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Unformatted text preview: Coarctation of the Aorta
postoperative hypertension noted
beyond the 10th postoperative yr:
-- alive and well and normotensive
-70% at 10 yrs
65% at 15 yrs
20% at 25 yrs.
3 arm leg gradient with exercise average
is 80 mm Hg.
3 SUDDEN DEATH in YOUNG
Maron, et al, Circ 1980 Clinical Findings
3 chest pain
3 mild fatigue
2/29 Circumstances of Death
death during or after severe exertion:
3 death occurred during mild exertion:
3 death occurred during sedentary
3 Causes of Sudden Death
Causes 22 Unequivocal CV dis.
No CV disease 29
29 3 ALCAPA
3 Probable CV Disease
1 Hypoplastic coronaries
(no fiber disarray) Magnitude of the Problem
excluding trauma, cardiac death is the
most frequent cause of sports related
3 5/100,000 have a condition which
predisposes them to sudden death.
3 1/200,000 athletes per yr have sudden
3 ~12 high school ath. die/yr in U.S.
3 Types of Sports
2.9% GOLF<1% Hypertrophic Cardiomyopathy
and Sudden Death
Annual mortality rate 2-4%
3 Mechanism probably acute
dysrhythmia(v.tach, v.fib., asystole)
3 Sudden death most common 10-25 yrs.
3 Peak age is 14 yrs.
3 Approx. 40% occur during ahtletics
3 If there is documented v. tach on
holter,death rate 8%.
3 HCM and Sudden Death
Increased risk of sudden death ass. with:
documented v. tach, family hx. of
sudden death, young age of onset of
Sudden death not related to presence or
degree of outflow gradient.
HAS BEEN SHOWN TO DECREASE
RISK OF SUDDEN DEATH.
RISK Abnormal Origin of CA’s and
Sudden Left CA from right cusp is the most
common cause of sudden death.
3 Potential mechanisms: coronary comes
off tangentially from the aorta, ostium
may be slit like,ostium may be partially
covered by flap valve, initial few mm’m
may be in wall of aorta.
3 97% die at < 22 yrs of age
3 Rule out in pat with exercise chest pain
or syncope . Tx. surgical
3 OTHER CAUSES of SUDDEN
DEATH in ATHLETES
Marfan Syndrome: related to aortic
3 Myocarditis: may be associated with
acute inflammation and chronic
multifocal scarring-- arrthymias
3 Drugs: anabolic steroids predispose to
thrombotic MI, CVA, and
3 Other Causes,
3 Primary dysrhythmias:
a. sudden death reported with SVT,long
b. exercise syncope most common
3 Scale: to identify 1000 atheletes at risk,
200,000 would have to be screened to prevent 1 death.
3 Routine screening by ECHO impractical
3 Routine EKG’s on all athletes probably
3 SMA 1: history and PE
focused hx of syncope, chest
pain, or seizures in patient- always ask
about sudden death in family members
focused PE looking for path.
murmur, gallop, or S4, obvious ectopy
murmur, LONG TERM EXPERIENCE
AFTER CARDIAC SURGERY
3 60% of important CHD:
CoA Long Term Experience,
Surgery for uncommon lesions- has
been available for 25 yrs.
3 These patients are now showing up in
3 RESIDUAE & SEQUELAE of
It ain’t over, til it’s over Surgical Residuae & Sequelae
3 pulm. artery hypertension/ distortion
3 valve regurg
3 Surgical Residuae & Sequelae
3 Systemic right ventricle- TGA
Mustard or Senning
3 Fontan physiology- physiologic
correction with single ventricle chamber
3 Coarction of the Aorta
50-85% incidence of bicuspid Ao valve.
-- Late developement of stenosis/insuf-ficiency.
Associated with calcific changes
-- infective endocarditis
-3 >50% have mitral abnormalities
3 Coarctation of the Aorta
-- intracranial aneurysms
--- late aortic dissection
--- intramural coronary artery disease
-- Coarctation of the Aorta
With dacron onlay patches
-- 38% incidence of aneurysms
-3 Aortic balloon angioplasty
-- incidence of aneurysms unknown
-native vs recoarc. For recoarctation,
balloon is procedure of choice
3 Coarctation of the Aorta
Surgical results; aim for gradient < 10
30-40% have recurrent gradient
when surgery done at less than 1yr.
3 Significant late mortality--10-20% have resting hypertension
This is directly related to age at
surgery.Exercise testing will provock
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- Fall '11