Exercise stress echocardiography in coarctation of the aorta

Abstract

Introduction

Aortic coarctation (COA) is frequent congenital heart disease. It can be difficult to assess the indication for intervention or re-intervention in some cases.

Exercise stress echocardiography (ESE) can be helpful for hemodynamic evaluation in patients with COA or reCOA.

Objective

We aimed to determine ESE parameters predictive of intervention (angioplasty or surgery).

Methods

We retrospectively reviewed 94 ESE performed in children (n = 14) and adults with native or repaired CoA and unclear indication for intervention in three centers in France.

Exercise test was performed concomitantly to echocardiography on the e-bike in semi-lying position. The protocol was adapted according to the age and the physical condition. Echocardiography protocol included left ventricular adaptation (LVA) to effort and peak systolic gradient (PSG) at isthmus and appearance of diastolic tail during effort.

We investigated risk marker associated with subsequent indication for intervention.

Results

Median age (min–max) was 26 years (10–72). Intervention was subsequently performed in thirteen patients (14.7%).

Fifty-six patients (60.2%) had simple COA and 37 (39.8%) had complex anatomy, 24 (25%) had hypertension. Poor LVA was present in 13 (14%). Diastolic tail during effort appeared in 65 cases. The mean pic isthmus gradient 50 ± 21 mmHg (min: 15; max: 124).

Poor LVA was associated with more interventions (log-rank, P = 0.004) (Fig. 1).

On univariate analysis presence of antihypertensive drugs (HR: 4.13, 95% CI [1.35–12.65]; P = 0.013), systolic blood pressure at rest (HR: 1.04, 95% CI [1.011–1.072]; P = 0.007); the lower exercise power (Watts) (HR: 0.98; 95% CI [0.96–0.99]; P = 0.001); poor LVA (HR: 5.95, 95% CI [1.56–22.65]; P = 0.009); peak systolic gradient at rest and on effort at isthmus (HR: 1.06, 95% CI [1.03–1.10] and HR: 1.04, 95% CI [1.02–1.06]) were significantly predictive of interventions (Table 1).

Conclusion

ESE is a useful tool for hemodynamic evaluation of COA. More severe forms that needed intervention showed less well adaption of the LV to effort and increase in the cardiac output and afterload.