Repaired coarctation of the aorta, persistent arterial hypertension and the selfish brain

J Cardiovasc Magn Reson. 2019 Nov 7;21(1):68. doi: 10.1186/s12968-019-0578-8.

Abstract

Background: It has been estimated that 20-30% of repaired aortic coarctation (CoA) patients develop hypertension, with significant cardiovascular morbidity and mortality. Vertebral artery hypoplasia (VAH) with an incomplete posterior circle of Willis (ipCoW; VAH + ipCoW) is associated with increased cerebrovascular resistance before the onset of increased sympathetic nerve activity in borderline hypertensive humans, suggesting brainstem hypoperfusion may evoke hypertension to maintain cerebral blood flow: the "selfish brain" hypothesis. We now assess the "selfish brain" in hypertension post-CoA repair.

Methods: Time-of-flight cardiovascular magnetic resonance angiography from 127 repaired CoA patients (34 ± 14 years, 61% male, systolic blood pressure (SBP) 138 ± 19 mmHg, diastolic blood pressure (DBP) 76 ± 11 mmHg) was compared with 33 normotensive controls (42 ± 14 years, 48% male, SBP 124 ± 10 mmHg, DBP 76 ± 8 mmHg). VAH was defined as < 2 mm and ipCoW as hypoplasia of one or both posterior communicating arteries.

Results: VAH + ipCoW was more prevalent in repaired CoA than controls (odds ratio: 5.8 [1.6-20.8], p = 0.007), after controlling for age, sex and body mass index (BMI). VAH + ipCoW was an independent predictor of hypertension (odds ratio: 2.5 [1.2-5.2], p = 0.017), after controlling for age, gender and BMI. Repaired CoA subjects with VAH + ipCoW were more likely to have difficult to treat hypertension (odds ratio: 3.3 [1.01-10.7], p = 0.049). Neither age at time of CoA repair nor any specific repair type were significant predictors of VAH + ipCoW in univariate regression analysis.

Conclusions: VAH + ipCoW predicts arterial hypertension and difficult to treat hypertension in repaired CoA. It is unrelated to age at time of repair or repair type. CoA appears to be a marker of wider congenital cerebrovascular problems. Understanding the "selfish brain" in post-CoA repair may help guide management.

Journal subject codes: High Blood Pressure; Hypertension; Magnetic Resonance Imaging (MRI); Cardiovascular Surgery; Cerebrovascular Malformations.

Keywords: Circle of Willis; Coarctation; Hypertension; Vertebral artery.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aortic Coarctation / complications
  • Aortic Coarctation / physiopathology
  • Aortic Coarctation / surgery*
  • Arterial Pressure*
  • Cardiac Surgical Procedures / adverse effects*
  • Central Nervous System Vascular Malformations / complications*
  • Central Nervous System Vascular Malformations / diagnostic imaging
  • Central Nervous System Vascular Malformations / physiopathology
  • Cerebrovascular Circulation*
  • Circle of Willis / abnormalities
  • Circle of Willis / diagnostic imaging
  • Circle of Willis / physiopathology*
  • Databases, Factual
  • Female
  • Humans
  • Hypertension / diagnosis
  • Hypertension / etiology*
  • Hypertension / physiopathology
  • Magnetic Resonance Angiography
  • Male
  • Middle Aged
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Treatment Outcome
  • Vertebral Artery / abnormalities
  • Vertebral Artery / diagnostic imaging
  • Vertebral Artery / physiopathology*
  • Young Adult