[Relationship between aortic arch shape and blood pressure response after coarctation repair]. / Relation entre l'architecture de la crosse aortique et la pression artérielle après cure de coarctation.

The mechanisms of secondary hypertension after repair of coarctation of the aorta are not well understood. Abnormalities of the architecture of the aortic arch and their consequences on blood pressure have not been studied. In order to study the relationship between abnormalities or aortic arch architecture and resting blood pressure ninety-four patients without re-coarctation were followed up prospectively from 1997 to 2004 (mean age 16.9 +/- 8.1 years; mean weight 57.5 +/- 18.3 Kg; interval since surgery 16.3 +/- 5.4 years). All underwent MRI angiography of the thoracic aorta which enabled the abnormalities to be classified in 3 groups: gothic arch, crenellated arch and roman arch. Twenty-four patients (25.5%) were hypertensive and 70 (74.4%) normotensive. There were 40 gothic arches (42.5%). 14 crenellated arches (15%) and 40 roman arches (42.5%). Gothic arches were more commonly observed in the hypertensive patients (18/40, [45%, 95% CI 31-62]) than the crenellated arches (4/14, [28.5%, 95% CI 7-48]) or the roman arches (2/40, [5%, 95% CI 2-12]). Only the gothic arch was independently correlated with hypertension on multivariate analysis. The authors conclude that gothic deformation of the aortic arch is an independent predictive factor of hypertension in patients operated for coarctation with an excellent result on the isthmic region. Patients with a gothic appearance of their aortic arch should be followed up closely.

[Operated and unoperated coarctation of the aorta in the adult]. / Les coarctations de l'adulte, opérées ou non.

The common denominator of patients operated for isthmic coarctation of the aorta in childhood who reach adulthood, is the risk of hypertension which is observed in about 70% of cases with its cortege of cerebral and coronary vascular complications or left ventricular hypertrophy, which considerably reduce life expectancy. Systematic follow-up of these patients includes, in addition to clinical and echocardiographic examination, three essential investigations: exercise stress testing, the study of arterial mechanics and angio MRI. Hypertension on exercise is observed in 70% of patients of whom 21% have critical hypertension despite excellent anatomical correction. Vascular study shows changes in arterial eactivity and endothelial function independent of the age at operation: MRI often demonstrates aortic irregularities which partially explain the hypertension. Three therapeutic choices are available: in cases of restenosis, balloon angioplasty with or without stenting gives good results: when hypoplasia of the aorta is observed, a surgical repair is recommended: otherwise, pharmacological treatment with life style adaptation including carefully managed physical exercise is appropriate. Coarctation diagnosed in adulthood is rare but poses special problems. Treatment by angioplasty is possible but is complicated by aneurysms of the isthmus in 20% of cases so that nowadays surgery is the treatment of choice. This is difficult and dangerous because of the collateral circulation, the fragility of the aorta and the risk of medullary ischaemia. Resection-anastomosis is the most effective technique with or without cardiopulmonary bypass, reducing the hypertension in 70% of cases.

[Aptitude for sports in children operated on for aortic coarctation. Contribution of the exercise test]. / Aptitude au sport des enfants opérés de coarctation de l'aorte. Apport de l'épreuve d'effort.

Pronouncing on the fitness of children operated upon for coarctation of the aorta to practise sports, as well as on the nature and level of this activity, depends, to a great extent, upon their blood pressure profile at exercise (BPE) as measured by an exercise test on an ergometric bicycle. We studied thi profile in 43 children aged 11.7 +/- 2.5 years who had undergone surgery for coarctation of the aorta (isolated in 93 p. 100 of the cases) at the age of 3.8 +/- 3.2 years Systolic arterial pressure (SAP) in the upper limbs was normal at rest in 80p. 100 of the children but reached abnormal values at exercise in 81 p. 100 and even exceeded 200 mmHg in 16 p. 100. Diastolic arterial pressure (DAP) in the upper limbs was sometimes slightly elevated at rest, but it clearly decreased at exercise and became normal in all cases. This suggested that systolic hypertension at exercise was due to low peripheral resistance and either to an exercise-induced isthmic gradient or to a poor vascular impedance. As a result of this study, we warn such children against playing sports with a strong static stress (e.g. martial sports) or with a risk of thoracic trauma (e.g. rugby). For the other sports, we make no reservation when the BPE is normal, and we forbid competitions when the BPE is abnormal but the SAP at exercise remains below 200 mmHg. Beyond this value, children must be investigated for residual coarctation of the aorta which may be amenable to a specific treatment.

[Development of aortic valve stenosis in infants and children. Apropos of 66 cases hospitalized from 1973 to 1984]. / Evolution des sténoses aortiques valvulaires du nourrisson et de l'enfant. A propos de 66 cas hospitalisés de 1973 à 1984.

Sixty-six children aged over 6 months hospitalized for isolated aortic valve stenosis without cardiac failure but with a transvalvar systolic pressure gradient of more than 40 mmHg were followed up and re-evaluated for a mean period of 5.4 +/- 3.5 years. Twenty-two children who were asymptomatic, had no ST-T changes and had a less than 60 mmHg gradient were not operated upon; they remained stable over a mean period of 5.4 +/- 3.4 years; their gradient was not significantly modified (53 instead of 51 mmHg) and none of them underwent surgery. Forty-four children with symptoms and/or a more than 60 mmHg gradient underwent valvotomy under extracorporeal circulation without mortality. Surgery was effective against the major symptoms in all cases, and it reduced the gradient from 75 +/- 25 to 36 +/- 18 mmHg at the expense of aortic regurgitation in 7 cases, 2 of them with significant haemodynamic repercussions. During the follow-up period (5.8 +/- 3.7 years) 1 patient died of bacterial endocarditis, 5 were reoperated upon (with prosthesis in 4) without mortality and with 4 good results, and 1 patient underwent valvoplasty which proved partially effective but resulted in moderate aortic regurgitation. All other children are now doing well; 29 are completely asymptomatic and without ST-T changes at rest or during exercise. We conclude that aortic valve stenoses with moderate gradient are very stable at mid-term and that surgical valvotomy is a generally effective and low-risk procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of the systolic pressure of the right ventricle by echocardiographic study of left ventricular geometry]. / Estimation de la pression systolique du ventricule droit par l'étude échocardiographique de la géométrie ventriculaire gauche.

Right ventricular systolic pressure is an important parameter in paediatric cardiology. A critical haemodynamic situation is attained if it exceeds the systemic pressure: strain proximal to severe pulmonary stenosis or the result of pulmonary hypertension. In these circumstances, the patient must be closely followed up at the least, and appropriate treatment, often surgical, has to be instituted. Ambulatory methods of assessing this parameter are either unreliable, like the surface electrocardiogram, or relatively complex, like certain ultrasonic methods. We therefore looked for a method relating the systolic pressures of the two ventricles and the end systolic geometry of the left ventricle as assessed simply from a short axis view of the left ventricle at the level of the junction between the chordae and papillary muscles. Two orthogonal diameters are measured and the ratio of the two dimensions calculated: this ratio which we call the "septal curvature" reflects left ventricular compression by the pressure that the right ventricle exerts through the interventricular septum. Seventy-two children aged 6 hours to 18 years (average 5.2 years) hospitalised for pre or post-operative investigation of congenital heart disease were evaluated by this method. The results were compared by statistical analysis with the ratio of ventricular pressures measured directly almost simultaneously during cardiac catheterisation. In general, a linear relation was observed between septal curvature (x) and ratio of pressures (y); y = 0.88, x - 0.63 and R = 0.92.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular function and cardiovascular adaptation to exercise in young sportsmen]. / Fonction ventriculaire gauche et adaptation cardiovasculaire à l'effort du jeune sportif.

In order to find out whether the expression "sports heart" can be used in children and if so, to give an objective definition of it, we studied a group of 40 young people (mean age 12.2 +/- 1.6 years) subjected to intensive training and practising sports regularly, i.e. about 12 hours of physical activity per weeks on average. The sports practised were mainly tennis among boys and ice-skating among girls. A group of 40 subjects with similar characteristics but no particular physical training was studied simultaneously and served as control. These 80 young people had normal heart structure. All underwent routine cardiovascular examinations (physical, radiological, electrocardiographic), complete one - and two - dimensional echocardiography to evaluate left ventricular function and an exercise-test on ergometric bicycle. No difference was found between the left ventricle of sportsmen and that of controls; in particular, there was neither dilatation nor parietal thickening in sportsmen, so that all functional values were the same. During exercise-tests sportsmen performed better than controls, with significantly longer duration of effort and greater maximal oxygen consumption. However, heart rate at rest, then during exercise and recovery, and variations in systolic blood pressure during exercise and in the 10 minutes which followed were identical in both groups. The only notable difference was a deeper fall in diastolic blood pressure in sportsmen, indicating a better opening of the peripheral vascular bed during exercise. It is concluded that there are few cardiovascular differences between trained sporting children and children with normal physical activity, probably because the relatively short training undergone does not leave sufficient time for most of the adaptation systems to become established.