Koarktacija aorte pri odraslih bolnikih
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1 MED RAZGL 2007; 46: PREGLEDNI ^LANEK Luka Klemen 1, Janez Svet 2, Katja Prok{elj 3 Koarktacija aorte pri odraslih bolnikih Coarctation of the Aorta in Adult Patients IZVLE^EK KLJU^NE BESEDE: aortna koarktacija, odrasli Koarktacija aorte je prirojena zo`itev aorte, ki jo ve~inoma odkrijemo in kirur{ko popravimo `e v otro{tvu. Diagnosti~ni postopek, s katerim ugotavljamo napako in spremljamo bolnike, poleg klini~nega pregleda zajema elektrokardiogram, rentgenogram prsnih organov, ehokardiografijo, magnetno resonanco ali ra~unalni{ko tomografijo aorte, obremenitveno testiranje ter 24-urno merjenje krvnega tlaka. S preiskavami ocenjujemo morfologijo koarktacije aorte in njeno hemodinami~no pomembnost. Zdravljenje je praviloma kirur{ko, v dolo~enih primerih napako zdravimo tudi s perkutano katetersko intervencijo. Kljub uspe{ni kirur{ki ali perkutani popravi napake ti bolniki niso ozdravljeni, saj se pogosto pojavijo pozni zapleti (npr. sistemska arterijska hipertenzija, rekoarktacija ali rezidualna koarktacija in dilatacija ali anevrizma ascendentne aorte), ki vodijo v obolevnost in kraj{o `ivljenjsko dobo. Redno spremljanje bolnikov in ustrezno ukrepanje ob pojavu poznih zapletov izbolj{ujeta pre`ivetje in kvaliteto `ivljenja. ABSTRACT 221 KEY WORDS: aortic coarctation, adult Coarctation of the aorta is a congenital aortic stenosis, which is usually diagnosed and surgically treated in childhood. Diagnostic work-up for initial diagnosis and follow-up in these patients comprises clinical examination, electrocardiogram, chest X-ray, echocardiography, magnetic resonance imaging or computed tomography of the aorta, exercise testing and 24-hour blood pressure study. These investigations are used to evaluate the morphology of the defect and to determine its hemodynamic significance. The treatment of choice is surgical repair or percutaneous catheter intervention. Despite successful surgical or percutaneous repair, patients with coarctation of the aorta are not cured. Late complications (systemic arterial hypertension, recoarctation or residual coarctation, and dilatation or an aneurysm of the ascending aorta) lead to increased morbidity and mortality. However, regular follow-ups and prompt treatment of late complications improve survival and quality of life in these patients. 1 Luka Klemen, dr. med., Klini~ni oddelek za kardiologijo, Univerzitetni klini~ni center Ljubljana, Zalo{ka 7, 1525 Ljubljana. 2 Janez Svet, abs. med., Klini~ni oddelek za kardiologijo, Univerzitetni klini~ni center Ljubljana, Zalo{ka 7, 1525 Ljubljana. 3 Asist. dr. Katja Prok{elj, dr. med., Klini~ni oddelek za kardiologijo, Univerzitetni klini~ni center Ljubljana, Zalo{ka 7, 1525 Ljubljana.
2 L. KLEMEN, J. SVET, K. PROK[ELJ KOARKTACIJA AORTE PRI ODRASLIH BOLNIKIH MED RAZGL 2007; UVOD Prirojene sr~ne napake se pojavljajo pri 8 10 od 1000 `ivorojenih otrok. Zaradi napredka v diagnostiki in zdravljenju danes skoraj 90 % otrok s prirojeno sr~no napako pre`ivi v odraslo obdobje, s tem pa se pove~uje tudi {tevilo odraslih bolnikov s prirojeno sr~no napako. ^eprav je {tevilo bolnikov s prirojeno sr~no napako v primerjavi z drugimi sr~no-`ilnimi boleznimi majhno, je pri vodenju teh bolnikov potrebna posebna skrb, ki zahteva dobro poznavanje patomorfolo{kih in hemodinami~nih zna~ilnosti posamezne prirojene sr~ne napake (1, 2). Koarktacija aorte (KoA) predstavlja 5 8 % vseh prirojenih sr~nih napak. Vzrok zanjo ni znan. Pojavlja se sporadi~no, znani pa so tudi genetski vplivi. Mo{ki obolevajo od 1,3- do 2-krat pogosteje (3, 4, 5). MORFOLOGIJA KoA je prirojena zo`itev aorte, ki se najpogosteje pojavlja na prehodu aortnega loka v descendentni del, to je tik za odcepi{~em leve podklju~ni~ne arterije v predelu arterijskega ligamenta (lat. ligamentum arteriosum) (slika 1). Redko je prizadeta trebu{na aorta. Glede na morfologijo KoA lo~imo omejeno (lokalizirano) in raz{irjeno (difuzno) obliko, glede na pridru`ene napake pa enostavno in zapleteno KoA. Pri omejeni obliki KoA se medija aorte razobli~i v polici podobno tvorbo, ki {trli v svetlino aorte. Pri raz{irjeni obliki KoA je zajet aortni lok ali aorta distalno od odcepi{~a leve podklju~ni~ne arterije (3). Enostavna KoA je KoA brez pridru`enih drugih sr~nih napak. Zapleteni KoA so pridru`ene druge prirojene sr~ne napake. Najpogosteje gre za dvolistno aortno zaklopko (v 85%), manj pogosto za defekt prekatnega pretina, nepravilnosti mitralne zaklopke, nepravilnosti brahiocefalnega `ilja (nepravilen izvor desne podklju~ni~ne arterije) in anevrizme mo`ganskih arterij. Razmerje med enostavno in zapleteno KoA je 1 : 1. Pri nekaterih bolnikih (do 25 %) so prisotne tudi nepravilnosti drugih organskih sistemov dihalnega, prebavnega, se~il in rodil ali mi{i~ja in okostja. Lahko je prisotna tudi difuzna arteriopatija (3, 4, 6). Slika 1. Koarktacija aorte; Asc Ao ascendentna aorta, Desc Ao descendentna aorta, KoA koarktacija aorte, PA plju~na arterija. Zo`enje aorte povzro~i nastanek obvodnega arterijskega obtoka, ki ga tvorijo predvsem medrebrne arterije (3). KLINI^NA SLIKA Klini~na slika KoA je odvisna od stopnje zo`itve, mesta zo`itve in razvitosti obvodnega `ilja. Simptomi se pri bolnikih s KoA ve~inoma poka`ejo `e v otro{tvu, nekateri bolniki pa so tudi v odraslem obdobju brez simptomov in jih odkrijemo naklju~no pri rutinskem klini~nem pregledu (3, 6). Simptomi so posledica sistemske arterijske hipertenzije nad mestom KoA in slab{e arterijske prekrvitve pod mestom KoA. Ti so: glavobol, omotice, krvavitve iz nosu, {umenje v u{esih, hladna stopala, abdominalna angina, utrujenost nog ob naporu in simptomi sr~nega popu{~anja. Tipi~na klavdikacijska bole~ina je zna~ilna za koarktacijo abdominalne aorte (6). S klini~nim pregledom ugotovimo vi{ji sistoli~ni krvni tlak na zgornjih okon~inah, v diastoli~nem krvnem tlaku pa ni razlike. Posledica je za KoA zna~ilen povi{an pulzni tlak. ^e je KoA pred odcepi{~em leve podklju~ni~ne arterije, je sistoli~ni krvni tlak povi{an le na desni zgornji okon~ini. S palpacijo ugotovimo zna~ilne odsotne ali {ibke in zakasnele femoralne pulze. Pri pregledu srca lahko tipamo zna~ilno suprasternalno sistoli~no predenje, sr~na konica je lahko pomaknje-
3 MED RAZGL 2007; 46 na v levo in navzdol. Pri avskultaciji sli{imo poudarjen drugi sr~ni ton. Nad mestom KoA, levo ob prsnici in na hrbtu sli{imo iztisni sistoli~ni {um. Zaradi obvodnega `ilja je na hrbtu sli{no sistoli~no {umenje. Pri 30 % bolnikov s KoA je kot posledica dvolistne aortne zaklopke nad bazo srca sli{en sistoli~ni {um. V tem primeru je lahko prisoten {e iztisni sistoli~ni tlesk dvolistne aortne zaklopke (3, 4, 6). PREISKOVALNE METODE Pri obravnavi in vodenju bolnikov s KoA se poslu`ujemo slede~ih preiskovalnih metod: elektrokardiogram, rentgensko slikanje prsnih organov, ehokardiografija (EHO), obremenitveno testiranje, magnetna resonanca (MR) ali ra~unalni{ka tomografija (CT) aorte in 24-urno merjenje krvnega tlaka, le redko pa opravimo sr~no kateterizacijo (3, 4). Elektrokardiogram nam razkrije morebitno hipertofijo levega prekata (4). Na rentgenogramu prsnih organov lahko ugotovimo pove~ano sr~no senco, dilatacijo ascendentne aorte in uzure reber, ki nastanejo zaradi raz- {irjenih medrebrnih arterij (2, 6). Obremenitveno testiranje izvajamo za ugotavljanje sistemske arterijske hipertenzije pri obremenitvi, redkeje pa za ugotavljanje sistemske arterijske hipertenzije opravimo tudi 24-urno merjenje krvnega tlaka (3, 7). EHO je osnovna diagnosti~na metoda za ugotavljanje KoA. Uporabljamo dvodimenzionalno in doplersko EHO. Dvodimenzionalna EHO omogo~a morfolo{ki prikaz aortnega loka in mesta KoA (slika 2). Z barvno doplersko EHO prika`emo pospe{en pretok skozi mesto KoA (slika 3). S kontinuirano doplersko EHO izmerimo hitrost toka krvi in izra~unamo gradient tlaka skozi aorto na mestu KoA (8). Najve~ja hitrost toka krvi = 3,2m/s ali najve~ji gradient > 30 mmhg ka`eta na hemodinami~no pomembno KoA (2, 3). ^e s kontinuirano doplersko EHO v descendentni aorti prika`emo antegradni tok krvi v diastoli (t. i. diastoli~ni rep), to ka`e na hemodinami~no pomembno KoA ali obse`en obvodni obtok (3, 9). Z EHO ocenjujemo tudi morebitno hipertrofijo levega prekata, sistoli~no in diastoli~no funkcijo levega prekata, delovanje zaklopk in ugotavljamo morebitne pridru`ene sr~ne napake (8). MR in CT aorte omogo~ata natan~en prikaz morfologije KoA. MR aorte je metoda izbora, ker nadome{~a invazivne slikovne preiskave, bolnik pa ob tem ni izpostavljen 223 Slika 2. Aortni lok in mesto koarktacije aorte. Na suprasternalnem vzdol`nem preseku je prikazan aortni lok in mesto koarktacije aorte (pu{~ica); KoA koarktacija aorte, AoL aortni lok, AKK arteria carotis communis.
4 L. KLEMEN, J. SVET, K. PROK[ELJ KOARKTACIJA AORTE PRI ODRASLIH BOLNIKIH MED RAZGL 2007; 46 Slika 3. Barvna doplerska ehokardiografija. Na suprasternalnem vzdol`nem preseku je viden barvni doplerski signal turbulentnega pretoka na mestu koarktacije aorte (pu{~ica); KoA koarktacija aorte. 224 Slika 4. Kontinuirana doplerska ehokardiografija. Prikazana je najve~ja hitrost pretoka skozi koarktacijo aorte; V max najve~ja hitrost pretoka skozi KoA, Dia rep diastoli~ni rep.
5 MED RAZGL 2007; 46 Sistemska arterijska hipertenzija povzro~i hipertrofijo levega prekata, ki lahko s~asoma vodi v levostransko sr~no popu{~anje. Povzro- ~i lahko tudi zgodnjo aterosklerozo (4, 13). Vzroki obolevnosti in umrljivosti bolnikov po popravi KoA so sr~no popu{~anje (28 %), disekcija in ruptura aorte (21 %), infekcijski endokarditis (18 %), mo`ganska krvavitev zaradi rupture anevrizme mo`ganske arterije (12%), prezgodnja koronarna bolezen in druge pridru`ene sr~ne napake (obi~ajno dvolistna aortna z nezdravljeno KoA imajo med nose~nostjo visoko tveganje za disekcijo doba nezdravljenih bolnikov je skraj{ana. Do 46. leta starosti umre 75 % nezdravljenih bolnikov, do 60. leta pa 92 % (4, 6, 13). Slika 5. Magnetna resonanca aorte. Slika prikazuje aorto pri odraslem bolniku po operaciji KoA; Asc Ao ascendentna aorta, Arkus Ao aortni lok, Desc Ao descendentna aorta, Lpa leva podklju~ni~na arterija. sevanju (9). Z MR ocenimo morfologijo aortnega loka, izmerimo premer aorte na razli~nih mestih, ocenimo stanje aorte pred KoA in za njo ter raz{irjenost obvodnega `ilja (10).Aorto je mogo~e ocenjevati pred popravo KoA in za njo (3, 4, 6). Pri bolnikih, kjer je MR kontraindicirana, opravimo CT. Pomembno je, da bolnike sledimo ves ~as z isto preiskovalno metodo, s ~imer se izognemo morebitnim razlikam v meritvah (11, 12). Sr~na kateterizacija se v nekaterih centrih {e vedno uporablja pri oceni KoA, saj omogo~a natan~no oceno morfologije KoA in meritev invazivnega gradienta tlaka skozi KoA (3, 4). NARAVNI POTEK KoA ZDRAVLJENJE KoA na~eloma zdravimo kirur{ko. Prvi~ so KoA kirur{ko popravili leta 1945 (13). Zdravljenje s perkutano katetersko intervencijo prihaja v po{tev predvsem pri rekoarktaciji (3). Ve~inoma se KoA popravi `e v zgodnjem otro{kem obdobju. Poprava KoA je indicirana pri bolnikih z neinvazivno izmerjenim gradientom tlaka na mestu KoA > 30 mm Hg (6). Kirur{ko zdravljenje Obstaja veliko razli~nih kirur{kih tehnik za zdravljenje KoA. Najpogostej{a je anastomoza konca s koncem (angl. end-to-end), pri kateri se zo`eni del aorte izre`e in prosta konca za{ije skupaj. Druga pogosta tehnika, ki pa se danes ne uporablja ve~, je plastika z obrnjenim re`njem leve podklju~ni~ne arterije (angl. subclavian flap), kjer se za premostitev uporabi leva podklju~ni~na arterija. Ta tehnika je primerna, kadar anatomske razmere ne dovoljujejo neposredne anastomoze, in je lahko povezana s kasnej{imi motnjami v prekrvitvi leve zgornje okon~ine. Ostale tehnike so vstavitev `ilnega vsadka (angl. graft interposition) in premostitev KoA z obvodom iz umetnega materiala (angl. bypass tube jump graft). V~asih so za popravo KoA uporabljali tudi material Dacron (angl. prostetic patch aortoplasty), vendar je pri tej tehniki zelo velika mo`nost nastanka anevrizme in kasnej{e rupture. Vsaka od omenjenih tehnik ima svoje prednosti in ne`elene posledice (3, 14, 15). Perkutani posegi Perkutani posegi vklju~ujejo balonsko {irjenje KoA in vgraditev `ilne opornice. Uporabljajo se za zdravljenje nativne KoA pri ve~jih otrocih, adolescentih in odraslih ter za ponovno popravo rezidualne koarktacije ali rekoarktacije (4, 16). Nativna KoA se zdravi z vgraditvijo `ilne opornice, pri rekoarktaciji pa pride v po{tev balonsko {irjenje KoA ali vgraditev `ilne opornice. ^eprav je poseg ve~inoma 225
6 L. KLEMEN, J. SVET, K. PROK[ELJ KOARKTACIJA AORTE PRI ODRASLIH BOLNIKIH MED RAZGL 2007; uspe{en, dolgoro~no pri 32 % bolnikov pride do hemodinami~no pomembne rekoarktacije (17). Vstavitev `ilne opornice prepre~i zo`itev lumna aorte zaradi elasti~nosti stene. Kratkoro~ni rezultati perkutanih posegov so dobri, vendar so mo`ni zapleti, kot sta anevrizma in disekcija aorte (16). Zdravljenje z zdravili Arterijsko hipertenzijo po popravi KoA in morebitno posledi~no sr~no popu{~anje zdravimo po ustaljenih smernicah (15, 18). Bolniki po operaciji KoA potrebujejo antibioti~no za{~ito za prepre~evanje bakterijskega endokarditisa po doktrini (4, 19). POZNI ZAPLETI PO OPERACIJI KoA Arterijska hipertenzija Arterijska hipertenzija v mirovanju ali pri obremenitvi se pogosto pojavlja tudi po uspe- {ni kirur{ki popravi KoA (20, 21). Vzrok ni povsem pojasnjen. ^e obstaja rezidualna KoA ali ~e se pojavi rekoarktacija, sta ti lahko vzrok za sistemsko arterijsko hipertenzijo. Rezidualna KoA in rekoarktacija sta vzrok za arterijsko hipertenzijo le pri manj{em dele- `u bolnikov, saj se arterijska hipertenzija pojavlja tudi pri bolnikih, ki nimajo rezidualne zo`itve aorte (22, 23). Drugi mo`ni vzroki so nenormalen `ilni odgovor arterij nad mestom KoA, zmanj{ana ob~utljivost baroreceptorjev, spremenjeno delovanje sistema renin-angiotenzin-aldosteron, zvi{ane koncentracije kateholaminov v plazmi in so~asna esencialna sistemska arterijska hipertenzija. Eden izmed dejavnikov, ki vplivajo na pojav arterijske hipertenzije, je tudi vi{ja starost ob operaciji, zato se KoA operira ~im prej po odkritju. Pri bolnikih, ki so imeli arterijsko hipertenzijo `e pred popravo napake, se ta pogosteje pojavi kot pozni zaplet (24 26). Posledica arterijske hipertenzije je tudi prezgodnja koronarna ateroskleroza (26). Rekoarktacija in rezidualna koarktacija Rekoarktacija in rezidualna KoA povzro~ata sistemsko arterijsko hipertenzijo in njene posledice. Rekoarktacija se po operaciji pojavi v 3 11 % (24). Rekoarktacija in rezidualna KoA se na mestu operacije lahko pojavita pri vseh kirur{kih tehnikah. Perkutana angioplastika z vstavitvijo `ilne opornice je uveljavljen na~in zdravljenja rekoarktacije in rezidualne KoA (27). Anevrizma ascendentne aorte Anevrizma aorte je najnevarnej{i zaplet pri bolnikih po popravi KoA in lahko vodi v rupturo aorte. Vzrok nastanka anevrizme ascendentne aorte ni povsem pojasnjen. Anevrizme so pogostej{e pri bolnikih z dvolistno aortno zaklopko, kjer so verjeten vzrok nastanka strukturne spremembe v steni ascendentne aorte (28, 29). Sistemska arterijska hipertenzija je dodaten dejavnik tveganja za nastanek anevrizme ascendentne aorte. Pogostnost nastanka anevrizme na mestu predhodne poprave KoA je odvisna tudi od kirur{ke tehnike in od starosti bolnika ob kirur{kem posegu (13, 26). Anevrizme mo`ganskih arterij Anevrizme mo`ganskih arterij (anevrizme Willisovega kroga) se pri bolnikih s KoA pojavljajo v do 10 %. Ruptura anevrizme mo`ganske arterije, ki je pogostej{a pri bolnikih z neurejeno arterijsko hipertenzijo, je povezana z visoko umrljivostjo (3, 6, 26). Ishemi~na bolezen srca Prezgodnja koronarna ateroskleroza je pri bolnikih s KoA pogostej{a. Njeni zapleti so vzrok smrti pri ve~ kot tretjini bolnikov s KoA (26). Ker se lahko pozni zapleti pojavijo kadar koli, moramo bolnike slediti celo `ivljenje, zaplete prepoznati in jih ustrezno zdraviti (19, 30). PRIPORO^ILA ZA VODENJE BOLNIKOV S KoA Bolniki z neoperirano ali operirano KoA potrebujejo redne ambulantne kontrole celo `ivljenje, in sicer pri kardiologu, ki je usmerjen v vodenje bolnikov s prirojenimi sr~nimi napakami. Po Evropskih smernicah za obravnavo odraslih bolnikov s prirojenimi sr~nimi napakami iz leta 2003, ki jih je Zdru`enje
7 MED RAZGL 2007; 46 kardiologov Slovenije prevzelo leta 2005, je potrebno vse neoperirane in operirane bolnike s KoA spremljati enkrat letno. Ob vsaki obravnavi je potrebno opraviti klini~ni pregled, EHO, MR ali CT aorte in obremenitveno testiranje (19). Ob pregledu zaradi ugotavljanja morebitne arterijske hipertenzije v mirovanju izmerimo krvni tlak v mirovanju, ki ga vselej merimo na desni roki, saj je leva podklju~ni~na arterija pogosto odstranjena ob kirur{kem posegu. Ker je lahko arterijska hipertenzija prisotna le ob obremenitvi, pri vseh bolnikih opravimo obremenitveno testiranje. Priporo~ljivo je tudi 24-urno merjenje krvnega tlaka. Z EHO ocenjujemo mesto KoA (izmerimo gradient tlaka skozi KoA in i{~emo morebitne anevrizme), ocenimo morfolo{ke in funkcijske spremembe aortne zaklopke, morebitno hipertrofijo levega prekata ter sistoli~no in diastoli~no funkcijo levega prekata (4, 8, 19). Z MR oziroma CT aorte ocenjujemo stanje aorte, morebitno rezidualno koarktacijo ali rekoarktacijo, dilatacijo ali anevrizmo ascendentne aorte ter morebitne druge pridru`ene spremembe (4, 19). Pri vseh bolnikih je potrebna dosmrtna antibioti~na za{~ita pred infekcijskim endokarditisom po doktrini (19). Bolniki brez rezidualne stenoze in z normalnim krvnim tlakom ne potrebujejo omejitev pri vsakodnevnih aktivnostih in lahko `ivijo normalno `ivljenje. Bolniki z rezidualno stenozo, arterijsko hipertenzijo ali drugimi poznimi zapleti se morajo izogibati telesnim naporom, predvsem izometri~nim obremenitvam (npr. dviganju bremen) (3, 4, s KoA odsvetujemo hormonsko kontracepcijo, ker zvi{uje krvni tlak. Bolnice po operaciji KoA brez poznih zapletov sodijo v skupino z majhnim tveganjem za nose~nost. Bolnicam s hemodinami~no pomembno KoA ali poznimi zapleti po popravi KoA pa nose~nost do poprave napake odsvetujemo. Med nose~nostjo je potrebno spremljanje nose~nice in skrben nadzor krvnega tlaka (4, 19). ZAKLJU^EK Koarktacija aorte je prirojena sr~na napaka, ki jo ve~inoma odkrijemo in zdravimo `e v otro{tvu. Kljub uspe{nemu zdravljenju ti bolniki niso ozdravljeni, saj se lahko pozni zapleti (npr. sistemska arterijska hipertenzija, rekoarktacija ali rezidualna koarktacija in dilatacija ali anevrizma ascendentne aorte) pojavijo {ele ve~ desetletij po operaciji KoA. Zato je potrebno redno spremljanje bolnikov pri kardiologu, ki je usmerjen v zdravljenje bolnikov s prirojenimi sr~nimi napakami. Le enotna strokovna obravnava in ustrezno ukrepanje bolnikom omogo~i optimalno kvaliteto `ivljenja. 227 LITERATURA 1. Warnes CA, Liberthson R, Danielson GK, et al. Task force 1: The changing profile of congenital heart disease in adult life. J Am Coll Cardiol 2001; 37: Stocker FP. Adults with congenital heart disease the important role and obligation of paediatric cardiologist and the general paediatrician. Eur J Pediatr 1995; 154: Kaemmerer H. Aortic coarctation and interrupted aortic arch. In: Gatzoulis MA, Webb GD, Daubeney PEF, eds. Diagnosis and management of adult congenital heart disease. Edinburgh: Churchill Livingstone, 2003: Therrien J, Gatzoulis M, Graham T, et al. Canadian Cardiovascular Society Consensus Conference 2001 update: Recommendations for the management of adults with congenital heart disease Part II. Can J Cardiol 2001; 17: Gotzche CO, Krag-Olsen B, Nielsen J, et al. Prevalence of cardiovascular malformations and association with kariotypes in Turner's syndrome. Arch Dis Child 1994; 71: Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. First of two parts. N Engl J Med 2000; 342: 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: Otto CM. The adult with congenital heart disease. In: Otto CM, ed. Textbook of clinical echocardiography. 3rd edition. Philadelphia: Elsevier Saunders, 2004: Tan JL, Babu-Narayan SV, Henein MY, et al. Doppler echocardiographic profile and indexes in the evaluation of aortic coarctation in patients before and after stenting. J Am Coll Cardiol 2005; 46: Therrien J, Thorne SA, Wright A, et al. Repaired coarctation: a»cost-effective«approach to identify complications in adults. J Am Coll Cardiol 2000; 35:
8 L. KLEMEN, J. SVET, K. PROK[ELJ KOARKTACIJA AORTE PRI ODRASLIH BOLNIKIH MED RAZGL 2007; Hager A, Kaemmerer H, Leppert A, et al. Follow-up of adults with coarctation of aorta: comparison of helical CT and MRI and impact on assessing diameter changes. Chest 2004; 126: Hager A, Kaemmerer H, Hess J. Comparison of helical CT scanning and MRI in the follow-up of adults with coarctation of aorta. Chest 2005; 127: Jenkins NP, Ward C. Coarctation of aorta: natural history and outcome after surgical treatment. Q J Med 1999; 92: Maia MM, Aiello VD, Barbero-Marcial M, et al. Coarctation of the aorta corrected during childhood. Clinical aspects during follow-up. Arq Bras Cardiol 2000; 74: Celermajer DS, Greaves K. Survivors of coarctation repair: fixed but not cured. Heart 2002; 88: Muellen MJ. Coarctation of the aorta in adults: do we need surgeons? Heart 2002; 89: Mendelsohn AM, Lloyd TR, Crowley DC, et al. Late follow-up of balloon angioplasty in children with a native coarctation of the aorta. Am J Cardiol 1994; 74: Bolger AP, Coats AJS, Gatzoulis MA. Congenital heart disease: the original heart failure syndrome. Eur Heart J 2003; 24: Deanfield J, Thaulow E, Warnes C, et al. Management of grown up congenital heart disease. Eur Heart J 2003; 24: Kaemmerer H, Oelert E, Bahlmann J, et al. Arterial hypertension in adults after surgical treatment of aortic coarctation. Thorac Cardiovasc Surg 1998; 46: Hauser M. Exercise blood pressure in congenital heart disease and in patients after coarctation repair. Heart 2003; 89: O'Sullivan JJ, Derrick G, Darnell R. Prevalence of hypertension in children after early repair of coarctation of the aorta: a cohort study using casual and 24 hour blood pressure measurement. Heart 2002; 88: Vriend JW, Zwinderman AH, de Groot E, et al. Predictive value of mild, residual descending aortic narrowing for blood pressure and vascular damage in patients after repair of aortic coarctation. Eur Heart J 2005; 26: Freed MD, Rocchini A, Rosenthal A, et al. Exercise induced hypertension after surgical repair of coarctation of aorta. Am J Cardiol 1979; 43: Ong CM, Canter CE, Gutierrez FR, et al. Increased stiffness and persistent narrowing of the aorta after successful repair of coarctation of the aorta: relationship to left ventricular mass and blood pressure at rest and with exercise. Am Heart J 1992; 123: Cohen M, Fuster V, Steele PM, et al. Coarctation of the aorta: long-term follow-up and prediction of outcome after surgical correction. Circulation 1989; 80: Yetman AT, Nykanen D, McCrindle BW, et al. Balloon angioplasty of recurrent coarctation: a 12-year review. J Am Coll Cardiol 1997; 30: Perloff JK. Congenital heart disease in adults. In: Braunwald E, ed. Heart disease: a textbook of cardiovascular medicine. 5th ed. Philadelphia, WB Saunders, 1997: Niwa K, Perloff JK, Bhuta SM, et al. Structural abnormalities of great arterial walls in congenital heart disease: Light and electron microscopic analyses. Circulation 2001; 103: Toro-Salazar OH, Steinberger J, Thomas W, et al. Long-term follow-up of patients after coarctation of the aorta repair. Am J Cardiol 2002; 89: Prispelo
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