Background

Coarctation of the aorta is a narrowing of the aorta most commonly found just distal to the origin of the left subclavian artery. This malformation is mostly discovered in the birth by the systematic palpation of the femoral pulses, but can be later diagnosed at the big child’s even at the adult. 

Casa Presensation:

We report here the case of a 32-year-old young man, who is treated for hypertension since two years and to whom a thoracic scanner realized for the assessment of a chronic cough revealed an aortic coarctation.

Conclusions

This observation reminds us that resistant hypertension in young adults justifies the search for a curable cause. Concerning the association between pregnancy and aortic coarctation, the literature, less alarming than twenty years ago, encourages a wait-and-see and "armed" attitude by favouring a natural delivery.

Coarctation of the aorta is a narrowing of the aorta most commonly found just distal to the origin of the left subclavian artery. This malformation is mostly discovered in the birth by the systematic palpation of the femoral pulses, but can be later diagnosed at the big child’s even at the adult. 

Case Presentation

We report a case of coarctation of the aorta discovered incidentally in a 32-year-old pregnant patient with newly discovered hypertension. An etiological work-up in search of a curable cause was negative a few years ago. A cardiological opinion is motivated by the observation of an unbalanced hypertension, in spite of a dual therapy associating clonidine and propranolol, in this patient at 37 and a half weeks of amenorrhea. This asymptomatic hypertension, without clinical signs of pre-eclampsia, was associated with intrauterine growth retardation detected in the third trimester of pregnancy Cardiac auscultation revealed an intense systolic murmur, medio-thoracic, radiating to the supra-clavicular recesses and the back. The femoral pulses are perceived, their amplitude is weak Blood pressure asymmetry is noted: 220/70 mmHg in the right arm, 150/70 mmHg in the left arm, and the systolic blood pressure of the lower limbs, measured with a continuous doppler, does not exceed 110 mmHg. The ECG is unremarkable: among other things, there is no left ventricular hypertrophy.               The echocardiography identified a moderately dilated left ventricle (LVd at 62 mm), not very hypertrophic with a preserved systolic function (EF at 69%), a minimal mitral insufficiency without aortic valve disease with a good focus of the ventricular.

The aortic arch is not identifiable supra-sternally, but blind continuous Doppler with the Pedoff probe shows a presumed transisthmic gradient calculated at 74 mmHg (Figure 1). Two diagnoses were then evoked: coarctation or hypoplasia of the aortic arch. A caesarean delivery was decided upon at 38 weeks, resulting in the birth of a 2250 g baby girl with an APGAR score of 10. Subsequently, the work-up was completed by magnetic resonance angiography (Figure 2, p. 19) which confirmed the existence of an extremely tight, almost completely occlusive aortic coarctation of the isthmic aorta immediately downstream of the start of the left subclavian. There is also a highly developed network of collaterals (intercostal, bronchial and parietal). 

Figure 1: Continuous supra-sternal flow Doppler flow: maximum pressure gradient estimated at 74 mmHg

Figure 2: Extremely tight coarctation of the isthmic aorta immediately downstream of the origin of the left subclavian. Highly developed collateral network

A surgical operation with placement of an aortaortic tube was performed two months after delivery, with simple postoperative care and normalization of blood pressure values in the absence of any drug treatment.

Early diagnosis and surgical treatment have considerably reduced the frequency of coarctation in young adults; this diagnosis is currently made exceptionally in pregnant and hypertensive women, especially in patients with difficult-to-control hypertension and asymmetric blood pressure. The discovery of an aortic coarctation is classically associated with a high maternal mortality (3 to 10

This observation reminds us that resistant hypertension in young adults justifies the search for a curable cause. Concerning the association between pregnancy and aortic coarctation, the literature, less alarming than twenty years ago, encourages a wait-and-see and "armed" attitude by favouring a natural delivery

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Consent For Publication

In accordance with international and academic standards, written consent for publication was obtained from the patient and retained by the authors

Conflicts of Interest

The authors declared no conflicts of interest

Funding

By myself

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Authors Contributions

-BNA: white the article

-NM: research bibliography

-FA: proofreading

-MK, SA, BG, AD, LA, DP, RH: corrected the article

This work was carried out in collaboration between all the authors. All authors have read and approved the final manuscript.

Acknowledgements

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Authors Informations: Cardiology department in CHU IBN ROCH OF CASABLANCA TO MORROCO and HOSPITAL SENS TO FRANCE