PERSISTENT HYPERDYNAMIC CARDIOVASCULAR STATE AT REST AND DURING EXERCISE IN CHILDREN AFTER SUCCESSFUL REPAIR OF COARCTATION OF THE AORTA

Objectives. The purposes of this study were to evaluate left ventricular performance and contractility at rest and during exercise to determine mechanisms and correlates for alterations in performance and blood pressure in pediatric patients after successful repair of coarctation of the aorta. Background. Blood pressure and left ventricular function are elevated in children despite successful repair. The mechanisms for these changes are not understood. Methods. Thirty asymptomatic pediatric patients with successful coarctation repair (mean age [+/-SD] 12.5 +/- 4 years) underwent echocardiographic determination of left ventricular mass, performance (shortening fraction), preload (indexed diastolic dimension), afterload (end-systolic wall stress), contractility (velocity of circumferential fiber shortening/wall stress relation) and Doppler gradient at rest and during exercise. Data were compared with those of 24 control subjects (mean age 21.0 +/- 4 years). Because of the age discrepancy between groups, age dependent echocardiographic data were indexed by body surface area. Results. The mean age at operation was 5 +/- 4 years, and the average follow-up period was 7.5 +/- 3 years. The average blood pressure gradient between upper and lower limbs was 4 mm Hg. Left ventricular mass was higher in the postoperative group than in the control group (1.58 vs. 1.31 g/ht(2.7), p = 0.04), as were values at rest for performance (44% vs. 31%, p = 0.0001), preload (3.9 vs. 3.7 cm/body surface area(0.5)), indexed systolic blood pressure (1.05 vs. 0.91, p = 0.0001) and contractility (0.23 vs. -0.05 circumferences/s, p = 0.001). Afterload was lower at rest (36 vs. 52 g/cm(2), p = 0.0004). These differences between groups persisted during and after exercise. Contractility underwent an exaggerated increase after exercise in the postoperative group. Conclusions. Left ventricular performance in children after coarctation repair is higher at rest and during exercise than in control subjects as a result of higher preload and contractility and lower afterload. These changes may be due to associated hypertrophy. Persistent postoperative hypertension may be due to a hyperdynamic, hypercontractile state caused by residual gradients manifested only during exertion.