7 to 5.9 +/- 1.1 liters/m per m2, p < 0.001) all increased during isoproterenol infusion. Angiographic systolic aortic arch measurements proximal to the innominate artery, left common carotid artery, left subclavian artery and the narrowest dimension at the coarctation repair site demonstrated hypoplasia at the left common carotid artery (11.8 +/- 1.7 vs. 16.7 +/- 2.9 mm/m2, p < 0.01) and left subclavian artery (11.6 +/- 1.7 vs. 15.4 +/- 3.1 mm/m2, p < 0.05) compared with findings in 10 patients with normal aortograms. Transverse aortic arch ratios were also smaller in the eight patients with abnormal findings. Preoperative angiographic ratios were not predictive of late postoperative findings.
Exercise testing detects hypertension and arch gradients in patients with a good coarctation repair as assessed at rest. The hypertension and arch "obstruction" appear to be related to discrepancies in the growth of the transverse aortic arch proximal to the repair site, rather than a "recoarctation" of the aorta.
本研究旨在评估静息时主动脉缩窄修复良好的患者运动期间高血压和主动脉弓梯度的发生率及病因。
既往成功手术修复后复发性主动脉弓梗阻（静息梯度>20 mmHg）的报道发生率为0%至60%，通常与手术修复部位的复发性狭窄有关。
对28例静息时主动脉缩窄修复良好（血压正常且主动脉弓梯度<20 mmHg）的患者进行了最大运动平板试验，并通过多普勒超声心动图估计梯度。这些患者平均在7.8年前接受了单纯主动脉缩窄修复。
8例（29%）患者出现年龄相关性收缩期高血压，平均多普勒梯度为45±13 mmHg。在心脏导管检查中，静息时收缩期峰-峰梯度（6±6至28±7 mmHg，p<0.001）、收缩期峰值瞬时梯度（16±11至48±9 mmHg，p<0.01）和心脏指数（3.5±0.7至5.9±1.1升/分钟每平方米，p<0.001）在异丙肾上腺素输注期间均升高。在无名动脉、左颈总动脉、左锁骨下动脉近端进行的血管造影收缩期主动脉弓测量以及主动脉缩窄修复部位的最窄尺寸显示，与10例主动脉造影正常的患者相比，左颈总动脉（11.8±1.7 vs. 16.7±2.9 mm/m2，p<0.01）和左锁骨下动脉（11.6±1.7 vs. 15.4±3.1 mm/m2，p<0.05）发育不全。8例有异常发现的患者的横主动脉弓比率也较小。术前血管造影比率不能预测术后晚期结果。
运动试验可检测出静息时主动脉缩窄修复良好的患者的高血压和主动脉弓梯度。高血压和主动脉弓“梗阻”似乎与修复部位近端横主动脉弓生长差异有关，而非主动脉“再缩窄”。
