100 QUESTIONS IN CARDIOLOGY

47 How do I follow up a patient who has had

correction of aortic coarctation? What should I

look for and how should they be managed?

Seamus Cullen

Long term follow up has demonstrated an increased cardio-

vascular morbidity and mortality following repair of coarctation

of the aorta. Repair at an older age has been associated with worse

complications. Recoarctation may occur and produces upper body

hypertension and pressure overload of the left ventricle. The type

of surgical repair does not protect against recoarctation.

Hypertension is a common complication affecting 8–20% of

patients who have undergone repair of coarctation of the aorta

and is associated with increased morbidity and mortality. It is

associated with a later age at operation. Indeed, patients who are

normotensive at rest may demonstrate an abnormally high

increase in systolic blood pressure in response to exercise,

probably related to baroreceptor abnormalities and/or reduced

arterial compliance. The bicuspid aortic valve is commonly seen

in patients with coarctation and may predispose to infective

endocarditis, aortic stenosis/regurgitation and to ascending aortic

aneurysm. In addition, mitral valve abnormalities have been

detected in approximately 20% of patients.

All patients who have undergone repair of aortic coarctation

should be followed up on a regular basis with careful monitoring

of upper and lower limb blood pressure. Cardiac examination is

directed towards palpation of the femoral pulses, monitoring of

blood pressure and auscultation. Serial 12-lead ECG will detect the

presence of left ventricular hypertrophy and annual transthoracic

echocardiography is useful for screening for left ventricular hyper-

trophy and recurrence of coarctation. A plain chest x-ray picture

may demonstrate mediastinal widening related to aneurysm

formation. However, magnetic resonance imaging is the gold

standard for non-invasive diagnosis of recoarctation and/or

aneurysm formation. Cardiac catheterisation confirms the presence

of recoarctation and permits transcatheter balloon dilatation with

stenting of the aortic coarctation. This is probably the procedure of

choice in suitable lesions because of the small but definite risk of

neurological complications associated with surgical correction of

coarctation of the aorta. Persisting hypertension should be