Coarctation of the Aorta

A 9-year-old boy was referred to our institution for evaluation of a heart murmur that had been discovered recently by his pediatrician. The boy had been physically active and asymptomatic. He had a history of eye surgery and a fracture of the left leg.

On physical examination, both femoral pulses were absent, both brachial pulses were strong, the blood pressure in the right arm was 122/78 mmHg, and the blood pressure in the legs could not be determined manually. A grade 1+/6 ejection systolic murmur was heard at the left sternal border and a grade 1/6 bruit was heard all around the chest.

The diagnosis of coarctation of the aorta, which was obvious from the physical examination of this patient, was confirmed by 2-dimensional and Doppler echo-cardiography (Figs. 1–3). The boy underwent resection of the coarcted segment of the aorta, followed by end-to-end anastomosis, with excellent results.

Fig. 1 Two-dimensional echocardiogram in the suprasternal long-axis view showing coarctation of the aorta (arrow) below the origin of the left subclavian artery. Post-stenotic dilatation of the descending thoracic aorta (DAO) is seen.

AAO = ascending aorta

Fig. 2 Spectral Doppler flow pattern across the coarcted segment, showing 3-m/sec systolic flow velocity. Note the double density, the denser proximal part (low velocity), and the lighter distal part (higher velocity). In addition, the diastolic runoff of the spectral Doppler is clearly visible.

Fig. 3 Spectral Doppler flow pattern in the abdominal aorta. The nonpulsatile continuous flow pattern lends strong support to the diagnosis of coarctation of the aorta.

In this patient, the quality of imaging was excellent. Frequently in children with coarctation of the aorta, the images are not as good. For example, when echocardiograms are performed in a small community hospital for evaluation of a heart murmur, they are usually done by technicians trained in echocardiography of adults; generally, there is no supervision by a pediatric cardiologist. Therefore, many congenital cardiac defects, including coarctation of the aorta, can be missed. However, with knowledge, experience, and a state-of-the-art echocardiogram machine, technicians performing echocardiography can obtain remarkably clear images (see figure legends for details).