Makindo Medical Notes

Related Subjects: |Aortic Anatomy |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Acute Heart Failure and Pulmonary Oedema |Aortic Regurgitation (Incompetence) |Aortic Stenosis |Aortic Sclerosis |Transcatheter aortic valve implantation (TAVI)

Coarctation of the aorta typically occurs just distal to the origin of the left subclavian artery, so the BP is lower in the legs than in the arms (opposite of the normal situation). Pulses are weaker in the lower than in the upper extremities, so blood pressure should be measured in the legs as well as in both arms. Intercostal collaterals can produce bruits on examination and rib notching on the chest radiograph. Coarctations can be cured with surgery or angioplasty

About

• Narrowing of the aorta
• Developmental defect. 5% of congenital heart disease
• Generalised aortopathy

Associations

• Males x 2-5, Turner's syndrome,
• Bicuspid aortic valve 50%, Berry aneurysms (SAH)

Aetiology

• Shelf like obstruction within the aortic arch
• Usually distal to the left subclavian artery
• Can occur anywhere in the descending aorta
• Extensive arterial collateralisation
• Aorta is stiff and non-compliant

Anatomy

Clinical

• Children may present with heart failure in infancy.
• Weak femoral pulses. Radial-femoral delay.
• Cold legs or feet from reduced circulation.
• Headaches, nosebleeds or upper body hypertension.
• Murmur between shoulder blades is continuous or systolic and reflects aortic blood flow.
• SAH due to Berry aneurysms are seen in about 5% of those with CoA.
• There is a 50 % incidence of bicuspid aortic valves in patients with CoA.
• Risk of aortic dissection

Investigations

• Basic bloods: FBC, U&E, LFT
• ECG: LV hypertrophy
• Echocardiogram: To detect LVHH, bicuspid valves
• MRI/MRA or CTA: is the examination of choice in the older child and adult
• CXR: The reversed "3" appearance is due to the pre and post stenotic dilatation. Rib notching is also seen usually laterally on the inferior surface (where the intercostal vessels are)
• Catheterisation and pressure studies Significant coarctation requires a gradient greater than 20 mmHg across the coarctation site

Complications

• Formation of aortic aneurysms later following repair
• Reformation of the Coarctation - consider stenting
• Coronary artery disease
• Aortic valve disease, Endocarditis

Management

• Medications: To control high blood pressure, especially before and after surgical repair. Hypertension may persist following correction operatively due to resetting of carotid baroreceptors which may be transient post-operatively replaced by activation of the RAA system.
• Surgical repair: Removal of the narrowed segment of the aorta or other surgical techniques to widen the constriction. Usually if Gradient > 30 mmHg.
• Balloon angioplasty and stenting: A minimally invasive procedure where a balloon is used to
• Long-term follow-up: Regular monitoring for recoarctation (re-narrowing) or other complications.

Life Long risks

• Berry aneurysms and SAH. Premature coronary atherosclerosis
• Hypertension, aortic dissection in their 20s