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Aortic Coarctation

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Khaled Ghanem, M.D * * * * * * * * * * * * * * * * * * * Aim of the Presentation Define the disease and the classifications Mention the epidemiology Discuss the ... – PowerPoint PPT presentation

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Title: Aortic Coarctation


1
Aortic Coarctation
  • Khaled Ghanem, M.D

2
Aim of the Presentation
  • Define the disease and the classifications
  • Mention the epidemiology
  • Discuss the etiology
  • Discuss the diagnostic approach and differential
    diagnosis
  • Discuss the treatment approach
  • Discuss the recommended follow-up and possible
    complications
  • Prevention?

3
Definition
  • Narrowing of the aorta
  • Mostly at side of DA insertion (juxtaductal)
  • Less like preductal, abdominal or infrarenal
  • 6-8 of CHD Am J Med Genet A. 2005134A180-186.
  • Males gt females
  • Mostly sporadic but could be familial Am J Med
    Genet A. 2005134A171-179.
  • Could be associated with others sydromes or CHD

4
Etiology
  • Incompletely understood
  • ? blood flow to the CoA site in the fetal life ?
    under-development
  • Ductal tissue extends into the thoracic aorta,
    and, when the ductus arteriosus constricts and
    closes postnatally, the thoracic aorta is
    constricted. Am J Cardiol. 197230514-525

5
Etiology
6
Diagnostic Approach
  • History and examination
  • Diagnostic tests
  • Differential diagnosis

7
Diagnostic Approach
  • History and examination
  • Diagnostic tests
  • Differential diagnosis

8
History and examination
Diagnostic factors Risk factors
Common Strong
presence of risk factors hypertension presenting at a young age or resistant to treatment diminished lower extremity pulses differential upper and lower extremity BPs systolic ejection murmur male young age Turner's syndrome DiGeorge's syndrome hypoplastic left heart syndrome Shone's complex PHACE syndrome
Uncommon Weak
claudication headache systolic ejection click Positive family history
9
Diagnostic Approach
  • History and examination
  • Diagnostic tests
  • Differential diagnosis

10
Diagnostic Tests
1st tests to order 1st tests to order
Test Result
Echocardiogram discrete narrowing in the thoracic aorta pressure gradient across narrowing
CXR age and severity dependent may be normal, have cardiomegaly, or show posterior rib notching
ECG may be normal show RVH or LVH
11
Diagnostic Tests
Tests to consider Tests to consider
Test Result
CT angiography abnormal anatomy of aortic arch
magnetic resonance angiography abnormal anatomy of aortic arch
cardiac catheterisation abnormal gradient across narrowing therapeutic intervention possible
12
Diagnostic Tests
13
Diagnostic Approach
  • History and examination
  • Diagnostic tests
  • Differential diagnosis

14
Differential Diagnosis
Condition Differentiating signs/symptoms Differentiating tests
Aortic stenosis (AS) With mild AS, the patient may be asymptomatic with a harsh systolic ejection quality murmur at the upper right sternal border with radiation to the carotids on physical examination. In moderate or severe AS, the patient may have significant SOB, especially on exertion. Differentiated from coarctation of the aorta by echocardiogram. Two-dimensional echocardiogram of the aortic valve shows an abnormally narrowed or dysplastic aortic valve. Patients with aortic coarctation with associated bicuspid aortic valve may also have AS.
15
Differential Diagnosis
Condition Differentiating signs/symptoms Differentiating tests
Left ventricular outflow tract obstruction Depending on the level and severity of the obstruction, patients may be asymptomatic or may present with SOB, especially on exertion. An echocardiogram will differentiate the level of the obstructed or narrowed area in the aorta. Using colour and pulse Doppler, any narrowing in the left ventricular outflow tract can be localised to the valvar, sub-valvar, or supra-valvar area, or across the aortic arch.
16
Differential Diagnosis
Condition Differentiating signs/symptoms Differentiating tests
Essential hypertension Similar clinical presentation. Lower extremity pulses usually normal unless peripheral vascular disease present. Four-extremity BP shows no gradient. Echocardiogram shows normal flow across the aortic arch and normal Doppler of the abdominal aorta.
Renal artery stenosis Similar clinical presentation. Renal artery Doppler shows renal artery stenosis. Normal echocardiogram.
17
Treatment Approach
  • Critical Coarctation
  • Non-critical coarctation lt 1 year of age
  • Non-critical coarctation gt 1 year of age

18
Treatment Approach
Patient Treatment
Critical CoA Keep PDA PLUS surgical repair
Non-critical lt 1 year Surgical repair
Non-critical gt 1 year Surgical OR percutaneus repair
Recurrent Percutaneus ballon angioplasty
19
Surgical Repair - 1
  • For short segment narrowing

20
Surgical Repair - 2
  • For medium-length and long narrowing

21
Percutaneus repair
  • For children gt 1 year of age or recurrent
    coarctation
  • By ballon angioplasty with or without stent
    implantation
  • Stent implantation only in older childrens

22
Complications
  • Post-op
  • HTN
  • recurrent laryngeal nerve and phrenic nerve
    injury
  • Ischemic mesenteric enteropathy
  • Long-term recoarctation
  • Paraplegia in patients with inadequate collateral
    circulation
  • Femoral artery access-related complications
  • Aneurysm formation
  • Aortic dissection
  • stroke
  • Others
  • Coronary artery disease Am J Cardiol 2002 8
    9541-547

23
Prevention
  • routine palpation of femoral pulses starting with
    the first nursery visit.
  • Any question of a differential in the pulses or
    an elevated upper extremity BP should prompt
    measurement of BP in all 4 extremities
  • Adults with a diagnosis of an intracranial berry
    aneurysm should have their BP measured
  • genetic evaluation is also warranted when there
    are dysmorphic features, multiple organ
    abnormalities or additional intracardiac or
    vascular abnormalities
  • Prophylaxis for infective endocarditis is
    recommended for 6 months after intervention or
    surgery is performed Circulation.
    20071161736-1754

24
conclusion
  • Aortic CoA is a common CHD
  • A careful nursery physical exam could prevent
    fatal complications
  • Treatment options depend on the severity and
    length of the narrowing, the age of patient.
  • Post-op complications is uncommon but could be
    dangerous or could affect the further quality of
    life
  • Close follow-up with pediatrics cardiologist is
    required for all patients

25
Thank you
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