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Coarctation of the Aorta PowerPoint PPT Presentation


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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. SUDDEN DEATH in YOUNG ATHLETES.

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Coarctation of the Aorta

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Coarctation of the aorta l.jpg

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.


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SUDDEN DEATH in YOUNG ATHLETES

Maron, et al, Circ 1980


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Clinical Findings

  • asymptomatic 21/29

  • syncope 3/29

  • presyncope 1/29

  • chest pain 2/29

  • mild fatigue 2/29


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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


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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)


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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.


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basketball 33%

football 20%

running 16%

swimming 4.8%

wrestling 3.8%

volleyball 2.9%

tennis 2.9%

baseball 2.9%

GOLF<1%

Types of Sports


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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%.


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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.


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Abnormal Origin of CA’s 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 mm’m may be in wall of aorta.

  • 97% die at < 22 yrs of age

  • Rule out in pat with exercise chest pain or syncope . Tx. surgical


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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


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Other Causes,

  • Primary dysrhythmias:

    a. sudden death reported with SVT,long QT, SSS.

    b. exercise syncope most common presentation.


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SCREENING?

  • Scale: to identify 1000 atheletes at risk, 200,000 would have to be screened to prevent 1death.

  • Routine screening by ECHO impractical

  • Routine EKG’s on all athletes probably impractical.


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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


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LONG TERM EXPERIENCE AFTER CARDIAC SURGERY

  • 60% of important CHD:

    VSD

    ASD

    PS

    PDA

    CoA


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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.


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RESIDUAE & SEQUELAE of CONGENITAL HEART SURGERY

It ain’t over, til it’s over


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Surgical Residuae & Sequelae

  • Obstructive lesions

  • Hypertension

  • Shunts

  • pulm. artery hypertension/ distortion

  • valve regurg


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Surgical Residuae & Sequelae

  • Arrhythmias

  • Systemic right ventricle- TGA

    Mustard or Senning

  • Fontan physiology- physiologic correction with single ventricle chamber


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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


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Coarctation of the Aorta

Associated abnormalities:

-- intracranial aneurysms

-- late aortic dissection

-- intramural coronary artery disease


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Coarctation of the AortaAortic 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


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Coarctation of the Aorta

  • Surgical results; aim for gradient < 10

    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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