Definition
Coarctation of aorta (COA) is the narrowing of the aorta.
Types:
2 Types
1. Postductal (adult type): Below the origin of left subclavian artery, where ductus arteriosus
joins the aorta.
2. Preductal (infantile type, 2%): Above the origin of left subclavian artery.
Causes
• Congenital (most common).
• Rarely, may be acquired in trauma, Takayasu’s disease.
Clinical Features
Symptoms
• More common in male.
• May be asymptomatic.
• Headache, nose bleeding, claudication of lower limbs and cold legs (due to poor blood flow
in lower limbs).
Signs
• BP—High in the upper limb and low in the lower limb.
• Pulse—Normal in upper limb, feeble in lower limb and radiofemoral delay.
Precordium
Inspection
• Visible cardiac impulse.
• Visible dilated tortuous artery around the scapula, anterior axilla and over the left sternal
border (due to collateral vessels).
Palpation
• Heaving Apex beat.
• There may be thrill over the collateral vessels.
Auscultation
• Both first and second heart sounds—normal.
• Murmur—systolic murmur audible close to the sternum and better heard in 4th intercostal
space posteriorly (site of coarctation).
Investigations
1. X-ray of chest P/A view—
–– Heart is enlarged.
–– Rib notching.
–– Figure of ‘3’ (constriction at coarctation, prestenotic and poststenotic dilatation).
2. ECG (LVH).
3. Echocardiogram.
4. CT scan and CMR.
Reverse Coarctation
When pulse is absent in upper limb, but present in lower limb, it is called reverse coarctation.
It occurs in Takayasu’s disease.
Complications of Coarctation of Aorta
• Hypertension and its complication (LVF, CVA).
• Infective endocarditis.
• Rupture at the coarctation site.
• Dissecting aneurysm.
• Aneurysm of aorta.
• Subarachnoid haemorrhage (rupture of Berry aneurysm of circle of Willis).
Causes of Death
• Acute LVF.
• Dissecting aneurysm of aorta.
• Subarachnoid haemorrhage.
• Cerebral haemorrhage.
Treatment of Coarctation of Aorta
It should be treated surgically as early as possible, preferably before the age of 5.
• Surgical resection and end to end anastomosis is usually done.
• If coarctation is extensive—prosthetic vascular graft may be done.
• If surgery is done in early childhood, hypertension usually resolves completely but if done
in adolescence or adulthood, hypertension may persist in 70% cases, because of irreversible
changes in arterioles or renal damage.
• Balloon angioplasty may be helpful. It is particularly effective after restenosis.
Prognosis after Surgery
• Surgical correction in childhood—25-year survival is 83%. But if delayed until adulthood,
25-year survival rate drops to 75%. Without surgery, only 25% live up to 50 years of age, while
cardiac failure occurs in two-thirds of surviving patients over 40.
• In few cases, there is restenosis as the child grows. This can be treated by balloon angioplasty.
• If operation is delayed, patient may have persistent hypertension because of irreversible changes in the arterioles.
• May develop paradoxical hypertension, due to baroreceptor-induced increased sympathetic activity (detected by increased serum and urinary catecholamines).
• Coexistent bicuspid aortic valve is present in 50% cases, may lead to progressive aortic stenosis
or regurgitation.