eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Coarctation of the Aorta: Differential Diagnoses & Workup

Author: P Syamasundar Rao, MD, Professor of Pediatrics and Medicine, University of Texas-Houston Medical School; Director, Division of Pediatric Cardiology, Children's Memorial Hermann Hospital; Professor of Pediatrics, MD Anderson Cancer Center, University of Texas
Coauthor(s): Paul M Seib, MD, Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital
Contributor Information and Disclosures

Updated: Jul 20, 2009

Differential Diagnoses

Adrenal Insufficiency
Hypoplastic Left Heart Syndrome
Aortic Stenosis, Valvar
Myocarditis, Viral
Cardiomyopathy, Dilated
Sepsis
Cardiomyopathy, Hypertrophic
Shock
Congenital Adrenal Hyperplasia
Endocardial Fibroelastosis
Hypertension

Other Problems to Be Considered

Trauma with aortic dissection

Workup

Laboratory Studies

The following studies may be indicated in coarctation of the aorta (CoA):

  • Laboratory studies in neonatal patients who present in shock include the following:
    • Septic workup includes blood, urine, and cerebral spinal fluid (CSF) cultures.
    • Electrolyte levels, BUN, creatinine, and glucose concentrations should be tested.
    • Measure arterial blood gases and serum lactate levels.
  • Laboratory studies in older patients who present with hypertension include urinalysis, electrolyte levels, BUN, creatinine, and glucose concentrations.

Imaging Studies

  • Chest radiography
    • Radiography in patients with early onset of coarctation of the aorta may reveal cardiomegaly, pulmonary edema, and other signs of congestive heart failure (CHF).
    • Radiography in patients with late onset of coarctation of the aorta may reveal cardiomegaly. An inverted "3" sign of the barium-filled esophagus or a "3" sign on a highly penetrated chest radiograph (frontal view) may be visualized. Rib notching secondary to collateral vessels may also be seen.
  • Echocardiography: Echocardiography delineates intracardiac anatomy and allows assessment of associated significant intracardiac anomalies. The suprasternal notch 2-dimensional echocardiographic view allows evaluation of the aortic arch to assess the transverse aortic arch, isthmus, and severity of coarctation. Doppler echocardiography is used to measure the gradient at the site of coarctation and to identify the pattern of diastolic runoff typically seen in patients with severe obstruction.
  • Instantaneous peak pressure gradients across the aortic coarctation can be estimated with a modified Bernoulli equation, as follows:
    ΔP = 4 (V2 2 – V1 2)
    ΔP is the peak instantaneous gradient, and V2 and V1 are the peak flow velocities in the descending aortic, distal to coarctation (continuous-wave Doppler) and proximal to the coarctation (pulsed Doppler), respectively. The calculated gradient usually overestimates the measured blood pressure gradient. Presence of pan-diastolic flow indicates significant obstruction. Inclusion of duration-related Doppler flow parameters in the gradient calculation may improve the accuracy of Doppler prediction of coarctation gradient.23
  • When aortic arch cannot be adequately evaluated, abdominal aortic Doppler parameters may help in the diagnosis.24 Absence of early diastolic reversal along with corrected pulse delay of 2.8 microseconds1/2 or more may best predict significant obstruction.
  • MRI and CT are useful in older or postoperative patients to assess residual arch obstruction, arch hypoplasia, or formation of aneurysms.25,26 Ultrafast CT scanning is preferable if multiple surgical clips or a stent is present in the area of coarctation.

    Aortic coarctation visualized by MR imaging.

    Aortic coarctation visualized by MR imaging.

    [ CLOSE WINDOW ]
    Aortic coarctation visualized by MR imaging.

    Aortic coarctation visualized by MR imaging.

Other Tests

  • Electrocardiography
    • ECG in the neonate or infant with early onset of coarctation of the aorta may reveal right ventricular rather than left ventricular (LV) hypertrophy. The reasons for right ventricular preponderance in the face of LV outlet obstruction are mentioned in Pathophysiology.
    • ECG findings in patients with late onset of coarctation of the aorta may be normal or may reveal LV hypertrophy and may show signs of LV ischemia or strain. Sometimes, LV hypertrophy may manifest as increased S waves in leads V5 and V6, the so-called posterobasal LV hypertrophy.
  • Preductal and postductal pulse oximetry readings may show evidence of ductal right-to-left shunting, especially in the neonate.

Procedures

  • Cardiac catheterization
    • Cardiac catheterization and selective cineangiography may not be required for diagnosis; however, they allow evaluation of the severity of coarctation, anatomic nature of the aortic obstruction (discrete vs long segment), and arch anatomy, including hypoplasia of the transverse arch or isthmus.
    • Cardiac catheterization helps confirm the diagnosis when echocardiography findings are not completely clear.
    • Cardiac catheterization allows the evaluation of intracardiac anatomy and the contribution of associated lesions to the overall hemodynamic disturbance.
    • Cardiac catheterization is a prerequisite for intervention in the form of either balloon angioplasty or stent implantation in native or recurrent coarctation.
    • When catheterization is performed, elevations of left ventricular and ascending aortic peak systolic pressures with a peak-to-peak systolic pressure gradient across the coarcted segment are usually found. A peak-to-peak gradient in excess of 20 mm Hg is generally considered indicative of significant obstruction. However, the magnitude of the gradient is not necessarily indicative of the degree of narrowing because the gradient depends on not only the extent of aortic narrowing but also the size and number of collateral vessels. In addition, cardiac output and the state of ductus arteriosus, particularly in the neonate and young infant, also determine the pressure gradient.
    • Selective aortic root or aortic arch angiography is necessary to clearly demonstrate the aortic narrowing. Aortography is useful in demonstrating the type of aortic coarctation (diffuse, long segment, aortic kinking [pseudocoarctation]); extent of collateral circulation; the size of ductus arteriosus, if patent; and the presence and degree of hypoplasia of transverse aortic arch and aortic isthmus, especially in neonates. If thoracic coarctation is not demonstrated despite clinical features of coarctation or if neurofibromatosis is suspected, abdominal aortography may be needed to demonstrate (or exclude) abdominal coarctation.
    • LV angiography is particularly useful in neonates and infants who demonstrate ventricular septal defects (VSDs) and in evaluating their function.

Histologic Findings

  • Coarctation of the aorta results from marked ridgelike thickening of the media of the aortic wall opposite the insertion of the patent ductus arteriosus or ligamentum arteriosum.
  • Intima in this area may be thin initially but may thicken over time.
  • This ridge or shelf becomes an obstruction when the patent ductus involutes and when ductal tissue in the wall of the aorta involutes.

More on Coarctation of the Aorta

Overview: Coarctation of the Aorta
Differential Diagnoses & Workup: Coarctation of the Aorta
Treatment & Medication: Coarctation of the Aorta
Follow-up: Coarctation of the Aorta
Multimedia: Coarctation of the Aorta
References
[ CLOSE WINDOW ]

References

  1. Rao PS. Should balloon angioplasty be used instead of surgery for native aortic coarctation?. Br Heart J. Dec 1995;74(6):578-9. [Medline].

  2. Rudolph AM, Heymann MA, Spitznas U. Hemodynamic considerations in the development of narrowing of the aorta. Am J Cardiol. Oct 1972;30(5):514-25. [Medline].

  3. Talner NS, Berman MA. Postnatal development of obstruction in coarctation of the aorta: role of the ductus arteriosus. Pediatrics. Oct 1975;56(4):562-9. [Medline].

  4. Cassels DE. The Ductus Arteriosus. Springfield, IL,: Charles C. Thomas; 1973:161.

  5. Skoda J. Demonstration eines Falles Ven Obliteration de Aorta. Wochenblatt Zeischrift de kaiserlichen-Konighiche Gesellschaft der Aerttze Zur Wien. 1995;1:710-720.

  6. Goldblatt H, Kahn JR, Hanzal RF. Studies on experimental hypertension. The effect on blood pressure of constriction of the abdominal aorta above and below the site of origin of both renal arteries. J Exper Med. 1939;69:649-674.

  7. Scott HW Jr, Bahnson HT. Evidence for a renal factor in the hypertension of experimental coarctation of the aorta. Surgery. Jul 1951;30(1):206-17. [Medline].

  8. Scott HW Jr, Collins HA, Langa AM, Olsen NS. Additional observations concerning the physiology of the hypertension associated with experimental coarctation of the aorta. Surgery. Sep 1954;36(3):445-59. [Medline].

  9. Alpert BS, Bain HH, Balfe JW, Kidd BS, Olley PM. Role of the renin-angiotensin-aldosterone system in hypertensive children with coarctation of the aorta. Am J Cardiol. Apr 1979;43(4):828-34. [Medline].

  10. Bagby SB. Dissection of pathogenetic factors: I. coarctation hypertension, in Loggie. In: JMH, Horan MJ, Hohn AR, et al Ieds). Proceedings of the NHLBI Workshop on Juvenile Hypertension. Biomedical Informatio Corp. New York, NY: 1984:pp. 253-266.

  11. Gersony WM. Riemenschneider TA (eds). Coarctation of the aorta, in Adams FH, Emmanouildes GC, Moss’ Heart Disease in Infants, Children and Adolescents. Baltimore, MD: Williams & Wilkins; 1989:pp. 243-255.

  12. Cody RJ. Hormonal alterations in heart failure. In: Hosenpud JD, Greenberg BH, eds. Congestive Heart Failure: Pathophysiology, Diagnosis and Comprehensive Approach to Management. 2nd ed. Lippincott Williams & Wilkins: 2000:199-212.

  13. Nadas, AS, Fyler DC. Pediatric Cardiology. 3rd Ed. Philadelphia, PA: Saunders; 1972:p. 683.

  14. Keith JD, Rowe RD, Vlad P. Heart Disease in Infancy and Childhood. 3rd Ed. New York, NY: Macmillan; 1978:pp. 4-6.

  15. Rao PS. Balloon angioplasty of native aortic coarctation. J Am Coll Cardiol. Sep 1992;20(3):750-1. [Medline].

  16. Campbell M. Natural history of coarctation of the aorta. Br Heart J. Sep 1970;32(5):633-40. [Medline].

  17. Strafford MA, Griffiths SP, Gersony WM. Coarctation of the aorta: a study in delayed detection. Pediatrics. Feb 1982;69(2):159-63.

  18. Thoele DG, Muster AJ, Paul MH. Recognition of coarctation of the aorta. A continuing challenge for the primary care physician. Am J Dis Child. Nov 1987;141(11):1201-4. [Medline].

  19. Norton JB Jr. Coarctation of the Aorta. In: Moller JH, ed. Surgery of Congenital Heart Disease: Pediatric Cardiac Care Consortium. Armonk, NY: Futura Publishing Co; 1984-1995.:143-57.

  20. Salahuddin N, Wilson AD, Rao PS. An unusual presentation of coarctation of the aorta in infancy: role of balloon angioplasty in the critically ill infant. Am Heart J. Dec 1991;122(6):1772-5. [Medline].

  21. Ing FF, Starc TJ, Griffiths SP, Gersony WM. Early diagnosis of coarctation of the aorta in children: a continuing dilemma. Pediatrics. Sep 1996;98(3 Pt 1):378-82. [Medline].

  22. Nora JJ. Multifactorial inheritance hypothesis for etiology of congenital heart disease: the genetic-environmental interaction. Circulation. 1968;38:604-17.

  23. Rao PS, Carey P. Doppler ultrasound in the prediction of pressure gradients across aortic coarctation. Am Heart J. Aug 1989;118(2):299-307. [Medline].

  24. Silvilairat S, Cetta F, Biliciler-Denktas G, Ammash NM, Cabalka AK, Hagler DJ. Abdominal aortic pulsed wave Doppler patterns reliably reflect clinical severity in patients with coarctation of the aorta. Congenit Heart Dis. Nov-Dec 2008;3(6):422-30. [Medline].

  25. Mohiaddin RH, Kilner PJ, Rees S, Longmore DB. Magnetic resonance volume flow and jet velocity mapping in aortic coarctation. J Am Coll Cardiol. Nov 1 1993;22(5):1515-21. [Medline].

  26. Pitlick PT, Anthony CL, Moore P, Shifrin RY, Rubin GD. Three-dimensional visualization of recurrent coarctation of the aorta by electron-beam tomography and MRI. Circulation. Jun 15 1999;99(23):3086-7. [Medline].

  27. Rao PS, Chopra PS. Role of balloon angioplasty in the treatment of aortic coarctation. Ann Thorac Surg. Sep 1991;52(3):621-31. [Medline].

  28. Rao PS, Chopra PS, Koscik R, et al. Surgical versus balloon therapy for aortic coarctation in infants < or = 3 months old. J Am Coll Cardiol. May 1994;23(6):1479-83.

  29. [Guideline] Lopez-Sendon J, Swedberg K, McMurray J, et al. Expert consensus document on beta-adrenergic receptor blockers. Eur Heart J. Aug 2004;25(15):1341-62. [Medline].

  30. [Best Evidence] Frobel AK, Hulpke-Wette M, Schmidt KG, Läer S. Beta-blockers for congestive heart failure in children. Cochrane Database Syst Rev. Jan 21 2009;CD007037. [Medline].

  31. Liberthson RR, Pennington DG, Jacobs ML, Daggett WM. Coarctation of the aorta: review of 234 patients and clarification of management problems. Am J Cardiol. Apr 1979;43(4):835-40. [Medline].

  32. Lacour-Gayet F, Bruniaux J, Serraf A, Chambran P, Blaysat G, Losay J. Hypoplastic transverse arch and coarctation in neonates. Surgical reconstruction of the aortic arch: a study of sixty-six patients. J Thorac Cardiovasc Surg. Dec 1990;100(6):808-16. [Medline].

  33. Krauser DG, Rutkowski M, Phoon CK. Left ventricular volume after correction of isolated aortic coarctation in neonates. Am J Cardiol. Apr 1 2000;85(7):904-7, A10. [Medline].

  34. Pinzon JL, Burrows PE, Benson LN, Moës CA, Lightfoot NE, Williams WG. Repair of coarctation of the aorta in children: postoperative morphology. Radiology. Jul 1991;180(1):199-203.

  35. Parikh SR, Hurwitz RA, Hubbard JE, Brown JW, King H, Girod DA. Preoperative and postoperative "aneurysm" associated with coarctation of the aorta. J Am Coll Cardiol. May 1991;17(6):1367-72. [Medline].

  36. Parks WJ, Ngo TD, Plauth WH Jr, Bank ER, Sheppard SK, Pettigrew RI. Incidence of aneurysm formation after Dacron patch aortoplasty repair for coarctation of the aorta: long-term results and assessment utilizing magnetic resonance angiography with three-dimensional surface rendering. J Am Coll Cardiol. Jul 1995;26(1):266-71. [Medline].

  37. Chiesa R, Melissano G, Civilini E, Bertoglio L, Setacci F, Baccellieri D. Giant aneurysm 25 years after patch aortoplasty for aortic coarctation. Tex Heart Inst J. 2008;35(2):220-1. [Medline].

  38. Rao PS. Neurologic complications following balloon angioplasty. Pediat Cardiol. 1993;14:63-4.

  39. Mendelsohn AM, Crowley DC, Lindauer A, Beekman RH 3rd. Rapid progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta. J Am Coll Cardiol. Aug 1992;20(2):381-5. [Medline].

  40. Crawford FA, Sade RB. Spinal cord injury associated with hyperthermia during aortic coarctation repair. J Thorac Cardiovasc Surg. 1984;87:610-6.

  41. Brewer LA, III, Fosburg RG, Mulder GA, et al. Spinal cord complications following surgery for coarctation of the aorta: a study of 66 cases. J Thorac Cardiovasc Surg. 1992;64:368-80.

  42. Connolly JE. Hume Memorial lecture. Prevention of spinal cord complications in aortic surgery. Am J Surg. Aug 1998;176(2):92-101. [Medline].

  43. Sealy WC, Harris JS, Young WG Jr, Callaway HA Jr. Paradoxical hypertension following resection of coarctation of aorta. Surgery. Jul 1957;42(1):135-47. [Medline].

  44. Ho ECK, Moss AJ. The syndrome of mesenteric arteriitis following surgical repair of aortic coarctation. Pediat. 1972;49:40-5.

  45. Tabbutt S, Nicolson SC, Adamson PC, Zhang X, Hoffman ML, Wells W. The safety, efficacy, and pharmacokinetics of esmolol for blood pressure control immediately after repair of coarctation of the aorta in infants and children: a multicenter, double-blind, randomized trial. J Thorac Cardiovasc Surg. Aug 2008;136(2):321-8. [Medline].

  46. Kittle CF, Schafer PW. Gangrene of the forearm after subclavian arterio-aortostomy for coarctation of the aorta. Thorax. 1953;8:319-22.

  47. Geiss D, Williams WG, Lindsay WK, Rowe RD. Upper extremity gangrene: a complication of subclavian artery division. Ann Thorac Surg. Nov 1980;30(5):487-9. [Medline].

  48. Todd PJ, Dangerfield PH, Hamilton DI, Wilkinson JL. Late effects on the left upper limb of subclavian flap aortoplasty. J Thorac Cardiovasc Surg. May 1983;85(5):678-81. [Medline].

  49. van Son JA, van Asten WN, van Lier HJ, Daniels O, Vincent JG, Skotnicki SH. Detrimental sequelae on the hemodynamics of the upper left limb after subclavian flap angioplasty in infancy. Circulation. Mar 1990;81(3):996-1004. [Medline].

  50. Maddali MM, Menon RG, Valliattu J, Maimouna HA. Left upper limb shortening following reverse flap subclavian artery angioplasty. Asian Cardiovasc Thorac Ann. Aug 2008;16(4):346-7. [Medline].

  51. Rao PS, Galal O, Smith PA, Wilson AD. Five- to nine-year follow-up results of balloon angioplasty of native aortic coarctation in infants and children. J Am Coll Cardiol. Feb 1996;27(2):462-70. [Medline].

  52. Rao PS. Balloon angioplasty for coarctation of the aorta in infancy. J Pediatr. May 1987;110(5):713-8. [Medline].

  53. Rao PS. Current status of balloon angioplasty for neonatal and infant aortic coarctation. Progress Pediat Cardiol. 2001;14:35-44.

  54. Rao PS. Rao PS (ed). Demographic features of tricuspid atresia in Tricuspid Atresia. 2nd Ed. NY, Futura: Mt. Kisco; 1992:pp. 23-37.

  55. Tracy EP, Duncan WJ, Tyrrell MJ, et al. Neurological complications of balloon angioplasty in children. Pediat Cardiol. 1991;12:98-101.

  56. Lock JE, Bass JL, Amplatz K, Fuhrman BP, Castaneda-Zuniga W. Balloon dilation angioplasty of aortic coarctations in infants and children. Circulation. Jul 1983;68(1):109-16. [Medline].

  57. Rao PS, Galal O, Wilson AD. Feasibility and effectiveness of repeated balloon dilatation of restenosed congenital obstructions after previous balloon valvuloplasty/angioplasty. Am Heart J. Aug 1996;132(2 Pt 1):403-7. [Medline].

  58. Rao PS, Wilson AD, Chopra PS. Immediate and follow-up results of balloon angioplasty of postoperative recoarctation in infants and children. Am Heart J. Dec 1990;120(6 Pt 1):1315-20. [Medline].

  59. Tynan M, Finley JP, Fontes V, Hess J, Kan J. Balloon angioplasty for the treatment of native coarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol. Mar 15 1990;65(11):790-2. [Medline].

  60. Rao PS. Should Balloon Angioplasty be Used as a Treatment of Choice for Native Aortic Coarctations?. J Invasive Cardiol. Sep 1996;8(7):301-313. [Medline].

  61. Rao PS. Stents in the management of congenital heart disease in pediatric and adult patients. Indian Heart J. Nov-Dec 2001;53(6):714-30. [Medline].

  62. Rao PS, Jureidini SB, Balfour IC, et al. Severe aortic coarctation in infants less than 3 months: successful palliation by balloon angioplasty. J Intervent Cardiol. 2003;15:203-208.

  63. Lababidi Z. Percutaneous balloon coarctation angioplasty: long-term results. J Interv Cardiol. Mar 1992;5(1):57-62. [Medline].

  64. Rao PS. Long-term follow-up results after balloon dilatation of pulmonic stenosis, aortic stenosis, and coarctation of the aorta: a review. Prog Cardiovasc Dis. Jul-Aug 1999;42(1):59-74. [Medline].

  65. Attia IM, Lababidi ZA. Early results of balloon angioplasty of native aortic coarctation in young adults. Am J Cardiol. Apr 15 1988;61(11):930-1. [Medline].

  66. Rao PS. Coarctation of the aorta. Curr Cardiol Rep. Nov 2005;7(6):425-34. [Medline].

  67. Fawzy ME, Fathala A, Osman A, Badr A, Mostafa MA, Mohamed G. Twenty-two years of follow-up results of balloon angioplasty for discreet native coarctation of the aorta in adolescents and adults. Am Heart J. Nov 2008;156(5):910-7. [Medline].

  68. Shaddy RE, Boucek MM, Sturtevant JE, Ruttenberg HD, Jaffe RB, Tani LY. Comparison of angioplasty and surgery for unoperated coarctation of the aorta. Circulation. Mar 1993;87(3):793-9. [Medline].

  69. Shim D, Lloyd TR, Moorehead CP, Bove EL, Mosca RS, Beekman RH 3rd. Comparison of hospital charges for balloon angioplasty and surgical repair in children with native coarctation of the aorta. Am J Cardiol. Apr 15 1997;79(8):1143-6. [Medline].

  70. Marvin WJ, Mahoney LT, Rose EF. Pathologic sequelae of balloon dilation angioplasty of unoperated coarctation of the aorta in children (Abstract). J Am Coll Cardiol. 1986;7:117A.

  71. Cooper RS, Ritter SB, Rothe WB, Chen CK, Griepp R, Golinko RJ. Angioplasty for coarctation of the aorta: long-term results. Circulation. Mar 1987;75(3):600-4. [Medline].

  72. Cowley CG, Orsmond GS, Feola P, McQuillan L, Shaddy RE. Long-term, randomized comparison of balloon angioplasty and surgery for native coarctation of the aorta in childhood. Circulation. Jun 28 2005;111(25):3453-6. [Medline].

  73. Rodes-Cabau J, Miro J, Dancea A, Ibrahim R, Piette E, Lapierre C. Comparison of surgical and transcatheter treatment for native coarctation of the aorta in patients > or = 1 year old. The Quebec Native Coarctation of the Aorta study. Am Heart J. Jul 2007;154(1):186-92. [Medline].

  74. Ebels T, Maruszewski B, Blackstone EH. What is the preferred therapy for patients with aortic coarctation--the standard gamble and decision analysis versus real results?. Cardiol Young. Feb 2008;18(1):18-21. [Medline].

  75. Rao PS. Balloon angioplasty of aortic coarctation: a review. Clin Cardiol. Nov 1989;12(11):618-28. [Medline].

  76. Hager A, Schreiber C, Nutzl S, Hess J. Mortality and restenosis rate of surgical coarctation repair in infancy: a study of 191 patients. Cardiology. 2009;112(1):36-41. [Medline].

  77. Bacha EA. Long-term outcomes after coarctation repair in infancy. Cardiology. 2009;112(1):35. [Medline].

  78. Singer MI, Rowen M, Dorsey TJ. Transluminal aortic balloon angioplasty for coarctation of the aorta in the newborn. Am Heart J. Jan 1982;103(1):131-2. [Medline].

  79. Kan JS, White RI Jr, Mitchell SE, Farmlett EJ, Donahoo JS, Gardner TJ. Treatment of restenosis of coarctation by percutaneous transluminal angioplasty. Circulation. Nov 1983;68(5):1087-94. [Medline].

  80. Hess J, Mooyaart EL, Busch HJ, Bergstra A, Landsman ML. Percutaneous transluminal balloon angioplasty in restenosis of coarctation of the aorta. Br Heart J. May 1986;55(5):459-61. [Medline].

  81. Lorber A, Ettedgui JA, Baker EJ, Jones OD, Reidy J, Tynan M. Balloon aortoplasty for recoarctation following the subclavian flap operation. Int J Cardiol. Jan 1986;10(1):57-63. [Medline].

  82. Saul JP, Keane JF, Fellows KE, Lock JE. Balloon dilation angioplasty of postoperative aortic obstructions. Am J Cardiol. Apr 15 1987;59(9):943-8. [Medline].

  83. Rao PS. Which aortic coarctations should we balloon-dilate?. Am Heart J. Apr 1989;117(4):987-9. [Medline].

  84. Hellenbrand WE, Allen HD, Golinko RJ, Hagler DJ, Lutin W, Kan J. Balloon angioplasty for aortic recoarctation: results of Valvuloplasty and Angioplasty of Congenital Anomalies Registry. Am J Cardiol. Mar 15 1990;65(11):793-7. [Medline].

  85. Anjos R, Qureshi SA, Rosenthal E, et al. Determinents of hemodynamic results of balloon dilation of aortic recoarctation. Am J Cardiol. 1992;69:665-71.

  86. Reich O, Tax P, Bartakova H, et al. Long-term (up to 20 years) results of percutaneous balloon angioplasty of recurrent aortic coarctation without use of stents. Eur Heart J. Aug 2008;29(16):2042-8.

  87. Yetman AT, Nykanen D, McCrindle BW, Sunnegardh J, Adatia I, Freedom RM. Balloon angioplasty of recurrent coarctation: a 12-year review. J Am Coll Cardiol. Sep 1997;30(3):811-6. [Medline].

  88. Minich LL, Beekman RH, Rocchini AP, et al. Surgical repair is safe and effective after unsuccessful balloon angioplasty of native coarctation of the aorta. J Am Coll Cardiol. 1993;19:389-3.

  89. Zollikofer CL, Antonucci F, Stuckmann G, Mattias P, Salomonowitz EK. Historical overview on the development and characteristics of stents and future outlooks. Cardiovasc Intervent Radiol. Sep-Oct 1992;15(5):272-8. [Medline].

  90. Rao PS. Stents in treatment of aortic coarctation. J Am Coll Cardiol. Dec 1997;30(7):1853-5. [Medline].

  91. O'Laughlin MP, Perry SB, Lock JE, Mullins CE. Use of endovascular stents in congenital heart disease. Circulation. Jun 1991;83(6):1923-39. [Medline].

  92. Reddington AN, Hayes AM, Ho SY:. Transcatheter stent implantation to treat aortic coarctation in infancy. Br Heart J. 1993;69:80-2.

  93. Suarez de Lezo J, Pan M, et al. Balloon-expandable stent repair of severe coarctation of aorta. Am Heart J. May 1995;129(5):1002-8. [Medline].

  94. Rosenthal E, Qureshi SA, Tynan M. Stent implantation for aortic recoarctation. Am Heart J. Jun 1995;129(6):1220-1. [Medline].

  95. Bulbul ZR, Bruckheimer E, Love JC, Fahey JT, Hellenbrand WE. Implantation of balloon-expandable stents for coarctation of the aorta: implantation data and short-term results. Cathet Cardiovasc Diagn. Sep 1996;39(1):36-42. [Medline].

  96. Chander JS, Wolfe SB, Rao PS. Role of stents in the management of congenital heart disease. J Invasive Cardiol. 1996;8:314-25.

  97. Thanopoulos BV, Triposkiadis F, Margetakis A, Mullins CE. Long segment coarctation of the thoracic aorta: treatment with multiple balloon-expandable stent implantation. Am Heart J. Apr 1997;133(4):470-3. [Medline].

  98. Ebeid MR, Prieto LR, Latson LA. Use of balloon-expandable stents for coarctation of the aorta: initial results and intermediate-term follow-up. J Am Coll Cardiol. Dec 1997;30(7):1847-52. [Medline].

  99. Suarez de Lezo J, Pan M, Romero M, Medina A, Segura J, Lafuente M. Immediate and follow-up findings after stent treatment for severe coarctation of aorta. Am J Cardiol. Feb 1 1999;83(3):400-6. [Medline].

  100. Thanopoulos BD, Hadjinikolaou L, Konstadopoulou GN, et al. Stent treatment for coarctation of the aorta: intermediate-term follow-up and technical considerations. Heart. 1999;84:65-70.

  101. Magee AG, Brzezinsk-Rajszys G, Qureshi SA, et al. Stent implantation for aortic coarctation and re-coarctation. Heart. 1999;82:600-6.

  102. Marshall AC, Perry SB, Keane JF, Lock JE. Early results and medium-term follow-up of stent implantation for mild residual or recurrent aortic coarctation. Am Heart J. Jun 2000;139(6):1054-60. [Medline].

  103. Harrison DA, McLaughlin PR, Lazzam C, Connelly M, Benson LN. Endovascular stents in the management of coarctation of the aorta in the adolescent and adult: one year follow up. Heart. May 2001;85(5):561-6. [Medline].

  104. Cheatham JP. Stenting of coarctation of the aorta. Cathet Cardiovascu Intervent. 2001;54:112-25.

  105. Ledesma M, Alva C, Gomez FD, et al. Results of stenting for aortic coarctation. Am J Cardiol. Aug 15 2001;88(4):460-2. [Medline].

  106. Hamdan MA, Maheshwari S, Fahey JT, Hellenbrand WE. Endovascular stents for coarctation of the aorta: initial results and intermediate-term follow-up. J Am Coll Cardiol. Nov 1 2001;38(5):1518-23. [Medline].

  107. Santoro G, Carminati M, Bigazzi MC, Palladino MT, Russo MG, Sarubbi B. Primary stenting of native aortic coarctation. Tex Heart Inst J. 2001;28(3):226-7. [Medline].

  108. Tyagi S, Singh S, Mukhopadhyay S, Kaul UA. Self- and balloon-expandable stent implantation for severe native coarctation of the aorta in adults. Am Heart J. 2003;146:920-8.

  109. Rao PS. Edited by Rao PS, Kern MJ. Newer stents in the management of vascular stenosis in children. In: Catheter Based Devices in the Treatment of Non-coronary Cardiovascular Disease in Adults and Children. Philadelphia, PA: Lippincott, William & Wilkins; 2003:369-378.

  110. Pedra CA, Fontes VF, Esteves CA, Pilla CB, Braga SL, Pedra SR. Stenting vs. balloon angioplasty for discrete unoperated coarctation of the aorta in adolescents and adults. Catheter Cardiovasc Interv. Apr 2005;64(4):495-506. [Medline].

  111. Golden AB, Hellenbrand WE. Coarctation of the aorta: stenting in children and adults. Catheter Cardiovasc Interv. Feb 1 2007;69(2):289-99. [Medline].

  112. Holzer RJ, Chisolm JL, Hill SL, Cheatham JP. Stenting complex aortic arch obstructions. Catheter Cardiovasc Interv. Feb 15 2008;71(3):375-82. [Medline].

  113. Rao PS. Current status of balloon angioplasty for neonatal and infant aortic coarctation. Prog Pediatr Cardiol. 2001;14:35-44.

  114. Dehghani P, Collins N, Benson L, Horlick E. Role of routine radial artery access during aortic coarctation interventions. Catheter Cardiovasc Interv. Oct 1 2007;70(4):622-3. [Medline].

  115. Recto MR, Ing FF, Grifka RG, Nihill MR, Mullins CE. A technique to prevent newly implanted stent displacement during subsequent catheter and sheath manipulation. Catheter Cardiovasc Interv. Mar 2000;49(3):297-300. [Medline].

  116. Bonnhoeffer P, Piechaud J, Stumper O, et al. The multi-track angiography catheter: a new tool for complex catheterization in congenital heart disease. Heart. 1996;76:173-7.

  117. Forbes TJ, Moore P, Pedra CA, Zahn EM, Nykanen D, Amin Z. Intermediate follow-up following intravascular stenting for treatment of coarctation of the aorta. Catheter Cardiovasc Interv. Oct 1 2007;70(4):569-77. [Medline].

  118. Amirghofran AA, Peiravian F, Borzoee M, Emaminia A, Mollazadeh R. A wandering stent in the ascending aorta. J Cardiovasc Med (Hagerstown). Sep 2008;9(9):969-70. [Medline].

  119. Rohit MK, Garg PK, Talwar K. Stent fracture after stent therapy for aortic coarctation: nightmares in invasive cardiology. Indian Heart J. Jan-Feb 2007;59(1):77-9. [Medline].

  120. Qureshi AM, McElhinney DB, Lock JE, Landzberg MJ, Lang P, Marshall AC. Acute and intermediate outcomes, and evaluation of injury to the aortic wall, as based on 15 years experience of implanting stents to treat aortic coarctation. Cardiol Young. Jun 2007;17(3):307-18. [Medline].

  121. Schaeffler R, Kolax T, Hesse C, Peuster M. Implantation of stents for treatment of recurrent and native coarctation in children weighing less than 20 kilograms. Cardiol Young. Dec 2007;17(6):617-22. [Medline].

  122. Al-Ata J, Arfi AM, Hussain A, Kouatly A, Galal MO. Stent angioplasty: an effective alternative in selected infants with critical native aortic coarctation. Pediatr Cardiol. May-Jun 2007;28(3):183-92. [Medline].

  123. Hijazi ZM, Fahey JT, Kleinman CS, Hellenbrand WE. Balloon angioplasty for recurrent coarctation of aorta. Immediate and long-term results. Circulation. Sep 1991;84(3):1150-6. [Medline].

  124. Duke C, Rosenthal E, Qureshi SA. The efficacy and safety of stent redilatation in congenital heart disease. Heart. Aug 2003;89(8):905-12. [Medline].

  125. Zabal C, Attie F, Rosas M, Buendia-Hernandez A, Garcia-Montes JA. The adult patient with native coarctation of the aorta: balloon angioplasty or primary stenting?. Heart. Jan 2003;89(1):77-83. [Medline].

  126. Macdonald S, Thomas SM, Cleveland TJ, Gaines PA. Angioplasty or stenting in adult coarctation of the aorta? A retrospective single center analysis over a decade. Cardiovasc Intervent Radiol. Jul-Aug 2003;26(4):357-64. [Medline].

  127. Anagnostopoulos-Tzifa A. Management of aortic coarctation in adults: endovascular versus surgical therapy. Hellenic J Cardiol. Sep-Oct 2007;48(5):290-5. [Medline].

  128. Weber HS, Cyran SE. Endovascular stenting for native coarctation of the aorta is an effective alternative to surgical intervention in older children. Congenit Heart Dis. Jan 2008;3(1):54-9. [Medline].

  129. Gunn J, Cleveland T, Gaines P. Covered stent to treat co-existent coarctation and aneurysm of the aorta in a young man. Heart. Sep 1999;82(3):351. [Medline].

  130. De Giovanni JV. Covered stents in the treatment of aortic coarctation. J Intervent Cardiol. 2001;14:187-90.

  131. Forbes T, Matisoff D, Dysart J, Aggarwal S. Treatment of coexistent coarctation and aneurysm of the aorta with covered stent in a pediatric patient. Pediatr Cardiol. May-Jun 2003;24(3):289-91. [Medline].

  132. Ewert P, Peters B, Nagdyman N, Miera O, Kuhne T, Berger F. Early and mid-term results with the Growth Stent--a possible concept for transcatheter treatment of aortic coarctation from infancy to adulthood by stent implantation?. Catheter Cardiovasc Interv. Jan 1 2008;71(1):120-6. [Medline].

  133. Duggal B, Radhakrishnan S, Mathur A, Khurana P, Shrivastava S. Covered stents deployed for coarctation of aorta with aneurysm. Indian Heart J. Jul-Aug 2005;57(4):346-9. [Medline].

  134. Butera G, Piazza L, Chessa M, Negura DG, Rosti L, Abella R. Covered stents in patients with complex aortic coarctations. Am Heart J. Oct 2007;154(4):795-800. [Medline].

  135. Eicken A, Kaemmerer H, Ewert P. Treatment of aortic isthmus atresia with a covered stent. Catheter Cardiovasc Interv. Nov 15 2008;72(6):844-6. [Medline].

  136. Preventza O, Wheatley GH 3rd, Williams J, Ramaiah VG, Rodriguez-Lopez JA, Diethrich EB. Novel endovascular repair of the small thoracic aorta: customizing off-the-shelf endoluminal grafts. J Card Surg. Sep-Oct 2007;22(5):434-5. [Medline].

  137. Collins N, Mahadevan V, Horlick E. Aortic rupture following a covered stent for coarctation: delayed recognition. Catheter Cardiovasc Interv. Oct 2006;68(4):653-5. [Medline].

  138. Butera G, Gaio G, Carminati M. Redilation of e-PTFE covered CP stents. Catheter Cardiovasc Interv. Aug 1 2008;72(2):273-7. [Medline].

  139. Rao PS, Koscik R. Validation of risk factors in predicting recoarctation following initially successful balloon angioplasty of native aortic coarctations. Am Heart J. 1995;130:116-21.

  140. Kaine SF, Smith EO, Mott AR, Mullins CE, Geva T. Quantitative echocardiographic analysis of the aortic arch predicts outcome of balloon angioplasty of native coarctation of the aorta. Circulation. Sep 1 1996;94(5):1056-62. [Medline].

  141. Rao PS, Waterman B. Relation of biophysical response of coarcted aortic segment to balloon dilatation with development of recoarctation following balloon angioplasty of native coarctation. Heart. Apr 1998;79(4):407-11. [Medline].

  142. Isner JM, Donaldson RF, Fulton D, Bhan I, Payne DD, Cleveland RJ. Cystic medial necrosis in coarctation of the aorta: a potential factor contributing to adverse consequences observed after percutaneous balloon angioplasty of coarctation sites. Circulation. Apr 1987;75(4):689-95. [Medline].

  143. Ho SY, Somerville J, Yip WC, Anderson RH. Transluminal balloon dilation of resected coarcted segments of thoracic aorta: histological study and clinical implications. Int J Cardiol. Apr 1988;19(1):99-105. [Medline].

  144. Elzenga NH, Gittenberger-de Groot AC, Oppenhein-Dekker A. Coarctation and obstructive aortic arch anomalies; their relationship to the ductus arteriosus. Int J Cardiol. 1986;13:289-308.

  145. Russell GA, Berry PJ, Watterson K, Dhasmana JP, Wisheart JD. Patterns of ductal tissue in coarctation of the aorta in the first three months of life. J Thorac Cardiovasc Surg. Oct 1991;102(4):596-601. [Medline].

  146. Tamai H, Igaki K, Kyo E, Kosuga K, Kawashima A, Matsui S. Initial and 6-month results of biodegradable poly-l-lactic acid coronary stents in humans. Circulation. Jul 25 2000;102(4):399-404. [Medline].

  147. Schranz D, Zartner P, Michel-Behnke I, Akinturk H. Bioabsorbable metal stents for percutaneous treatment of critical recoarctation of the aorta in a newborn. Catheter Cardiovasc Interv. May 2006;67(5):671-3. [Medline].

  148. Ewert P, Abdul-Khaliq H, Peters B, Nagdyman N, Schubert S, Lange PE. Transcatheter therapy of long extreme subatretic aortic coarctations with covered stents. Catheter Cardiovasc Interv. Oct 2004;63(2):236-9. [Medline].

  149. Morris CD, Reller MD, Menashe VD. Thirty-year incidence of infective endocarditis after surgery for congenital heart defect. JAMA. Feb 25 1998;279(8):599-603. [Medline].

  150. Bobby JJ, Emami JM, Farmer RD, Newman CG. Operative survival and 40 year follow up of surgical repair of aortic coarctation. Br Heart J. May 1991;65(5):271-6. [Medline].

  151. Saidi AS, Bezold LI, Altman CA, Ayres NA, Bricker JT. Outcome of pregnancy following intervention for coarctation of the aorta. Am J Cardiol. Sep 15 1998;82(6):786-8. [Medline].

  152. Crafoord O, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Cardiovasc Surg. 1945;14:347-361.

  153. Dotter CT. Transluminally placed coil spring endarterial grafts. Invest Radiol. 1969;4:654-70.

  154. Gross RE, Hufnagl CA. Coarctation of the aorta: experimental studies regarding its surgical correction. N Engl J Med. 1945;233:287-291.

  155. Haji-Zeinali AM, Ghasemi M. Coarctoplasty with self-expandable stent implantation for treatment of coarctation of aorta in adults. Arch Iran Med. Oct 2006;9(4):348-53. [Medline].

  156. Ho SY, Anderson RH. Coarctation, tubular hypoplasia, and the ductus arteriosus. Histological study of 35 specimens. Br Heart J. Mar 1979;41(3):268-74. [Medline].

  157. Lababidi Z, Madigan N, Wu JR, Murphy TJ. Balloon coarctation angioplasty in an adult. Am J Cardiol. Jan 15 1984;53(2):350-1. [Medline].

  158. McCrindle BW, Jones TK, Morrow WR, Hagler DJ, Lloyd TR, Nouri S. Acute results of balloon angioplasty of native coarctation versus recurrent aortic obstruction are equivalent. Valvuloplasty and Angioplasty of Congenital Anomalies (VACA) Registry Investigators. J Am Coll Cardiol. Dec 1996;28(7):1810-7. [Medline].

  159. Qureshi SA, Zubrzycka M, Brzezinska-Rajszys G, Kosciesza A, Ksiazyk J. Use of covered Cheatham-Platinum stents in aortic coarctation and recoarctation. Cardiol Young. Feb 2004;14(1):50-4. [Medline].

  160. Rao PS. Faculty of 1000 Medicine: Evaluation of Cowley CG et al. Long-term, randomized comparison of balloon angioplasty and surgery for native coarctation of the aorta in childhood. Circulation. 2005; Jun 28;111 (25):3453-6. [Full Text].

  161. Rao PS. Fatal aortic rupture following balloon angioplasty of aortic recoarctation. Br Heart J. 1991;66:406-7.

  162. Rao PS. Pseudoaneurysm following balloon angioplasty of aortic coarctation (Editorial). Am Heart J. 1993;125:1205-6.

  163. Rao PS. Coarctation of the aorta. In: Ram CVS (ed). Secondary Forms of Hypertension, Seminars in Nephrology, Kurtzman NA (ed). 15(2). Philadelphia, PA: W.B. Saunders; 1995:81-105.

  164. Rao PS. Balloon angioplasty of native aortic coarctation. In: Rao PS (ed). Transcatheter Therapy in Pediatric Cardiology. New York, NY: Wiley-Liss; 1993:pp. 153-196.

  165. Rao PS. Transcatheter treatment of pulmonary stenosis and coarctation of the aorta: experience with percutaneous balloon dilatation. Br Heart J. Sep 1986;56(3):250-8. [Medline].

  166. Rao PS, Balfour IC, Singh GK, Jureidini SB, Chen S. Bridge stents in the management of obstructive vascular lesions in children. Am J Cardiol. Sep 15 2001;88(6):699-702. [Medline].

  167. Rao PS, Thapar MK, Kutayli F, Carey P. Causes of recoarctation after balloon angioplasty of unoperated aortic coarctation. J Am Coll Cardiol. Jan 1989;13(1):109-15. [Medline].

  168. Rao PS, Wilson AD, Brazy J. Transumbilical balloon coarctation angioplasty in neonates with critical aortic coarctation. Am Heart J. Dec 1992;124(6):1622-4. [Medline].

  169. Rao PS. Rao PS (ed). Balloon angioplasty for aortic recoarctation following previous surgery in Transcatheter Therapy in Pediatric Cardiology. New York, NY: Wiley-Liss; 1993:pp. 197-212.

  170. Rao PS. Technique of balloon valvuloplasty. In: Rao PS (ed). Transcatheter Therapy in Pediatric Cardiology, Wiley-Liss. New York, NY: 1993:pp 29-44.

  171. Siblini G, Rao PS, Nouri S, Ferdman B, Jureidini SB, Wilson AD. Long-term follow-up results of balloon angioplasty of postoperative aortic recoarctation. Am J Cardiol. Jan 1 1998;81(1):61-7. [Medline].

  172. Sos T, Sniderman KW, Rettek-Sos B, Strupp A, Alonso DR. Percutaneous transluminal dilatation of coarctation of thoracic aorta post mortem. Lancet. Nov 3 1979;2(8149):970-1. [Medline].

  173. Sperling DR, Dorsey TJ, Rowen M, Gazzaniga AB. Percutaneous transluminal angioplasty of congenital coarctation of the aorta. Am J Cardiol. Feb 1983;51(3):562-4. [Medline].

  174. Wong D, Benson LN, Van Arsdell GS, Karamlou T, McCrindle BW. Balloon angioplasty is preferred to surgery for aortic coarctation. Cardiol Young. Feb 2008;18(1):79-88. [Medline].

  175. Zellers TM. Balloon angioplasty for recurrent coarctation of the aorta in patients following staged palliation for hypoplastic left heart syndrome. Am J Cardiol. Jul 15 1999;84(2):231-3, A9. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

coarctation of the aorta, CoA, left ventricular obstruction, LV outflow tract obstruction, aortic arch obstruction, interrupted aortic arch, left ventricular hypertrophy, left ventricular afterload, aortic obstruction, bicuspid aortic valve, ventricular septal defect, VSD, left heart obstruction, aortic stenosis, heart defects, congenital heart disease, congestive heart failure, CHF, hypertension, perinatal circulatory insufficiency, Takayasu arteritis, transposition of the great arteries, Taussig-Bing anomaly, double-inlet left ventricle, tricuspid atresia, hypoplastic left heart syndrome, right ventricular outflow tract obstructions, tetralogy of Fallot, pulmonary atresia with intact ventricular septum, cerebral aneurysm, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

P Syamasundar Rao, MD, Professor of Pediatrics and Medicine, University of Texas-Houston Medical School; Director, Division of Pediatric Cardiology, Children's Memorial Hermann Hospital; Professor of Pediatrics, MD Anderson Cancer Center, University of Texas
P Syamasundar Rao, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Medical Association, American Pediatric Society, Medical Association of Georgia, Society for Cardiac Angiography and Interventions, Society for Pediatric Research, Southern Society for Pediatric Research, and Western Society for Pediatric Research
Disclosure: Nothing to disclose.

Coauthor(s)

Paul M Seib, MD, Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital
Paul M Seib, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, International Society for Heart and Lung Transplantation, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Medical Editor

Juan Carlos Alejos, MD, Clinical Professor, Department of Pediatrics, Division of Cardiology, University of California at Los Angeles
Juan Carlos Alejos, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Medical Association, and International Society for Heart and Lung Transplantation
Disclosure: Actelion Honoraria Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Julian M Stewart, MD, PhD, Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College
Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.