Introduction Systemic hypertension manifesting after surgical coarctation repair is a known long term sequela and affects about two thirds of subjects. Previous studies suggest the risk of developing hypertension is reduced if the coarctation repair is performed at a younger age with the optimal time for repair between the first year of life up to 9 years of age.
Objective Using our experience of patients operated on since the opening of the new Evelina London Children’s Hospital in 2005, we sought to further clarify the optimal age at which coarctation repair is most effective in reducing the risk of systemic hypertension. Risk of developing re-coarctation related to the age of primary surgical repair was also examined.
Methods Retrospective analysis of patients with coarctation undergoing primary surgical repair from October 2005 to October 2014, identified from the institutional database (Heartsuite, Systeria, Glasgow, UK). Included patients were all <16 years age. Patients with complex congenital heart disease and no follow up data were excluded. Owing to inconsistent documentation of blood pressure at follow up (the documentation of blood pressure was available on only 195 (65%) out of 299 follow up episodes) a surrogate marker of hypertension, regular antihypertensive medication, was used. The two primary outcome events at follow up were: 1) age when commenced on regular anti-hypertensive medication and 2) the presence of re-coarctation of the aorta.
Results Eighty seven patients were included: 58 neonates (<4 weeks), 19 infants (4 weeks to 1 year), 10 children (over 1 year). Median time of follow up was 700 days. The proportion of those requiring long term anti-hypertensives rose the older the child was at the time of first coarctation surgery, being 6.9% in the neonatal group, 26.3% as an infant and 40% if over the age of 1 year. These differences were statistically significant (Chi2 9.83, P = 0.0073). The relative risk of requiring long term anti-hypertension medication if repaired during the neonatal period versus during infancy was 0.26 (95% CI 0.078 to 0.88, P = 00.03), 0.65 (95% CI 0.23 to 1.92, P = 00.44) for repair during infancy versus over 1 year of age, and 0.17 (95% CI 0.051 to 0.58, P = 00.0045) for repair during the neonatal period versus being over 1 year of age. There was no significant difference in the proportion of those developing re-coarctation depending on the age they were first operated, though the prevalence was lowest in the infant age group, 5.3%, versus 22.4% in the neonatal group and 20% in those over 1 year of age.
Conclusion We have demonstrated that the risk of being on long term anti-hypertensive medication if operated on during neonatal period was 74% less compared to being operated on during infancy and 83% less if operated in the neonatal period compared to surgery after the first year of life. Therefore primary surgical repair of coarctation of the aorta to reduce the future risk of hypertension is optimal in the neonatal period. We were unable to demonstrate a significant difference in the prevalence of re-coarctation depending on age of first coarctation repair.
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