Masked Hypertension and Aortic Coarctation: Impact on Ventricular Function and Morphology

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1 Masked Hypertension and Aortic Coarctation: Impact on Ventricular Function and Morphology Giovanni Di Salvo MD, PhD, MMSc, FESC

2 BACKGROUND

3 MASKED HYPERTENSION Masked hypertension (MH) consists of an elevated daytime or awake ambulatory blood pressure (BP) in the presence of a normal BP on conventional measurement at the office. Previous studies demonstrated that MH in adults is associated with left ventricular (LV) hypertrophy and a worse cardiovascular prognosis. Lurbe E et al. Hypertension. 2005;45: Papadopoulos DP et al. J Clin Hypertens. 2007; 9: Stabouli S et al. J Hypertens. 2007;25:

4 AIMS Assess the prevalence of MH among AoC normotensive young patients, >12 months after successful decoarctation Evaluate the impact of MH on LV geometry and function in such patients.

5 METHODS AND RESULTS We studied 76 AoC patients (mean age 14.5 ± 5.7 years, male 64%) >12 months after a succesful decoarctation. Succesful decoarctation: <20 mmhg pressure gradient at continuous Doppler in the aortic arch and the absence of a diastolic tail. According to 24h- Ambulatory blood Pressure Monitoring (ABPM) our sample was divided in real normotensive patients (Group RN, n=40) and MH patients (Group MH, n=36).

6 Aortic Arch Morphology Assessment Gothic arch was characterized by an acute angulation between ascending and descending aorta with the horizontal part of the aorta being either shortened or absent. Gothic Normal Aortic arch was visualized by echo or when available by angio.

7 2D - Strain Rate Imaging The ultrasound tissue image contains many small elements, natural acoustic markers, which move together with the tissue and do not change their pattern significantly between adjacent frames.

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9 TWIST LV twist was defined as apical LV rotation relative to the base

10 Type of Repair AoC repair had been performed at a median age of 24 months (range 0.1 to 156 months). 61 subjects (80%) undergoing surgery within the first year of life. All were in the typical juxtaductal position. Patch angioplasty in 50 (66%) patients, End-to-end anastomosis in 16 (21%), Primary percutaneous stent implantation in 8 (10%), Subclavian flap in 2 (3%). In 20 patients there was a restenosis treated with balloon angioplasty (12 cases), with stent implantation (6 cases), and three patients underwent repeat surgery.

11 RESULTS RN (n=40) MH (n=36) P Value Age (yrs) 14.6 ± ± Sex (M %) Weight (Kg) 52.2 ± ± Height (m) 1.56 ± ± Body Mass Index (Kg/m 2 ) 21 ± ± Office SBP (mmhg) 111 ± ± Office DBP (mmhg) 61 ± 8 64 ± h-SBP (mmhg) 115 ±8 134 ±10 < h-DBP (mmhg) 65 ± 5 73 ± 11 < Daytime SBP (mmhg) ± ± 9.76 < Daytime DBP (mmhg) ± ± 8.33 < Nighttime SBP (mmhg) ± ± 7.85 < Nighttime DBP (mmhg) ± ±8.65 < Heart Rate (bpm) 75 ± ± Age at Correction (days) 845 ± ± Family history of hypertension (%)

12 METHODS AND RESULTS RN (n=40) MH (n=36) P Value LVd (mm) 44.6 ± ± LVM (g) ± ± LVMI (g/m 2.7 ) 43 ± ± RWT a 0.33± ± LA (mm) 33 ± 6 34 ± E/A 1.8 ± ± Deceleration Time 189 ± ± (msec) E/Em 9.4 ± ± Pressure Gradient in 13 ± 5 15 ± the Aortic Arch (mmhg) Bicuspide Aortic Valve (%) Gothic Arch Morphology (%) Mean Longitudinal ± ± Strain(%) Basal Septal ± 5-15 ± 2.5 < Longitudinal Strain (%) Twist ( ) 14 ± ± 1.9 < Gothic

13 STATISTICAL ANALYSIS LINEAR REGRESSION 24 SPB-BASAL STRAIN LINEAR REGRESSION 24 SPB-TWIST

14 STATISTICAL ANALYSIS At multivariate analysis performed including all the variables significantly different at the univariate analysis the best predictors of MH were basal septal peak systolic strain and LV twist

15 CONCLUSIONS MH occurred in 47% of AoC children and adolescents successfully treated. MH is associated with: LV Hypertrophy Diastolic Abnormalities Reduced Basal Septal Longitudinal Strain Reduced LV Twist

16 CONCLUSIONS TAKE AWAY- Messages Suspect MH in AoC young patients If MH is demonstrated: institute further close follow-up and lifestyle measures If MH is persistent: consider blood pressure-lowering therapy

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18 AORTIC COARCTATION Incidenza fetale 6-7% Incidenza neonatale 4-6% 4-7 % di tutte le cardiopatie congenite

19 METHODS AND RESULTS There was an increased pressure gradient in the aortic arch (15 mmhg ± 4 vs 13mmHg ±4.7 p<0.05) in MH AoC patients There was increased LV mass (51 g/m 2.7 ± 13 vs 46 g/m 2.7 ± 12, p<0.05) in MH AoC patients Regional longitudinal deformation properties of the basal septal segment (-15% ± 2.4 vs -20% ± 5, p < 0.01) were reduced in the MH group LV twist values (14 ± 1.6 vs 12 ± 1.9, p < ) were reduced in the MH group.