Coarctation of the Aorta in an Adult: Problems of Diagnosis and Management

A 41-year-old man was initially evaluated 6 years previously by his family physician, found to be hypertensive, and managed with pharmacologic agents. Over the next several years, control of his BP became increasingly difficult, requiring multiple agents. He was referred to a cardiologist for further evaluation. Throughout the entire period, he has remained asymptomatic. The patient’s history revealed that 3 years ago, he underwent echocardiography, which disclosed a strong likelihood of a bicuspid aortic valve that, by Doppler interrogation, was mildly regurgitant. The mitral valve was believed to demonstrate prolapse with mild regurgitation. He was also found to have hyperlipidemia and was treated with simvastatin. Results of a treadmill exercise test at that time were normal. His mother had undergone mitral valve replacement several years previously; otherwise, no other cardiovascular disease was evident in family members. Current medications consisted of hydrochlorothiazide/losartan, 25/100 mg/d; amlodipine, 5 mg/d; and simvastatin, 20 mg/d. Physical examination disclosed a BP of 160/94 mm Hg and a heart rate of 75 beats/min. Precordial pulsations were normal. Auscultation disclosed a latepeaking systolic murmur heard well at the apex; however, it was also heard over the entire thoracic cage and upper back (Fig 1). No diastolic murmurs were audible. Simultaneous palpation of the radial and femoral pulses disclosed a significant delay of the latter. The systolic pressure in the lower extremities was 130 mm Hg, determined with a Doppler probe over the pedal vessels, yielding an ankle/ brachial index of 0.85. The remainder of the examination was normal. Chest radiography disclosed clear lung fields, with the cardiac silhouette at the upper limits of normal. The aortic arch demonstrated slight tortuosity, but notching of the ribs was absent. The echocardiogram disclosed mild dilatation of the left ventricle (diastolic diameter, 5.5 cm) and left atrium (4 cm). Interventricular septum was mildly thickened (1.3 cm), and the left ventricle contracted normally. The aortic valve was bicuspid in configuration and displayed mild regurgitation. The ascending aorta was mildly dilated; however, Doppler echocardiographic interrogation of the descending aorta was technically impossible, thus precluding detection of an area of stenosis with increased flow velocity. Because of the strong suspicion of coarctation of the aorta, cardiac catheterization with aortography was performed. Initial attempts using the right femoral approach were unsuccessful because of marked arterial tortuosity beyond the coarctation; therefore, the right radial artery was used for access. This disclosed coarctation of the aorta located just distal to the left subclavian artery (Fig 2). This was associated with a 35-mm Hg gradient on pullback. Intracardiac study disclosed normal systolic function of the left ventricle, normal coronary arteries, and the presence of mild aortic regurgitation.