Coarctation Of Aorta

I. What Is Coarctation Of Aorta?

Coarctation of the aorta — or aortic coarctation — is a narrowing of the aorta, the large blood
vessel that branches off your heart and delivers oxygen-rich blood to your body. When this
occurs, your heart must pump harder to force blood through the narrowed part of your aorta.
Coarctation of the aorta is generally present at birth (congenital). The condition can range from
mild to severe, and might not be detected until adulthood, depending on how much the aorta is
narrowed.
Coarctation of the aorta often occurs along with other heart defects. While treatment is usually
successful, the condition requires careful lifelong follow-up.

II. Signs & Symptoms

Coarctation of the aorta symptoms depend on the severity of the condition. Most people don't
have symptoms. Children with serious aortic narrowing may show signs and symptoms earlier in
life, but mild cases with no symptoms might not be diagnosed until adulthood. People may also
have signs or symptoms of other heart defects that they have along with coarctation of the aorta.
Babies with severe coarctation of the aorta may begin having signs and symptoms shortly after
birth. These include:

• Pale skin • Difficulty breathing
• Irritability • Difficulty feeding

• Heavy sweating
Left untreated, aortic coarctation in babies might lead to heart failure or death.
Older children and adults with coarctation of the aorta often don't have symptoms because their
narrowing may be less severe. If you have signs or symptoms that appear after infancy, you most
commonly will have high blood pressure (hypertension) measured in your arms. However, your
blood pressure is likely to be lower in your legs. Signs and symptoms might include:

• High blood pressure • Leg cramps or cold feet
• Headache • Nosebleeds
• Muscle weakness • Chest pain


III. Causes
Doctors aren't certain what causes coarctation of the aorta (aortic coarctation). For unknown
reasons, mild to severe narrowing develops in part of the aorta. Although aortic coarctation can
occur anywhere along the aorta, the coarctation is most often located near a blood vessel called the
ductus arteriosus. The condition generally begins before birth (congenital). Congenital heart
defects are the most common of all birth defects.
Rarely, coarctation of the aorta develops later in life. Traumatic injury might lead to coarctation
of the aorta. Rarely, severe hardening of the arteries (atherosclerosis) or a condition causing
inflamed arteries (Takayasu's arteritis) can narrow the aorta, leading to aortic coarctation.
 Coarctation of the aorta usually occurs beyond the blood vessels that branch off to your upper
body and before the blood vessels that lead to your lower body. This can often lead to high blood
pressure in your arms but low blood pressure in your legs and ankles.
With coarctation of the aorta, the lower left heart chamber (left ventricle) of your heart works
harder to pump blood through the narrowed aorta, and blood pressure increases in the left ventricle.
This may cause the wall of the left ventricle to thicken (hypertrophy).

IV. Risk Factors

Coarctation of the aorta often occurs along with other congenital heart defects, although doctors
don't know what causes multiple heart defects to form together. The condition is more common in
males than in females. You or your child may be more likely to have aortic coarctation if certain
heart conditions exist, including:
- Bicuspid aortic valve. The aortic valve separates the lower left chamber (left ventricle) of the
heart from the aorta. A bicuspid aortic valve has two flaps (cusps) instead of the usual three. Many
people with coarctation of the aorta have a bicuspid aortic valve.
- Patent ductus arteriosus. Before birth, the ductus arteriosus is a blood vessel connecting the left
pulmonary artery to the aorta — allowing blood to bypass the lungs.

Shortly after birth, the ductus arteriosus usually closes. If it remains open, it's called a patent
ductus arteriosus.
- Holes in the wall between the left and right sides of the heart. You may have a hole in the wall
(septum) between the upper chambers of the heart (atrial septal defect) or the lower chambers of
the heart (ventricular septal defect) when you're born.

This causes oxygen-rich blood from the left side of the heart to mix with oxygen-poor blood in the
right side of the heart.
- Aortic valve stenosis. This is a narrowing of the valve that separates the left ventricle of the heart
from the aorta (aortic valve). This means your heart has to pump harder to get adequate blood
flow to your body.

Over time, this can cause your heart muscle to thicken and lead to symptoms such as chest pain,
fainting spells and breathlessness, or heart failure.
- Aortic valve regurgitation. This occurs when the aortic valve doesn't close tightly, causing blood
to leak backward into the left ventricle.
- Mitral valve stenosis. This is a narrowing of the valve (mitral valve) between the upper left heart
chamber (left atrium) and the left ventricle that lets blood flow through the left side of your heart.

In this condition, blood may back up into your lungs, causing shortness of breath or lung
congestion. Like aortic valve stenosis, this condition can also lead to heart failure.
- Mitral valve regurgitation. This occurs when the mitral valve doesn't close tightly, causing blood
to leak backward into the left atrium.
Coarctation of the aorta is also more common in people who have certain genetic conditions,
such as Turner syndrome. Women and girls with Turner syndrome have 45 chromosomes, with one
missing or incomplete X chromosome, instead of 46. About 10 percent of women and girls with
Turner syndrome have aortic coarctation.
Talk to you doctor if you or your child has of any of these risk factors or a family history of
congenital heart disease.

V. Complications
Untreated coarctation of the aorta frequently leads to complications. Some complications may be
a result of long-standing high blood pressure caused by the aortic coarctation. Complications are
also possible after treatment for coarctation of the aorta.
Complications of coarctation of the aorta may include:

Narrowing of the aortic valve (aortic Premature coronary artery disease —
stenosis) narrowing of the blood vessels that supply
High blood pressure the heart
Stroke Heart failure
Enlargement in a section of the wall of the A weakened or bulging artery in the brain
aorta (aneurysm) (brain aneurysm) or bleeding in the brain
Aortic rupture or tear (dissection) (hemorrhage)

In addition, if the coarctation of the aorta is severe, your heart might not be able to pump enough
blood to your other organs. This can cause damage to your heart and also can result in kidney
failure or other organ failure.
If your coarctation of the aorta was treated when you were young, you have a risk of the aorta re-
narrowing (re-coarctation) over time. You also have a higher risk of developing high blood pressure.
You will need lifelong follow-up for coarctation of the aorta, and you may require additional
treatments.

VI. Diagnostics

Echocardiogram Magnetic resonance imaging (MRI)
Electrocardiogram (ECG) Computerized tomography (CT) scan
Chest X-ray Cardiac catheterization


VII. Pathophysiology
The problem in this condition will be on the left side of the heart (hence the aorta). Remember
the left side of the heart’s mission is to pump oxygenated blood that just LEFT the lungs to the
body, and the aorta is the last structure in the heart that plays that vital role of delivering fresh
oxygenated blood to the body.
When there is narrowing of a section of the aorta, the side that is proximal (before the
narrowing)will have a high blood pressure, while the distal side (side after the narrowing) will have
a lower blood pressure.
 So, in other words, the branches of arteries that supply certain areas of the body found BEFORE
the narrowing will experience a high blood pressure, while the branches of arteries that supply
certain areas of the body found AFTER the narrowing will experience a decrease in blood pressure.
What are the structures that will experience high blood pressure BEFORE the narrowing?
Typically, it includes the heart (specifically the left ventricle…this can lead to heart failure
overtime along with decreased cardiac output if not treated) because the left ventricle will have to
work harder to pump against the high pressure. In addition, the upper body (includes head, neck,
and upper extremities) is affected as well.
What are the structures that will experience decreased blood pressure AFTER the narrowing?
The lower body, particularly the pulses (femoral) and lower extremities (feel cool).

VIII. Prevention
Coarctation of the aorta can't be prevented, because it's usually present at birth (congenital).
However, if you or your child has a condition that increases the risk of aortic coarctation, such as
Turner syndrome, bicuspid aortic valve or another heart defect, or a family history of congenital
heart disease, early detection can help. Discuss the risk of aortic coarctation with your doctor.

IX. Treatment
A. Surgery
There are several surgical techniques to repair aortic coarctation. Your doctor can discuss with
you which type is most likely to successfully repair your or your child's condition. The options
include:
• Resection with end-to-end anastomosis. This method involves removing the narrowed
segment of the aorta (resection) followed by connecting the two ends of the aorta together
(anastomosis).
• Subclavian flap aortoplasty. A portion of the blood vessel that delivers blood to your left
arm (left subclavian artery), might be used to expand the narrowed area of the aorta.
• Bypass graft repair. This technique involves bypassing the narrowed area by inserting a
plastic tube called a graft between the portions of the aorta.
 • Patch aortoplasty. Your doctor might treat your coarctation by cutting across the narrowed
area of the aorta and then attaching a patch of synthetic material to widen the blood vessel.
Patch aortoplasty is useful if the coarctation involves a long segment of the aorta.
B. Balloon angioplasty and stenting
Balloon angioplasty, often with stenting, is an option for initially treating aortic coarctation or for
treating re-narrowing (re-coarctation) that has occurred after surgery.
C. Medication
Medication isn't used to repair coarctation of the aorta, but it might be used to control blood
pressure before and after stent or surgery. Although repairing aortic coarctation improves blood
pressure, many people still need to take blood pressure medication, even after a successful surgery
or stenting.
Babies with severe coarctation of the aorta often are given a medication that keeps the ductus
arteriosus open. This provides a bypass for blood flow around the constriction until the coarctation
is repaired.

X. Nursing Management
1. Monitoring for signs and symptoms of heart failure (decrease cardiac output or fluid volume
overload): fluid in lungs with crackles, difficulty breathing, increased respiratory rate, fatigue,
trouble feeding.
2. Monitoring and reporting blood pressure and pulse differences in upper and lower extremities
3. Mild cases may go undetected until later in childhood when abnormal blood pressures or pulses
are detected in the upper vs. lower extremities…sometimes a heart murmur may be present
(systolic) that is located on the back on the left side near the shoulder blades “interscapular”.
4. If CoA is severe in a newborn, the patient may be started on a prostaglandin infusion to keep the
ductus arteriosus open until surgery. This will help:
• decrease the work load on the left ventricle
• help blood to flow to the lower extremities
5. In addition, other medications may be ordered prior to surgery to help the heart’s function:
Digoxin (causes the heart to pump stronger but at a slower rate) and diuretics (to remove fluid)
6. Educating about treatments and possible complications:
• aorta can narrow again at some point and will require a procedure to re-open
• hypertension: some child can continue to experience hypertension long-term and will need
medications to control
• long-term follow-up care with a cardiologist