Case 5/2016 - Native Coarctation of the Aortic Arch, Relieved By Percutaneous Treatment in an Adult

Clinical data: the patient had a good clinical course after repair of severe coarctation of the aortic isthmus with end‑to‑end technique, closure of the interventricular communication at 18 days of life, and relief of moderate subaortic stenosis at 3 years of age. Currently, the patient can tolerate well routine exercise, with no symptoms. At last evaluation, blood pressure in the right arm was 140/70 mmHg and the systolic pressure in the left arm and lower limbs was 90 mmHg, suggesting aortic arch obstruction. Previous evaluations have shown a pressure gradient of 15 mmHg between the upper limbs. Physical examination: good general health, normal breathing, acyanotic, unequal pulse between the right upper arm and lower extremities. Weight: 65 Kg, height: 165 cm, right upper arm arterial pressure: 140/70 mmHg, left upper arm arterial pressure: 115/80 mmHg, right lower limb arterial pressure: 105/80 mmHg, and heart rate: 82 bpm. The aorta was palpable in the supra‑sternal notch, with fremitus and systolic murmur (grade 2). In the precordium, the apex beat was not palpable and no impulse was detected during systole. Heart sounds were normal, and a harsh, grade 2 systolic murmur was heard in the aortic area and left sternal border with fremitus. The liver was not palpable. Electrocardiogram showed sinus rhythm, signs of complete right bundle branch block wit QRS duration of 0.14'', and block of the anterior superior division of the left bundle branch (unchanged since neonatal aortic coarctation repair and interventricular communication). P axis: +20 o , QRS axis: +250 o , T axis: +35 o. Chest radiograph showed normal heart area and myocardial hypertrophy, and normal pulmonary vasculature. Echocardiogram showed normal‑sized cardiac chambers, mild myocardial hypertrophy (septum = 14 mm and posterior wall = 11 mm), pressure gradient across the aortic arch = 61 mmHg, and bicuspid aortic valve. Ascending aorta = 29 mm, LA = 32 mm, RV = 26 mm, LV = 48 mm. Septum and left ventricle wall thickness = 10 mm three years ago. Tomography of thoracic aorta showed aortic arch obstruction with diameters in the ascending aorta (19 mm), in the arch after left carotid artery (14 mm), in the isthmus after the left subclavian artery at the level where aortic coarctation repair had been performed (24 mm) (Figure 1). Ambulatory Blood Pressure Monitoring showed normal blood pressure in the left arm and blood pressure levels higher than 135/85 mmHg in the right …