Hostname: page-component-78c5997874-xbtfd Total loading time: 0 Render date: 2024-11-13T01:42:00.422Z Has data issue: false hasContentIssue false
  • English
  • Français

Unmasking the borderline coarctation: the utility of isoproterenol in the paediatric cardiac catheterisation laboratory

Published online by Cambridge University Press:  14 March 2018

Neil D. Patel ,
Patrick M. Sullivan ,
Cheryl M. Takao ,
Sarah Badran ,
Joseph Ahdoot  and
Frank F. Ing
Neil D. Patel
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Patrick M. Sullivan
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Cheryl M. Takao
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Sarah Badran
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Joseph Ahdoot
Affiliation:
Children’s Hospital Los Angeles, Pacific Pediatric Cardiology Medical Group, Los Angeles, CA, USA
Frank F. Ing*
Affiliation:
Divison of Pediatric Cardiology, University of California Davis Children’s Hospital, Sacramento, CA, USA
*
Author for correspondence: F. F. Ing, MD, Chief, Division of Pediatric Cardiology, Department of Pediatrics, UC Davis Health, 2516 Stockton Blvd, Rm. 2208, Sacramento, CA 95817, USA. Tel: +281 768 9509; Fax: 916 734 5533; E-mail: frankfing@gmail.com
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

One indication for intervention in coarctation of the aorta is a peak-to-peak gradient >20 mmHg. Gradients may be masked in patients under general anaesthesia and may be higher during exercise. Isoproterenol was given during cardiac catheterisation to simulate a more active physiologic state.

Objectives

We aimed to describe the haemodynamic effects of isoproterenol in patients with coarctation and the impact of intervention on the elicited gradients.

Methods

A retrospective study was performed on two-ventricle patients who underwent cardiac catheterisation for coarctation with isoproterenol testing.

Results

25 patients received isoproterenol before and after intervention. With isoproterenol, the mean diastolic (p=0.0015) and mean arterial (p=0.0065) blood pressures proximal to the coarctation decreased significantly. The mean systolic, diastolic, and mean arterial blood pressures distal to the coarctation decreased significantly (p<0.0001). In patients with a baseline gradient ⩽20 mmHg (n=17) at catheterisation, the median gradient increased from 10 (0–20) to 30 (15–50) mmHg (p<0.0001) with isoproterenol. Of these, 15 patients developed a gradient >20 mmHg. Post intervention, the median gradient decreased to 2 (0–29) mmHg, versus baseline, p=0.005, and with isoproterenol it decreased to 8 (0–27) mmHg, versus pre-intervention isoproterenol, p<0.0001. There were significant improvements in the gradients by Doppler (<0.0001) and by blood pressure cuff (p=0.0313). The gradients on isoproterenol best correlated with gradients by blood pressure cuff in the awake state (R2=0.76, p<0.0001).

Conclusions

Isoproterenol can be a useful tool to assess the significance of a coarctation and the effectiveness of an intervention. Percutaneous interventions can effectively reduce the gradients elicited by isoproterenol.

Keywords

Coarctationisoproterenolexercise testingstent
Type
Original Articles
Information
Cardiology in the Young , Volume 28 , Issue 6 , June 2018 , pp. 804 - 810
Check for updates
Copyright
© Cambridge University Press 2018 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Moore, JW, Vincent, RN, Beekman, RH, et al. Procedural results and safety of common interventional procedures in congenital heart disease: initial report from the National Cardiovascular Data Registry. J Am Coll Cardiol 2014; 64: 2439–2451.CrossRefGoogle ScholarPubMed
2. Hijazi, ZM, Fahey, JT, Kleinman, CS, Hellenbrand, WE. Balloon angioplasty for recurrent coarctation of aorta. Immediate and long-term results. Circulation 1991; 84: 1150–1156.CrossRefGoogle ScholarPubMed
3. Siblini, G, Rao, PS, Nouri, S, Ferdman, B, Jureidini, SB, Wilson, AD. Long-term follow-up results of balloon angioplasty of postoperative aortic recoarctation. Am J Cardiol 1998; 81: 61–67.Google Scholar
4. Holzer, R, Qureshi, S, Ghasemi, A, et al. Stenting of aortic coarctation: acute, intermediate, and long-term results of a prospective multi-institutional registry – Congenital Cardiovascular Interventional Study Consortium (CCISC). Catheter Cardiovasc Interv 2010; 76: 553–563.CrossRefGoogle ScholarPubMed
5. Meadows, J, Minahan, M, McElhinney, DB, McEnaney, K, Ringel, R, and COAST Investigators. Intermediate Outcomes in the Prospective, Multicenter Coarctation of the Aorta Stent Trial (COAST). Circulation 2015; 131: 1656–1664.CrossRefGoogle ScholarPubMed
6. Feltes, TF, Bacha, E, Beekman, RH, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation 2011; 123: 2607–2652.CrossRefGoogle ScholarPubMed
7. Günthard, J, Buser, PT, Miettunen, R, Hagmann, A, Wyler, F. Effects of morphologic restenosis, defined by MRI after coarctation repair, on blood pressure and arm-leg and Doppler gradients. Angiology 1996; 47: 1073–1080.Google Scholar
8. Cyran, SE, Grzeszczak, M, Kaufman, K, et al. Aortic “recoarctation” at rest versus at exercise in children as evaluated by stress Doppler echocardiography after a “good” operative result. Am J Cardiol 1993; 71: 963–970.Google Scholar
9. Chen, CK, Cifra, B, Morgan, GJ, et al. Left ventricular myocardial and hemodynamic response to exercise in young patients after endovascular stenting for aortic coarctation. J Am Soc Echocardiogr 2016; 29: 237–246.Google Scholar
10. Weber, HS, Cyran, SE, Grzeszczak, M, Myers, JL, Gleason, MM, Baylen, BG. Discrepancies in aortic growth explain aortic arch gradients during exercise. J Am Coll Cardiol 1993; 21: 1002–1007.CrossRefGoogle ScholarPubMed
11. Engvall, J, Sonnhag, C, Nylander, E, Stenport, G, Karlsson, E, Wranne, B. Arm-ankle systolic blood pressure difference at rest and after exercise in the assessment of aortic coarctation. Br Heart J 1995; 73: 270–276.CrossRefGoogle ScholarPubMed
12. Markham, LW, Knecht, SK, Daniels, SR, Mays, WA, Khoury, PR, Knilans, TK. Development of exercise-induced arm-leg blood pressure gradient and abnormal arterial compliance in patients with repaired coarctation of the aorta. Am J Cardiol 2004; 94: 1200–1202.CrossRefGoogle ScholarPubMed
13. Markel, H, Rocchini, AP, Beekman, RH, et al. Exercise-induced hypertension after repair of coarctation of the aorta: arm versus leg exercise. J Am Coll Cardiol 1986; 8: 165–171.CrossRefGoogle ScholarPubMed
14. Nathan, D, Ongley, PA, Rahimtoola, SH. The dynamics of left ventricular ejection in “normal” man with infusion of isoproterenol. Chest 1977; 71: 746–752.Google Scholar
15. Elesber, A, Nishimura, RA, Rihal, CS, Ommen, SR, Schaff, HV, Holmes, DR. Utility of isoproterenol to provoke outflow tract gradients in patients with hypertrophic cardiomyopathy. Am J Cardiol 2008; 101: 516–520.Google Scholar
16. Kim, KS, Eryu, Y, Asakai, H, Hayashi, T, Kaneko, M, Kato, H. Isoproterenol stress test during catheterization of patients with coarctation of the aorta. Pediatr Int 2012; 54: 461–464.Google Scholar
17. Flynn, JT, Kaelber, DC, Baker-Smith, CM, et al; SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017; 140(3): e20171904.Google Scholar
18. Truccone, NJ, Steeg, CN, Dell, R, Gersony, WM. Comparison of the cardiocirculatory effects of exercise and isoproterenol in children with pulmonary or aortic valve stenosis. Circulation 1977; 56: 79–82.CrossRefGoogle ScholarPubMed
19. Neal, WA, Lucas, RV, Rao, S, Moller, JH. Comparison of the hemodynamic effects of exercise and isoproterenol infusion in patients with pulmonary valvar stenosis. Circulation 1974; 49: 948–951.Google Scholar
20. Das, BB, Raj, S, Shoemaker, L. Exercise testing is useful to screen for residual coarctation in children. Pediatr Cardiol 2009; 30: 763–767.Google Scholar
21. Kappetein, PA, Guit, GL, Bogers, AJ, et al. Noninvasive long-term follow-up after coarctation repair. Ann Thorac Surg 1993; 55: 1153–1159.Google Scholar
22. Dexter, L, Whittenberger, JL, Haynes, FW, Goodale, WT, Gorlin, R, Sawyer, CG. Effect of exercise on circulatory dynamics of normal individuals. J Appl Physiol 1951; 3: 439–453.Google Scholar
23. Kuramoto, K, Matsushita, S, Kuwajima, I, Iwasaki, T, Murakami, M. Comparison of hemodynamic effects of exercise and isoproterenol infusion in normal young and old men. Jpn Circ J 1979; 43: 71–76.Google Scholar
24. Wolthuis, RA, Froelicher, VF, Fischer, J, Triebwasser, JH. The response of healthy men to treadmill exercise. Circulation 1977; 55: 153–157.Google Scholar
25. Pelech, AN, Kartodihardjo, W, Balfe, JA, Balfe, JW, Olley, PM, Leenen, FH. Exercise in children before and after coarctectomy: hemodynamic, echocardiographic, and biochemical assessment. Am Heart J 1986; 112: 1263–1270.CrossRefGoogle ScholarPubMed
26. De Caro, E, Spadoni, I, Crepaz, R, et al. Stenting of aortic coarctation and exercise-induced hypertension in the young. Catheter Cardiovasc Interv 2010; 75: 256–261.CrossRefGoogle ScholarPubMed
27. Banaszak, P, Szkutnik, M, Kusa, J, Banaszak, B, Białkowski, J. Utility of the dobutamine stress echocardiography in the evaluation of the effects of a surgical repair of aortic coarctation in children. Cardiol J 2009; 16: 20–25.Google Scholar
28. Cnota, JF, Mays, WA, Knecht, SK, et al. Cardiovascular physiology during supine cycle ergometry and dobutamine stress. Med Sci Sports Exerc 2003; 35: 1503–1510.Google Scholar
29. Kowalik, E, Kowalski, M, Klisiewicz, A, Hoffman, P. Global area strain is a sensitive marker of subendocardial damage in adults after optimal repair of aortic coarctation: three-dimensional speckle-tracking echocardiography data. Heart Vessels 2016; 31: 1790–1797.Google Scholar