Currently, there is insufficient evidence to indicate which is the best treatment for CoA: surgical or stent repair. Choice of treatment strategy will continue to depend on the operator’s skills or institutional preference until a prospective randomized controlled clinical trial is performed.13
Follow-Up
Based on recommendations from the ACC/AHA and the 2009 Canadian Cardiovascular Society Consensus Conference on the management of adults with congenital heart disease, lifelong follow-up is recommended for all patients with aortic coarctation (whether repaired or not), including an evaluation by a cardiologist with expertise in ACHD.4,8
A baseline cardiac MRI or CT for complete evaluation of the thoracic aorta and intracranial vessels is required for follow-up. Patients who have previously undergone surgical or interventional CoA repair should be followed annually with echocardiography to assess for potential late complications, such as aortic dilatation and aneurysm formation. Evaluation of the coarctation repair site by MRI and/or CT at intervals of five years or less is also recommended. Moreover, patients should be monitored for recurrent resting or exercise-induced hypertension, which should be treated aggressively after recoarctation is excluded.
The guidelines recommend that every patient with systemic arterial hypertension have the brachial and femoral pulses palpated simultaneously.4,8 This additional physical assessment will help detect significant aortic coarctation by assessing timing and amplitude of both pulses in search for a brachial-femoral delay. Moreover, measuring the differential pressure between bilateral arms (brachial artery) in a supine position and prone right or left supine leg (popliteal artery) BP should be performed.4,8 Initial imaging and hemodynamic evaluation by transthoracic echocardiogram is recommended in suspected aortic coarctation.
CONCLUSION
This case represents a missed CoA and provides an example of recoarctation as a late complication after repair. Unfortunately, the critical need to screen for coarctation was not recognized by the patient’s primary care providers in a timely manner. Had the guidelines for CoA screening been applied, this defect would have been detected earlier, avoiding many years of cardiovascular system stress from the sequelae of hypertension.
Measuring the BP gradient between the upper and lower extremities and searching for brachial-femoral timing delay are simple but crucial steps in the initial application of the clinical guidelines for early detection of CoA and recoarctation.
References
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