Arrhythmic and thromboembolic outcomes in adults with coarctation of the aorta

https://doi.org/10.1016/j.ijcard.2023.05.050Get rights and content

Highlights

  • Atrial arrhythmia occurs at a greater rate in adults with aortic coarctation.

  • Increasing age and intracardiac interventions are associated with atrial arrhythmia.

  • Strokes develop at younger ages in adults with aortic coarctation.

  • Larger studies are required to better characterize risk factors for stroke.

Abstract

Background

Adults with congenital heart disease (ACHD) experience a high prevalence of atrial arrhythmia (AA) and thromboembolic cerebrovascular complications. However, data on AA and associated long-term outcomes are limited in ACHD patients with coarctation of the aorta (CoA).

Objectives

This study aimed to characterize the prevalence and risk factors for AA and thromboembolic complications in adults with CoA.

Methods

We conducted a retrospective cohort study in a tertiary ACHD care center and included consecutive CoA patients older than 18 years old with more than one year of follow-up.

Results

Two hundred seventy patients with CoA were followed for 7.2 ± 3.95 years. The mean age was 35.3 ± 11.1 and 55.2% were male. Patients had a mean of 2.1 ± 1.8 cardiovascular surgical or transcatheter procedures. Thirty-five patients (13%) had AA. Ten subjects (3.8%) had a thromboembolic cerebrovascular event, of which four (1.4%) had AA. In univariate analysis, age (p = 0.005) and total intracardiac interventions (p = 0.007) were associated with the presence of AA. Age (p = 0.021), history of heart failure (p = 0.022), and dyslipidemia (p = 0.019) were associated with thromboembolism. In multivariate analysis, age (p < 0.001) and intracardiac interventions (p = 0.007) were associated with AA.

Conclusions

The rate of AA is higher in adults with CoA than in the general population but lower than in other ACHD. Increasing age and intracardiac interventions were associated with AA. The rate of thromboembolic events was low. Some traditional risk factors for stroke may apply. Larger studies are needed to validate predictors for stroke in this population.

Introduction

Coarctation of the aorta (CoA) constitutes 6–8% of congenital heart disease, with an incidence of approximately one per 2500 live births [1]. Definitive treatment of CoA with a surgical or catheter-based repair is the standard of care in children, with most patients surviving adulthood [2]. In adults with congenital heart disease (ACHD), CoA stent placement is an alternative option [3].

Stroke is a devastating complication in patients with CoA. Ischemic and hemorrhagic strokes occur at significantly younger age than in the general population [4]. Stroke may be multifactorial in the CoA cohort, with hypertension, intracranial aneurysm, and atrial arrhythmia (AA) as possible confounding factors. Patients with CoA have a higher prevalence of intracranial aneurysms (5.7%), prompting routine screening [5,6]. Hypertension, which is present in 35–68% of CoA patients, can also increase the risk of coronary artery disease, contributing to long-term mortality [[7], [8], [9], [10]].

AA and thromboembolic cerebrovascular events are highly associated with complex ACHD, especially following tetralogy of Fallot repair, atrial switch procedures, and the Fontan procedure. However, AA has not been well studied in the context of CoA [[11], [12], [13], [14]]. Improving our understanding of CoA complications will help reduce overall morbidity and mortality in this subgroup of ACHD [3].

We aimed to determine the prevalence and risk factors associated with AA and cerebrovascular thromboembolic events in ACHD with CoA.

Section snippets

Study population

We conducted a retrospective cohort observational study on patients aged 18 years or older with CoA at the Pacific Adult Congenital Heart Clinic in St. Paul's Hospital in Vancouver, British Columbia, Canada. Patients with at least one year of longitudinal follow-up were included.

Ethical considerations

Ethics approval was obtained through the University of British Columbia Providence Health Care Research Ethics Board to conduct the study. Informed consent for the use of data on patient characteristics was documented

Sample demographics

270 patients with CoA (20.7% isolated CoA) were identified from the database, as summarized in Fig. 1. The mean age of the group was 35.3 ± 11.1 years. 55.2% were male. 87.4% had surgical repair as the initial procedure for CoA, 7.4% had catheter-based treatment, and 5.2% had no intervention for CoA. Patients had a mean of 2.1 ± 1.8 cardiovascular surgical or transcatheter procedures. (Table 1).

26 patients were on oral anticoagulation at the time of their last clinic visit, of which 25 were on

Discussion

Our study examined the prevalence and risk factors for AA and thromboembolic events in patients with CoA. 13% of our CoA patients had AA, higher than 0.95% in the general population but lower than 20.1% with Tetralogy of Fallot or 30.2% post-Fontan operation [[11], [12], [13]]. The increasing incidence of AA with age in CoA is consistent with the trend in the general population [13,15]. The association between left atrial dilation, mitral valve prolapse, and atrial arrhythmia documented in our

Conclusions

Our study explored the prevalence and predictors associated with AA and thromboembolism in adult patients with repaired CoA. AA was more prevalent than in the general population but less than in other cohorts with complex congenital heart disease. Increasing age and total intracardiac interventions correlated with AA. The risk of AA significantly increases in patients with CoA after 50 years of age. Therefore, proactive screening for AA should be considered in older CoA patients. More extensive

Grant support

None.

Conflicts of interest

The authors report no relationships that could be construed as a conflict of interest.

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    This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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