Coarctation of the Aorta


Article Author:
Mark Law


Article Editor:
Vijai Tivakaran


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
5/13/2019 11:22:35 PM

Introduction

Coarctation of the aorta is a narrowing of the aorta, most commonly occurring just beyond the left subclavian artery. However, it can occur in various other locations of the aortic arch (proximal transverse) or even in the thoracic or abdominal aorta. The narrowing of the aorta raises the upper body blood pressure, causing upper extremity hypertension. Unrepaired coarctation leads to premature coronary artery disease, ventricular dysfunction, aortic aneurysm/dissection, and cerebral vascular disease by the third or fourth decade of life.[1][2][3]

Etiology

The most common etiology of coarctation of the aorta is constriction of the aorta in the region of the patent ductus arteriosus or ductal ligamentum. The ductal tissue is thought to cause constriction in the adjacent region of the aorta. This narrows the lumen of the aorta. Coarctation also can be more complex and present as aortic arch hypoplasia and as a component of other left-sided heart lesions (mitral stenosis, aortic stenosis, hypoplastic left heart syndrome). Mid-thoracic coarctation can occur with mid-aortic syndromes. Over time, the body compensates by developing collaterals around the coarctation segment.[4]

Epidemiology

Coarctation is found in 6% to 8% of patients with congenital heart disease or approximately 0.06% to 0.08% of the general population. Coarctation of the aorta accounts for a percentage of children diagnosed with systemic hypertension. Patients with Turner syndrome (XO) have an increased risk of left-sided obstructed heart disease that includes isolated coarctation, and karyotype screening is recommended for females with the diagnosis of coarctation. Bicuspid aortic valve is commonly associated with coarctation of the aorta. Offspring and other first-degree relatives diagnosed with an obstructive left-sided cardiac lesion are at ten times the risk of coarctation and other cardiac lesions.[5]

Pathophysiology

Coarctation of the aorta causes an increase in the upper extremity blood pressure, resulting in two common presentations. The first is the neonatal presentation that is associated with left ventricular dysfunction and shock from the neonatal myocardium's intolerance of the sudden increase in afterload that occurs with closure of the ductus arteriosus. This presentation often occurs within the first one to two weeks after birth. In patients with neonatal coarctation evolving while the patent ductus arteriosus is closing, the lower extremity saturation can be low as perfusion to the lower body can be maintained by ductal patency. In the era of lower extremity pulse oximetry screening in newborns, a neonate could often pass with an acceptable saturation as it is less common for the ductus to contribute significantly unless other left heart structures are hypoplastic. The second presentation occurs in older children and adults. Coarctation of the aorta in this scenario results in upper extremity hypertension, leading to early coronary artery disease, aortic aneurysm, and cerebrovascular disease.

History and Physical

The most important physical finding is upper extremity hypertension. In neonates, there can be a history of poor feeding, evidence of shock with poor perfusion, gallop heard on auscultation, and a murmur of mitral regurgitation. In significant coarctation, the femoral and dorsal pedis artery pulsations are difficult to palpate, and there is associated brachiofemoral delay. Upper extremity hypertension is most often present, and four extremity blood pressure measurements should be performed in all children and young adults being evaluated for this condition. In older children, a systolic murmur with diastolic continuation can be heard in the left infrascapular region. This murmur can represent blood flow across the coarctation or through dilated collaterals. A systolic ejection click and systolic ejection murmur in the left upper sternal border is a consistent exam finding with a bicuspid aortic valve. It is very rare in today's era for an adult to present with an aortic dissection or cerebrovascular accident from an undiagnosed coarctation of the aorta.

Evaluation

The EKG in a patient with coarctation can demonstrate increased voltage in the lateral precordial leads consistent with left ventricular hypertrophy. The echocardiogram will demonstrate left ventricular hypertrophy. In neonates, the left ventricular function can be diminished. There also can be mitral regurgitation and left atrial dilation from elevated left atrial pressures. The echocardiogram can demonstrate a narrowing in the aortic arch at the level of the isthmus (just beyond the left subclavian) with Doppler velocities increased in this region, but the arch can also appear hypoplastic. The abdominal aortic pulsations are decreased with diastolic runoff. CT scanning and MRI are useful to provide a detailed anatomy of the aortic arch before and after treatment.[6][7]

Treatment / Management

In a neonate presenting with shock, stabilization should occur first with cardiorespiratory support. Prostaglandin E1 infusion occasionally can open the ductus arteriosus but also seems to relax the tissue of the coarctation segment. Often medical support alone will allow some recovery of ventricular function. The treatment for coarctation of the aorta is to eliminate the narrowed segment. This can be accomplished surgically or via transcatheter techniques. Surgery requires removal of the coarctation segment and direct anastomosis of the normal aorta. The transcatheter technique utilizes balloon and stent angioplasty. Most institutions perform surgery for neonates and small children. Many institutions will perform cardiac catheterization and primary stent angioplasty in adolescents and adults. Balloon angioplasty has been performed in neonates and children. No surgical or interventional technique is a cure for coarctation. In neonates, the risk of recoarctation following surgical intervention is approximately 10%. When recoarctation occurs, balloon angioplasty is advised. There is a lifelong risk of developing an aortic aneurysm, which seems to increase when the treatment is balloon angioplasty alone. Furthermore, even after an intervention, there is an increased risk of developing essential hypertension. There also is an increased risk of cerebral aneurysms in patients with coarctation of the aorta (treated or untreated). For these reasons, patients diagnosed with coarctation of the aorta should seek lifelong follow-up with a congenital heart disease specialist.[8][3][9]

Prognosis

  • Aortic coarctation of the aorta is a lifelong disease, and the long-term prognosis is guarded. Follow up care is vital as recurrence of coarctation and hypertension are not uncommon.
  • These individuals also need prophylaxis for endocarditis if they undergo any invasive procedure.
  • Short-Term who fail to manage hypertension tend to have a worse outcome compared to normotensive individuals.
  • Long-term data are lacking as most patients are lost to follow up. However, the survival is decreased compared to the normal population.
  • Individuals who fail to get the coarctation repaired are usually dead by age 50.

Complications

  • Recurrent coarctation
  • Aortic aneurysm

  • Hypertension

  • Cerebral aneurysm

  • Cardiomyopathy

  • Paralysis

  • Post coarctectomy syndrome

Postoperative and Rehabilitation Care

Once the coarctation is repaired, the patient's blood pressure must be monitored and treated if elevated.

Deterrence and Patient Education

  • Coarctation cannot be prevented but timely referral to a cardiologist for an echo is recommended.
  • The patient should enroll in regular exercise, not smoke and maintain a healthy weight.



Pearls and Other Issues

Follow up for coarctation of the aorta should be lifelong with a congenital heart specialist. Even after effective treatment, the risk of developing hypertension increases. Regardless of the chosen therapy, there is a risk of developing aortic aneurysms, and periodic aorta imaging is required. Aneurysm development is highest after balloon angioplasty alone, but it also is associated with surgical repair and stent implantation. Cerebral imaging could be recommended to screen for aneurysms in adults.

Enhancing Healthcare Team Outcomes

There are many recommendations on the diagnosis and management of aortic coarctation, especially in adult males and females. There is no cure for the disorder and even after treatment, there is a risk of recurrence and development of hypertension. Thus, patients need lifelong follow up with a multidisciplinary group of health professionals including a cardiologist, cardiac surgeon, internist and a critical care consultant. After surgery, the patient must be educated by the nurse and pharmacist on the importance of compliance to blood reassure medications. Regular follow up is vital to ensure that the blood pressure is controlled and the distal pulses are not diminished. The primary care provider must ensure that the patient receives endocarditis prophylaxis when undergoing any type of invasive procedure.[10][11] (Level III)

Outcomes

The short-term outlook for surgically patients with coarctation of the aorta is excellent, but even these patients have a guarded prognosis. Long-term data are not yet available primarily because patients are lost to follow up. Data indicate that in the long-term recurrence of aortic coarctation, hypertension, stroke, paraplegia and adverse cardiac events are not rare. In view of these negative observations, a multidisciplinary team approach is highly recommended to prevent the high morbidity and mortality. [12][13][14] (level III)


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Attributed To: Contributed by chestatlas.com (H. Shulman MD)

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Coarctation of the Aorta - Questions

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A 16-year-old girl has coarctation of the aorta. With which of the following lesions is this most likely associated?



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A bicuspid aortic valve is most likely observed in a patient with what other congenital heart disorder?



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Coarctation of the aorta is typically associated with which of the following?



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A 17-year-old male is seen with elevated blood pressure. He has a significant radial-femoral delay in his pulses. Of the following, what would be found on further investigation?



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Coarctation of aorta is not typically associated with which of the following?



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Hypertensive cerebral hemorrhage is a typical complication of what congenital heart disorder?



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Which of the following is most often associated with bilateral rib notching?



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Coarctation of aorta just distal to the subclavian artery is diagnosed in a one-week-old neonate. There is a drop in blood pressure of 50% distal to the lesion. Which value would be increased in this patient?



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Which of the following is not associated with coarctation of aorta in adults?



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What causes rib notching in people with aortic coarctation?



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A 17-month-old asymptomatic child is found to have a systolic murmur, upper extremity hypertension, and diminished femoral pulses. What feature is typical of this disorder at this age?



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A patient with only upper extremity hypertension may have what condition?



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A 16-year-old girl was found to have coarctation of aorta. Which of the following is likely to be seen in this patient?



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Select the condition that is not a complication of repair of coarctation of aorta.



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Select the biggest concern in a patient with coarctation of aorta who becomes pregnant.



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What complication is not associated with aortic coarctation repair?



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Which is a major potential complication for aortic coarctation in pregnancy?



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An infant is brought to you because the mother thinks his legs are pale while his arms and face are normal in color. On examination you hear a soft systolic murmur over the medial part of the left scapula. Your diagnosis would be:



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A young patient presents with numbness and tingling in both feet. On examination, there is somewhat high blood pressure in the arm arteries and somewhat subnormal blood pressure in the leg vessels. Which congenital condition would be most likely suspect?



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Preductal coarctation of aorta is associated with patent ductus arteriosus. Surgical ligature of the patent ductus in this condition would result in:



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Preductal coarctation of aorta is associated with:



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A neonate born with coarctation of the aorta is found to have very cold extremities and declining urine output. What intravenous medication may help improve perfusion of the body?



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A 4-year-old undergoes elective repair of the below congenital heart disorder with a primary resection and end-to-end anastomosis. The surgery is uncomplicated. On postoperative day 2, the child develops moderate to severe abdominal pain, nausea, and vomiting. A physical exam reveals signs of peritonitis. This complication could have been prevented by which of the following?

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Definitive treatment of aortic coarctation usually involves which of the following?



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Coarctation of the Aorta - References

References

Hoffman JI, The challenge in diagnosing coarctation of the aorta. Cardiovascular journal of Africa. 2017 Dec 11     [PubMed]
Boris JR, Primary-care management of patients with coarctation of the aorta. Cardiology in the young. 2016 Dec     [PubMed]
Beckmann E,Jassar AS, Coarctation repair-redo challenges in the adults: what to do? Journal of visualized surgery. 2018     [PubMed]
Hanneman K,Newman B,Chan F, Congenital Variants and Anomalies of the Aortic Arch. Radiographics : a review publication of the Radiological Society of North America, Inc. 2017 Jan-Feb     [PubMed]
Yetman AT,Starr L,Sanmann J,Wilde M,Murray M,Cramer JW, Clinical and Echocardiographic Prevalence and Detection of Congenital and Acquired Cardiac Abnormalities in Girls and Women with the Turner Syndrome. The American journal of cardiology. 2018 Jul 15     [PubMed]
Kaya U,Colak A,Becit N,Ceviz M,Kocak H, Surgical Management of Aortic Coarctation from Infant to Adult. The Eurasian journal of medicine. 2018 Feb     [PubMed]
Conti L,Borg Savona S,Spiteri T,Degiovanni J,Borg A,Caruana M, Aortic coarctation - never too late to diagnose, never too late to treat. Images in paediatric cardiology. 2017 Jul-Sep     [PubMed]
Wu Y,Jin X,Kuang H,Lv T,Li Y,Zhou Y,Wu C, Is balloon angioplasty superior to surgery in the treatment of paediatric native coarctation of the aorta: a systematic review and meta-analysis. Interactive cardiovascular and thoracic surgery. 2018 Jul 28     [PubMed]
Brzezinska-Rajszys G, Stents in treatment of aortic coarctation and recoarctation in small children. International journal of cardiology. 2018 Jul 15     [PubMed]
Mühler EG,Franke A,Lepper W,Grabitz RG,Herrmann G,Klues HG,Messmer BJ,Hanrath P,von Bernuth G, [The management of adolescents and adults with congenital heart defects: 3 years experiences with interdisciplinary consultation]. Zeitschrift fur Kardiologie. 1995 Jul     [PubMed]
Rajbanshi BG,Joshi D,Pradhan S,Gautam NC,Timala R,Shakya U,Sharma A,Biswakarma G,Sharma J, Primary surgical repair of coarctation of the aorta in adolescents and adults: intermediate results and consequences of hypertension. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2018 Jun 22     [PubMed]
Gurvitz M,Burns KM,Brindis R,Broberg CS,Daniels CJ,Fuller SM,Honein MA,Khairy P,Kuehl KS,Landzberg MJ,Mahle WT,Mann DL,Marelli A,Newburger JW,Pearson GD,Starling RC,Tringali GR,Valente AM,Wu JC,Califf RM, Emerging Research Directions in Adult Congenital Heart Disease: A Report From an NHLBI/ACHA Working Group. Journal of the American College of Cardiology. 2016 Apr 26     [PubMed]
Ramnarine I, Role of surgery in the management of the adult patient with coarctation of the aorta. Postgraduate medical journal. 2005 Apr     [PubMed]
Lala S,Scali ST,Feezor RJ,Chandrekashar S,Giles KA,Fatima J,Berceli SA,Back MR,Huber TS,Beaver TM,Beck AW, Outcomes of thoracic endovascular aortic repair in adult coarctation patients. Journal of vascular surgery. 2018 Feb     [PubMed]

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