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Aortic coarctation in adults: the role of multimodality cardiac imaging. Series of case reports and review of literature

Carmen Beladan
Carmen Beladan
, 
Maria Magdalena Gurzun
Maria Magdalena Gurzun
, 
Mihai Teodor Bica
Mihai Teodor Bica
, 
Dan Deleanu
Dan Deleanu
, 
Pavel Platon
Pavel Platon
, 
Sebastian Botezatu
Sebastian Botezatu
, 
Carmen Ginghina
Carmen Ginghina
 et 
Bogdan A. Popescu
Bogdan A. Popescu
   | 30 avr. 2022
Romanian Journal of Cardiology's Cover Image
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Article Category: Case Presentation
Publié en ligne: 30 avr. 2022
Pages: 76 - 84
DOI: https://doi.org/10.47803/rjc.2021.31.1.76
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© 2021 Carmen Beladan et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1

Transthoracic parasternal long axis view with M mode echocardiography showing dilated left ventricle (A); continuous Doppler interrogation of the descending aorta from the suprasternal transthoracic view showcasing increased velocities at this level (B). MDCT visualisation of the aorta in the longitudinal MPR plane (C) and 3D volume rendering (D) showing stenosis of the aorta after the origin of left subclavian artery (yellow arrow). Angiographic visualisation of aortic coarctation (E) (yellow arrow) and final stent position after percutaneous intervention (F).
Transthoracic parasternal long axis view with M mode echocardiography showing dilated left ventricle (A); continuous Doppler interrogation of the descending aorta from the suprasternal transthoracic view showcasing increased velocities at this level (B). MDCT visualisation of the aorta in the longitudinal MPR plane (C) and 3D volume rendering (D) showing stenosis of the aorta after the origin of left subclavian artery (yellow arrow). Angiographic visualisation of aortic coarctation (E) (yellow arrow) and final stent position after percutaneous intervention (F).

Figure 2

Appearance of descending aorta in 2D suprasternal view (A) and high gradient measured at this level by continuous wave Doppler (B). MDCT visualisation of the aorta in the longitudinal MPR plane (C) and 3D volume rendering (D) showing aortic coarctation distal to the origin of left subclavian artery (yellow arrow). Angiographic view during stent deployment procedure: balloon post-dilatation (E) and final stent position (F). To note: the increase size of the internal mammary arteries.
Appearance of descending aorta in 2D suprasternal view (A) and high gradient measured at this level by continuous wave Doppler (B). MDCT visualisation of the aorta in the longitudinal MPR plane (C) and 3D volume rendering (D) showing aortic coarctation distal to the origin of left subclavian artery (yellow arrow). Angiographic view during stent deployment procedure: balloon post-dilatation (E) and final stent position (F). To note: the increase size of the internal mammary arteries.

Figure 3

Suprasternal view with color Doppler echocardiography showing turbulent flow in the descending aorta (A) (yellow arrow) and high gradient measured at this level by continuous wave Doppler (B). MDCT visualisation of the aorta in the longitudinal MPR plane (C) and 3D volume rendering (D) showing aortic coarctation distal to the origin of left subclavian artery (yellow arrow). Angiographic view of aortic coarctation (E) and final stent position (F). To note important collateral circulation (red arrow) suboclusive stenosis of thoracic descending aorta (yellow arrow).
Suprasternal view with color Doppler echocardiography showing turbulent flow in the descending aorta (A) (yellow arrow) and high gradient measured at this level by continuous wave Doppler (B). MDCT visualisation of the aorta in the longitudinal MPR plane (C) and 3D volume rendering (D) showing aortic coarctation distal to the origin of left subclavian artery (yellow arrow). Angiographic view of aortic coarctation (E) and final stent position (F). To note important collateral circulation (red arrow) suboclusive stenosis of thoracic descending aorta (yellow arrow).

Figure 4

Chest radiograph in a patient with aortic coarctation. To note are the “figure 3 sign” (black line) and the costal erosion at the inferior edge (*).
Chest radiograph in a patient with aortic coarctation. To note are the “figure 3 sign” (black line) and the costal erosion at the inferior edge (*).

Figure 5

Important collateral circulation with dilated internal mammary arteries visualized by echo (A) and by CCT (B) (red *). Low flow present at the level of superficial femoral artery (C). Decreased renal circulation with low flow measured in the arcuate arteries (D).
Important collateral circulation with dilated internal mammary arteries visualized by echo (A) and by CCT (B) (red *). Low flow present at the level of superficial femoral artery (C). Decreased renal circulation with low flow measured in the arcuate arteries (D).

Magnetic resonance imaging techniques used for the initial evaluation, pre-procedural assessment, and follow-up of patients with CoA10,11

Spin-echo CMR Initial assessment of the location and degree of stenosis
Contrast-enhanced 3D CMR Better visualization of the aorta in patients with repaired CoA10
Phase-contrast, velocity-encoded cine CMR Hemodynamic measurements - flow deceleration in descending aorta, pressure gradients Assessment of the smallest aortic cross-sectional area11
4D flow CMR Measurement of peak systolic pressure across CoA, wall-shear stress, and oscillatory shear index using computational fluid dynamics11

Recommendations for intervention in CoA or re-coarctation.

Class. Level Recommendations
I C Repair of CoA or re-coarctation (either surgical or interventional) is indicated in hypertensive patients with an increased non-invasive gradient between upper and lower limbs confirmed invasively (peak-to-peak ≥20 mmHg).
IIa C Stenting should be considered in hypertensive patients with >50% narrowing relative to the aortic diameter at the level of the diaphragm even if invasive peak-to-peak gradient is <20 mmHg.
IIa C Stenting should be considered in normotensive patients with an increased non-invasive gradient confirmed invasively (peak-to-peak gradient of ≥20 mmHg).
IIb C Stenting may be considered in normotensive patients with >50% narrowing relative to the aortic diameter at the level of the diaphragm even if invasive peak-to-peak gradient is <20 mmHg.
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