Aortic Coarctation With Extensive Collateral Circulation

HomeCirculation: Cardiovascular ImagingVol. 11, No. 8Aortic Coarctation With Extensive Collateral Circulation Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBAortic Coarctation With Extensive Collateral CirculationA Not-to-Miss Diagnosis for Arterial Hypertension Violeta González-Salvado, MD, Pablo Bazal, MD and Rafael Alonso-González, MD Violeta González-SalvadoVioleta González-Salvado Violeta González-Salvado, MD, Cardiology Department, University Clinical Hospital of Santiago, A Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain. E-mail E-mail Address: [email protected] Cardiology Department, University Clinical Hospital of Santiago, Santiago de Compostela, A Coruña, Spain (V.G.-S.). , Pablo BazalPablo Bazal Cardiology Department, University Hospital of Navarra, Pamplona, Spain (P.B.) and Rafael Alonso-GonzálezRafael Alonso-González Adult Congenital Heart Disease Unit, Cardiology Department, Royal Brompton Hospital, London, United Kingdom (R.A.-G.). Originally published17 Aug 2018https://doi.org/10.1161/CIRCIMAGING.118.007918Circulation: Cardiovascular Imaging. 2018;11:e007918IntroductionA 21-year-old asymptomatic male was incidentally diagnosed with systemic hypertension on a routine assessment performed by the rugby medical team. Physical examination revealed regular heart rate at 70 beats per minute, an ejection systolic click, and significant radio-femoral pulse delay. Blood pressure was measured on both left and right arms and on the right leg, showing values of 158/94 mm Hg, 148/94 mm Hg, and 120/82 mm Hg, respectively. Blood tests and chest radiography were initially performed to investigate secondary causes of arterial hypertension and treatment with ramipril was initiated.Blood tests revealed no significant abnormalities. Chest radiography showed normal heart silhouette and rib notching (Figure 1). Transthoracic echocardiogram was performed, demonstrating a peak gradient across the thoracic descending aorta of 20 mm Hg, with significant diastolic tail and continuous flow in the abdominal aorta. Cardiac magnetic resonance confirmed severe discrete coarctation of the aorta at the level of the aortic isthmus (<3 mm) and revealed extensive compensatory collateral circulation (Figure 2 and Movie I in the Data Supplement). There was a bicuspid aortic valve with mildly dilated aortic root and ascending aorta. Right and left ventricles were of normal size and function, with mild left ventricular concentric hypertrophy.Download figureDownload PowerPointFigure 1. Chest radiography shows rib notching of the posterior third to eighth ribs, related to collateral blood flow through the intercostal arteries.Download figureDownload PowerPointFigure 2. Cardiac Magnetic Resonance shows severe coarctation at the level of the aortic isthmus and extensive thoracic and abdominal collateral circulation.Coarctation of the aorta is a common malformation (4/10 000 live births) to be ruled out in this setting.1 Early diagnosis and timely intervention are paramount to prevent further complications. Symptoms are generally absent but careful physical examination, including proximal and distal pulse palpation and blood pressure measure, may lead to the diagnosis. Although echocardiography and cardiac magnetic resonance are the diagnostic techniques of choice for initial assessment and follow up, simple chest radiography may already raise suspicion, as in our case. Rib notching is more common, when collateral vessels are well developed than the 3-sign, which is caused by indentation at the site of coarctation with prestenotic dilatation of the aortic arch and left subclavian artery.Intervention is indicated in all patients with supine arm-to-leg noninvasive blood pressure gradient >20 mm Hg and radiological evidence of coarctation of the aorta (≥50% aortic narrowing relative to the diaphragmatic aortic diameter) with or without significant collateral flow. Intervention might be considered in patients with upper limb hypertension even in the absence of significant blood pressure gradient, in the presence of significant left ventricular hypertrophy or hypertensive response to exercise.1,2 Percutaneous repair is feasible in most of the adult patients with coarctation of the aorta, with an excellent long-term outcome. Based on our patient's preferences, percutaneous intervention was delayed until the end of the university academic year, 3 months after diagnosis.DisclosuresNone.Footnoteshttps://www.ahajournals.org/journal/circimagingThe Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.118.007918.Violeta González-Salvado, MD, Cardiology Department, University Clinical Hospital of Santiago, A Choupana s/n, 15706 Santiago de Compostela, A Coruña, Spain. E-mail [email protected]comReferences1. Dijkema EJ, Leiner T, Grotenhuis HB. Diagnosis, imaging and clinical management of aortic coarctation.Heart. 2017; 103:1148–1155. doi: 10.1136/heartjnl-2017-311173CrossrefMedlineGoogle Scholar2. Baumgartner H, Bonhoeffer P, De Groot NM, de Haan F, Deanfield JE, Galie N, Gatzoulis MA, Gohlke-Baerwolf C, Kaemmerer H, Kilner P, Meijboom F, Mulder BJ, Oechslin E, Oliver JM, Serraf A, Szatmari A, Thaulow E, Vouhe PR, Walma E; Task Force on the Management of Grown-up Congenital Heart Disease of the European Society of Cardiology (ESC); Association for European Paediatric Cardiology (AEPC); ESC Committee for Practice Guidelines (CPG). ESC Guidelines for the management of grown-up congenital heart disease (new version 2010).Eur Heart J. 2010; 31:2915–2957. doi: 10.1093/eurheartj/ehq249CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jiang Q, Du J, Yu T, Huang X, Zuo M and Huang K (2022) Ascending Aortic Aneurysm and Dissection Secondary to Bicuspid Aortic Valve with Concomitant Coarctation of Descending Aorta Successfully Repaired with Extracorporeal Membrane Oxygenation Support: A Case Report, Cardiology Discovery, 10.1097/CD9.0000000000000041, 2:2, (124-126), Online publication date: 1-Jun-2022. August 2018Vol 11, Issue 8 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.118.007918PMID: 30354495 Originally publishedAugust 17, 2018 Keywordspatientsaortic coarctationhypertensionblood pressurecollateral circulationPDF download Advertisement