Aortic Coarctation Follow-up

  • Author: Sandy N Shah, DO, MBA; Chief Editor: Park W Willis IV, MD   more...
 
Updated: Nov 29, 2011
 

Further Outpatient Care

  • According to the Canadian Adult Congenital Heart Association, all patients with coarctation of the aorta need to be monitored by a cardiologist.
  • Patients should have at least one MRI or angiogram following repair of the coarctation.
  • Close surveillance and aggressive management are necessary for residual hypertension, heart failure or intracardiac disease, associated bicuspid aortic valve, recurrent coarctation of the aorta, or significant arm-leg blood pressure gradient at rest or with exercise.
  • Ascending aortic dilation in the presence of a bicuspid aortic valve, new or unusual headache from berry aneurysm formation, late dissection proximal or distal to the repair site, and aneurysm formation at the site of coarctation repair are late sequelae of this disease.
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Complications

  • Postoperative complications
    • Hoarseness due to damage to the recurrent laryngeal nerve as it loops around the patent ductus arteriosus or ligamentum.
    • Ipsilateral diaphragmatic paralysis may result from injury to the phrenic nerve.
    • Chylothorax can occur due to damage to the thoracic duct that crosses behind the aortic arch and left subclavian artery.
    • Serious postoperative hemodynamic collapse may result from hemorrhage due to injury to the chest wall collaterals.
    • Rebound and paradoxical hypertension is observed frequently and may be related to the baroreceptor-mediated increase in sympathetic activity and reflex vasospasm in the vascular territory distal to the coarctation.
    • Postcoarctectomy syndrome is a unique problem early in the postoperative period. Increases in blood flow and pressure in the mesenteric arteries after repair of coarctation may result in abdominal distention and pain, vomiting, and decreased bowel sounds. This syndrome may be masked because of poorly controlled postoperative hypertension and early enteral feeding. By aggressively controlling postoperative hypertension and delaying enteral feeding for 2 days after surgery, incidence of postcoarctectomy syndrome may be reduced.
    • Paralysis of the lower body resulting from spinal cord injury is the most serious complication. Because of complex collateral formation, ischemia of the spinal cord is often difficult to predict and, therefore, may be unavoidable.
  • Long-term complications
    • Systemic hypertension is the most common long term complication. This may be accentuated by exercise, creating a need to exclude residual or recurrent obstruction.
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Prognosis

  • Patients who are not treated for coarctation of the aorta may reach the age of 35 years; fewer than 20% survive to age 50 years. If coarctation is repaired before the age of 14 years, the 20-year survival rate is 91%. If coarctation is repaired after the age of 14 years, the 20-year survival rate is 79%.
  • After repair of coarctation of the aorta, 97-98% of patients are NYHA class I. Impaired diastolic left ventricular function and persistent hypertrophy due to increased pressure gradient at the coarctation site during exercise may result in myocardial hypertrophy despite successful hemodynamic results. Overall, left ventricular systolic function is normal or hyperdynamic in these patients.
  • Pregnancy
    • Most women reach childbearing age. If maternal coarctation is not repaired, risks to fetus and mother are increased. The maternal mortality rate is approximately 3-8%.
    • Despite repair, women have an increased risk of aortic dissection and rupture of cerebral aneurysm in the third trimester and peripartum period due to hemodynamic and hormonal changes.
    • All pregnant women with a history of coarctation, either native or repaired, should be considered high risk.
    • Significant stenosis—native, residual, or recurrent—is a contraindication to pregnancy.
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Patient Education

  • Most adults with coarctation have undergone repair; however, continued education regarding exercise, endocarditis and endarteritis prevention, and pregnancy issues is necessary.
  • For the rare adult with uncorrected coarctation, extensive patient education is necessary on issues ranging from pathology and repair to lifestyle modification and follow-up care.
  • The medical practitioner must understand that coarctation is a complex lifelong condition that may be repaired but is never truly corrected.
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Contributor Information and Disclosures
Author

Sandy N Shah, DO, MBA  Cardiologist, Houston, Texas

Sandy N Shah, DO, MBA, is a member of the following medical societies: American College of Cardiology, American College of Osteopathic Internists, and American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Alan D Forker, MD  Professor of Medicine, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research, MidAmerica Heart Institute of St Luke's Hospital

Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa

Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Frank M Sheridan, MD  Cardiology, Providence Everett Medical Center

Frank M Sheridan, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Park W Willis IV, MD  Sarah Graham Distinguished Professor of Medicine and Pediatrics, University of North Carolina at Chapel Hill School of Medicine

Park W Willis IV, MD is a member of the following medical societies: American Society of Echocardiography

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Dawn M Calderon, DO to the development and writing of this article.

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