Neurological complications in aortic coarctation: Results of a Nationwide analysis based on 11,907 patients
Trenk L, Lammers AE, Radke R, Baumgartner H, Wort SJ, Gatzoulis MA, Diller GP, Kempny A.
Int J Cardiol. 2020 Aug 14:S0167-5273(20)33568-3. doi: 10.1016/j.ijcard.2020.08.041. Online ahead of print.
Take Home Points:
- In patients presenting for coarctation repair, the rate of spinal injury at the time of primary repair is low – 0.05-0.2%
- Patients with coarctation have a reduced survival rate compared to the general population
- Ongoing neurological complications, mainly in the form of subarachnoid bleeding and ischemic strokes occur in patients with repaired coarctation of the aorta
- Many patients had, at last follow-up, traditional risk factors for atherosclerosis
- Almost 25% had hypertension at last visit
- Subarachnoid bleeds occurred at a median age of 28.6 years
- Ischemic strokes displayed a bimodal peak with the median adult age 56.1 years
- The one-year mortality after a subarachnoid bleed was 16.2 % and post an ischemic infarct was 20%.
- Arterial hypertension (OR 3.75) was an independent risk factor for subarachnoid bleeding and both arterial hypertension (OR 4.10) and smoking (OR 13.46) emerged as independent risk factors for ischemic infarcts.
- This study findings emphasize the need for diligent ongoing care and control of risk factors for patients with repaired coarctation of the aorta
Commentary from Dr. Blanche Cupido (Cape Town, South Africa), section editor of ACHD Journal Watch: Coarctation of the aorta represent 6-8% of congenital heart disease malformations. The timing and mode of clinical presentation depends largely on the severity of the lesion. Neurological complications following surgical or percutaneous have been reported. In this United Kingdom, nationwide retrospective study, the socio-demographic, clinical and surgical data of all patients being hospitalized with a diagnosis of coarctation of the aorta between 1997 and 2015 were reviewed. Data was obtained from the National Health Service Hospital Episode Statistics Database (HES, NHS Digital) using the appropriate search ICD-10 coding for the various diagnoses of interest.
A total of 11 907 patients with coarctation of the aorta were identified. Almost 60% were male. During the period of 1997-2015, 8456 surgical or interventional procedures were performed. For the surgical procedure group, mortality on the same admission amounted to 2.5% (150 of 5905 surgeries) and the intervention mortality 0.3% (8 of 2550 interventions). The first operation was an end-to-end anastomosis in 56.9% of cases (n=2737), a subclavian flap in 12.5% (n=603) and a patch graft in 9.7%(n=469). Four hundred and seventy-two (9.8%) had percutaneous intervention as a first procedure.
Neurological complications related to surgical or percutaneous intervention occurred in 10 patients (0.1% of all procedures): eight hemiplegia, one paralytic syndrome and one upper limb monoplegia. In those patients born after 1997, the neurological complication rate was 0.05% for surgeries and 0.21% for percutaneous interventions. For those with a revision, the complication rate was slightly higher – for a first revision, the surgical neurological complication rate was 0.24%.
Cardiovascular risk factors in this cohort included: arteriosclerotic disease (3.3%), current smoking (5.3%), diabetes (1.7%), hyperlipidemia (3.5%), obesity (1.9%), renal dysfunction 4.3%), SVT’s (4.6%), and arterial hypertension in 24.5%. Subarachnoid bleeds (n=37) and cerebral infarction (lnn= late neurological complications) were seen in 225 patients over a follow-up period of 146 295 patient-years at a rate of 0.15% per year.
Subarachnoid bleeds occurred in 37 patients; the median age was 28.7 years (20.2-44.5 years). All but one had no history of a previously diagnosed cerebral aneurysm. 10.8% died on the same admission and the one year mortality in this complication was 16.2%. When matched for age and gender with those coarctation patients who did not experience a bleed, only arterial hypertension was an independent risk factor for bleeding (OR 3.75, 95% CI 1.25-11.3, p=0.019).
Ischemic stroke occurred in 188 patients with a bimodal age distribution (peak in 1st year of life and then again over age 60). The median age of the adult population was 56.1 years. Index admission mortality was 6.9% and the one year mortality 20%. On multivariate analysis, arterial hypertension (OR 4.10, 95% CI 1.55-10.79, p=0.004) and smoking (OR 13.46 ,95% CI 1.57-115.35), p=0.018) remained adverse risk factors for ischemic stroke.
The Kaplan -Meier curves show the greatest mortality rates are in the first year post-event but it continues to drop off in both cohorts.