Aortic "recoarctation" at rest versus at exercise in children as evaluated by stress Doppler echocardiography after a "good" operative result

The mechanism for exercise systolic hypertension after a "good" operative repair of coarctation of the aorta remains speculative. Twenty-four children (mean age ± SD 10.3 ± 3.8 years) were studied with continuous-wave Doppler echocardiography while they performed continuous, graded, maximal treadmill exercise. Patients were free of "recoarctation" based on conventional resting echocardiography. Measurements of ascending and descending aortic peak instantaneous systolic velocity were obtained at rest, throughout exercise and during recovery. Results were compared with 24 age- and gender-matched control subjects. Fifteen patients were normotensive (group 1) (peak systolic Mood pressure, 147 ± 21 mm Hg) and 9 developed systolic hypertension during exercise (group 2) (196 ± 32 mm Hg) (p < 0.05) (control subjects, 143 ± 21 mm Hg). Descending aortic peak systolic velocity at rest ranged from 1.50 ± 0.27 m/s in the control group to 2.57 ± 0.57 m/s (group 1) and 2.93 ± 0.43 m/s (group 2) (p < 0.05, group 2 vs control). Differences were amplified at peak exercise with systolic velocity increasing to 4.26 ± 0.61 m/s in group 2 but only to 3.61 ± 0.70 m/s in group 1 and 2.26 ± 0.38 m/s in control subjects (p < 0.05, group 2 vs group 1 and control). Seven patients developed a descending aortic diastolic velocity during exercise. Stepwise linear regression analysis identified 2 variables to be significant determinants of peak exercise systolic blood pressure in the "total" patient group: (1) age at exercise testing, and (2) descending aortic peak systolic velocity at peak exercise (r² = 0.88, p < 0.001) (group 2, alone - r² = 0.98, p < 0.001). Stress Doppler echocardiography therefore suggests that residual structural/ functional aortic arch defects may be responsible for exercise hypertension in children thought to have a "successful" coarctation repair by conventional resting assessment.