Evaluating coarctation repairs

Stenting is the preferred form of repairing a coarctation, but not every situation is suited to this procedure. There are three possible outcomes after a coarctation repair—and only one of these is a good one! In this video, from our Echo Masterclass: Adult Congenital Heart Disease course, you'll learn about what can go wrong after a coarctation repair, how to evaluate a repair long after it's been done, and the important things to keep in mind.

Flustered at the thought of performing an adult congenital echo? Don’t be! In our Echo Masterclass: Adult Congenital Heart Disease course, you’ll learn about the lesions associated with common types of defects, as well as the common surgical repair complications. Explore the hemodynamics of intracardiac defects, master key assessment strategies (such as the sequential segmental approach), and know what to leave out of the echo report.

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[00:00:00] We've already learned how to diagnose coarctation of the aorta, so now let's talk about how it is repaired. Let's start with this aortic arch with a tight coarctation. It causes pressure to build up in the brain and the heart and results in reduced blood flow down to the gut and the legs. That's not good so how do we fix this problem? Here's a real case of a patient with a very narrow coarctation. It's a pretty discrete or focal narrowing, so it can be opened up with a stent. This particular patient

[00:00:30] had a pretty nice result from the coarctation stenting and done with minimal invasion through the groin which means no scars. Stenting is currently the preferred form of repair of coarctation but not every case is well suited for this type of procedure. Coarctations can occur at the top of the arch or involve the head and neck vessels and this makes stenting very difficult so surgery is required. It might even involve repairing the head and neck vessels themselves. There have been a lot of different approaches to surgery in the past. So if you're scanning a patient with a repaired coarctation,

[00:01:00] it's good to know what type of repair they've had. For most of the repairs, though, the features to watch out for are similar. There are really three things that can happen. The first and best result is that everything works amazingly well, the repair holds and there's no concern. The second is that despite having a repair, sometimes there can be scar lines or the material shrinks or the coarctation just narrows up again in the adjacent tissue. So renarrowing is definitely something to watch out for. Assess this in the same way as the original coarctation. And the third thing that can happen

[00:01:30] is just the opposite. The tissue abnormality within the aortic wall can go the other way and turn into an aneurysm. Let's have a look at a real case. Here's a 45-year-old male patient with the previous coarctation repair. He presented with ongoing hypotension. As often happens, the area of repair is fairly unclear in the suprasternal view. The color certainly doesn't look [inaudible 00:01:51]. Maybe everything's okay. The Doppler tells us that there is no significant gradient but look at diastole. Let's check out the abdominal aortic Doppler flow.

[00:02:00] Interestingly, the Doppler from the abdominal aorta looks pretty normal. The systolic flow drops back to the baseline before continuing throughout diastole. That's a normal flow profile. So what could be causing diastolic flow in the aortic arch but not in the abdominal aorta? Well, this might explain it. This is the aortic arch enhanced with ultrasound contrast. It shows a huge aneurism at the repair site. Magnetic Resonance Imaging shows it beautifully. So the diastolic flow on the Doppler trace

[00:02:30] was blood swirling around within the circular aneurysm. Coarctations can be repaired but shouldn't be forgotten. The various types of repairs work really well in the majority of patients but complications are well described.