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Unmasking the borderline coarctation: the utility of isoproterenol in the paediatric cardiac catheterisation laboratory

Published online by Cambridge University Press:  14 March 2018

Neil D. Patel ,
Patrick M. Sullivan ,
Cheryl M. Takao ,
Sarah Badran ,
Joseph Ahdoot  and
Frank F. Ing
Neil D. Patel
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Patrick M. Sullivan
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Cheryl M. Takao
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Sarah Badran
Affiliation:
Division of Pediatric Cardiology, Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
Joseph Ahdoot
Affiliation:
Children’s Hospital Los Angeles, Pacific Pediatric Cardiology Medical Group, Los Angeles, CA, USA
Frank F. Ing*
Affiliation:
Divison of Pediatric Cardiology, University of California Davis Children’s Hospital, Sacramento, CA, USA
*
Author for correspondence: F. F. Ing, MD, Chief, Division of Pediatric Cardiology, Department of Pediatrics, UC Davis Health, 2516 Stockton Blvd, Rm. 2208, Sacramento, CA 95817, USA. Tel: +281 768 9509; Fax: 916 734 5533; E-mail: frankfing@gmail.com
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Abstract

Background

One indication for intervention in coarctation of the aorta is a peak-to-peak gradient >20 mmHg. Gradients may be masked in patients under general anaesthesia and may be higher during exercise. Isoproterenol was given during cardiac catheterisation to simulate a more active physiologic state.

Objectives

We aimed to describe the haemodynamic effects of isoproterenol in patients with coarctation and the impact of intervention on the elicited gradients.

Methods

A retrospective study was performed on two-ventricle patients who underwent cardiac catheterisation for coarctation with isoproterenol testing.

Results

25 patients received isoproterenol before and after intervention. With isoproterenol, the mean diastolic (p=0.0015) and mean arterial (p=0.0065) blood pressures proximal to the coarctation decreased significantly. The mean systolic, diastolic, and mean arterial blood pressures distal to the coarctation decreased significantly (p<0.0001). In patients with a baseline gradient ⩽20 mmHg (n=17) at catheterisation, the median gradient increased from 10 (0–20) to 30 (15–50) mmHg (p<0.0001) with isoproterenol. Of these, 15 patients developed a gradient >20 mmHg. Post intervention, the median gradient decreased to 2 (0–29) mmHg, versus baseline, p=0.005, and with isoproterenol it decreased to 8 (0–27) mmHg, versus pre-intervention isoproterenol, p<0.0001. There were significant improvements in the gradients by Doppler (<0.0001) and by blood pressure cuff (p=0.0313). The gradients on isoproterenol best correlated with gradients by blood pressure cuff in the awake state (R2=0.76, p<0.0001).

Conclusions

Isoproterenol can be a useful tool to assess the significance of a coarctation and the effectiveness of an intervention. Percutaneous interventions can effectively reduce the gradients elicited by isoproterenol.

Keywords

Coarctationisoproterenolexercise testingstent
Type
Original Articles
Information
Cardiology in the Young , Volume 28 , Issue 6 , June 2018 , pp. 804 - 810
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Copyright
© Cambridge University Press 2018 

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