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Coarctation of the Aorta

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Coarctation of the Aorta. postoperative hypertension noted beyond the 10th postoperative yr: ... 10-20% have resting hypertension ... – PowerPoint PPT presentation

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Title: Coarctation of the Aorta


1
Coarctation of the Aorta
  • postoperative hypertension noted beyond the 10th
    postoperative yr
  • -- alive and well and normotensive
  • 70 at 10 yrs
  • 65 at 15 yrs
  • 20 at 25 yrs.
  • arm leg gradient with exercise average is 80 mm
    Hg.

2
SUDDEN DEATH in YOUNG ATHLETES
  • Maron, et al, Circ 1980

3
Clinical Findings
  • asymptomatic 21/29
  • syncope 3/29
  • presyncope 1/29
  • chest pain 2/29
  • mild fatigue 2/29

4
Circumstances of Death
  • death during or after severe exertion 22/29
  • death occurred during mild exertion 2/29
  • death occurred during sedentary activity 5/29

5
Causes of Sudden Death
22
Unequivocal CV dis.
14
29
1
3
ALCAPA
3
HOCM
2
Atherosclero. CA
No CV disease
Ruptured aorta
Probable CV Disease
6
5
1
Hypoplastic coronaries
Idiopathic
Concentric hypertrophy
(no fiber disarray)
6
Magnitude of the Problem
  • excluding trauma, cardiac death is the most
    frequent cause of sports related death.
  • 5/100,000 have a condition which predisposes them
    to sudden death.
  • 1/200,000 athletes per yr have sudden death
  • 12 high school ath. die/yr in U.S.

7
Types of Sports
  • basketball 33
  • football 20
  • running 16
  • swimming 4.8
  • wrestling 3.8
  • volleyball 2.9
  • tennis 2.9
  • baseball 2.9
  • GOLF

8
Hypertrophic Cardiomyopathy and Sudden Death
  • Annual mortality rate 2-4
  • Mechanism probably acute dysrhythmia(v.tach,
    v.fib., asystole)
  • Sudden death most common 10-25 yrs.
  • Peak age is 14 yrs.
  • Approx. 40 occur during ahtletics
  • If there is documented v. tach on holter,death
    rate 8.

9
HCM and Sudden Death
  • Increased risk of sudden death ass. with
    documented v. tach, family hx. of sudden death,
    young age of onset of symptoms.
  • Sudden death not related to presence or degree of
    outflow gradient.
  • NO INTERVENTION(SURG,MEDICAL)
  • HAS BEEN SHOWN TO DECREASE RISK OF SUDDEN DEATH.

10
Abnormal Origin of CAs and Sudden Death
  • Left CA from right cusp is the most common cause
    of sudden death.
  • Potential mechanisms coronary comes off
    tangentially from the aorta, ostium may be slit
    like,ostium may be partially covered by flap
    valve, initial few mmm may be in wall of aorta.
  • 97 die at
  • Rule out in pat with exercise chest pain or
    syncope . Tx. surgical

11
OTHER CAUSES of SUDDEN DEATH in ATHLETES
  • Marfan Syndrome related to aortic rupture.
  • Myocarditis may be associated with acute
    inflammation and chronic multifocal scarring--
    arrthymias
  • Drugs anabolic steroids predispose to thrombotic
    MI, CVA, and cardiomyopathy. COCAINE

12
Other Causes,
  • Primary dysrhythmias
  • a. sudden death reported with SVT,long QT,
    SSS.
  • b. exercise syncope most common presentation.

13
SCREENING?
  • Scale to identify 1000 atheletes at risk,
    200,000 would have to be screened to prevent 1
    death.
  • Routine screening by ECHO impractical
  • Routine EKGs on all athletes probably
    impractical.

14
SCREENING?
  • SMA 1 history and PE
  • focused hx of syncope, chest pain,
    or seizures in patient- always ask about sudden
    death in family members
  • focused PE looking for path.
    murmur, gallop, or S4, obvious ectopy

15
LONG TERM EXPERIENCE AFTER CARDIAC SURGERY
  • 60 of important CHD
  • VSD
  • ASD
  • PS
  • PDA
  • CoA

16
Long Term Experience,
  • Surgery for uncommon lesions- has been available
    for 25 yrs.
  • TGA
  • TA
  • Single ventricle
  • These patients are now showing up in adult
    clinics.

17
RESIDUAE SEQUELAE of CONGENITAL HEART SURGERY
  • It aint over, til its over

18
Surgical Residuae Sequelae
  • Obstructive lesions
  • Hypertension
  • Shunts
  • pulm. artery hypertension/ distortion
  • valve regurg

19
Surgical Residuae Sequelae
  • Arrhythmias
  • Systemic right ventricle- TGA
  • Mustard or Senning
  • Fontan physiology- physiologic correction with
    single ventricle chamber

20
Coarction of the Aorta
  • 50-85 incidence of bicuspid Ao valve.
  • -- Late developement of stenosis/insuf-
  • ficiency.
  • Associated with calcific changes
  • midlife event
  • -- infective endocarditis
  • 50 have mitral abnormalities

21
Coarctation of the Aorta
  • Associated abnormalities
  • -- intracranial aneurysms
  • -- late aortic dissection
  • -- intramural coronary artery disease

22
Coarctation of the Aorta Aortic aneurysms
  • With dacron onlay patches
  • -- 38 incidence of aneurysms
  • Aortic balloon angioplasty
  • -- incidence of aneurysms unknown
  • native vs recoarc. For recoarctation,
  • balloon is procedure of choice

23
Coarctation of the Aorta
  • Surgical results aim for gradient
  • 30-40 have recurrent gradient when
    surgery done at less than 1yr.
  • Significant late mortality-
  • --10-20 have resting hypertension
  • This is directly related to age at
    surgery.Exercise testing will provock gradient.
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