DELAYED PRESENTATION OF COARCTATION OF THE AORTA

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Coarctation of the aorta (CoA) is a congenital malformation usually identified in infancy with life-threatening presentations of heart failure and cardiogenic shock. In adulthood, common features are incidental auscultation of a cardiac murmur or high blood pressure. We present the case of a patient who presents with complaints of chest pain, progressively worsening dyspnea and bilateral lower extremity claudication who was found to have a high-grade coarctation of the aorta. We aim to highlight the importance of delayed presentation of coarctation of the aorta in adults with hypertension and recurrent chest pain. CASE PRESENTATION: A 57-year-old female with a past medical history of hypertension presented to the emergency department complaining of vague chest pain, dyspnea, upper back pain, and intermittent bilateral lower extremity claudication with exertion. The patient had prior episodes of chest pain, however prior workup was unremarkable. Physical exam was unrevealing. Her blood pressure measurements were 140 mmHg and 130 mmHg on the right and left arm respectively, with ankle pressures of 89 mmHg and 95 mmHg of the right and left lower extremity. The resulting ankle-brachial indices (ABI) of 0.68 on the right and 0.61 on the left. Although chest radiograph was unremarkable, computed tomography of the chest revealed high-grade coarctation of the proximal descending aorta at the isthmus with numerous well-developed collaterals. Echocardiogram showed a normal trileaflet aortic valve without any evidence of regurgitation or stenosis and no evidence of left ventricular hypertrophy. There was normal transvalvular flow through the mitral valve, normal pulmonary vein flow, and no regional wall abnormalities. Further evaluation consisted of computed tomography angiography and magnetic resonance imaging of the chest which revealed high-grade coarctation of the aorta at the isthmus with collateral vessels and a 2.4 cm thrombosed pseudoaneurysm between the first and second intercostal arteries. The patient underwent a Thoracic Endovascular Aortic Repair (TEVAR) with placement of a thoracic aortic graft, balloon angioplasty with stent placement. ABIs post-procedure showing marked improvement, 1.04 and 1.10 of the right and left respectively. DISCUSSION: Since the vast majority of coarctations are diagnosed and corrected during childhood, coarctations identified for the first time in adulthood are rare. The most common presentation in adulthood is hypertension or a cardiac murmur. If left untreated, this congenital heart defect can result in life-threatening complications such as hypertensive crisis, heart failure, infective endocarditis, and cardiac arrest. CoA should be considered in the differential diagnosis of patients presenting with recurrent chest pain and lower extremity claudication. CONCLUSIONS: CoA is infrequently seen in the adult population and may even remain clinically silent for several years until symptoms worsen, as was the case with our patient. This case demonstrates that early diagnosis and a high degree of suspicion is necessary in order to prevent complications from long-standing disease. Reference #1: Hazuková, R., Cermáková, E., & Pleskot, M. (2016). Frequency of emergencies in adults due to unrecognized coarctation of the aorta. Anatolian journal of cardiology, 16(1), 74. doi:10.14744/AnatolJCardiol.2015.6817 Reference #2: Ringel RE, Gauvreau K, Moses H, Jenkins KJ. Coarctation of the Aorta Stent Trial (COAST): study design and rationale. Am Heart J. 2012;164:7-13. Reference #3: Torok, R. D., Campbell, M. J., Fleming, G. A., & Hill, K. D. (2015). Coarctation of the aorta: Management from infancy to adulthood. World journal of cardiology, 7(11), 765–775. doi:10.4330/wjc.v7.i11.765 DISCLOSURES: No relevant relationships by Livasky Concepcion Perez, source=Web Response No relevant relationships by Aunie Danyalian, source=Web Response No relevant relationships by Ivan Pagan Colon, source=Web Response No relevant relationships by Umair Shaikh, source=Web Response