Miss Sathi was treated by many anti-hypertensive drugs. But her hypertension was not being controlled. Latter it was diagnosed as a case of Coarctation of Aorta. It was then operated on. Post op events were uneventful. Now she is fine and no more anti-hypertensive drugs needed.

1. Case Presentation
PresenterDr. Hriday Ranjan Roy
Assistant Professor,
Surgery
Rangpur Medical
College Hospital

2. Case Presentation
Miss Sathi, 24 years old, student, hailing
from Kishoreganj, admitted into this
hospital with the complaints of 1) Headache, dizziness and fatigue-2
years
2) Shortness of breath- 2 years.
3) Pain in leg after prolong walking- 2
years.

3. The patient states that she developed
headache, dizziness and fatigue two years
back. Symptoms gradually aggravated
during last two years. She also felt
tiredness and shortness of breath after
walking or heavy works. It was also
associated with leg cramps specially after
walking prolong distance. She had no H/O
rheumatic fever, asthma or cyanosis of
lower limbs.

4. For these above complaints, she attended to
local doctor and was diagnosed as a case
of hypertension and absent of lower limb
pulses.
She had no family history of the same
disease. Her menstrual history is normal.
She used to take ARB (Losartan potassium)
and Beta blocker (tenoren) to control her
hypertension.

5. General examination on admission
Appearance – normal
No anemia, jaundice or cyanosis.
No edema or dehydration.
No clubbing or koilonychias.
Neck glands- not palpable.
JVP- not raised.
Pulse- 80/min
B.P- 185/95mmHG ( in arm)
Leg- not recordable.

6. CVS examination
Pulses
Radial
Brachial
Axillary
Carotid
Femoral
Popliteal
Post. Tibial
Dorsalis pedis
Right
+
+
+
+
-
Left
+
+
+
+
-

7. Precordium
Inspection- Normal
Palpation- Apex beat- left 5th ICS medial to
midclavicular line. No parasternal heave.
Auscultation- S1, S2- audible.
Added sound- An ejection systolic murmur over
left sternal border, more prominent over
posterior interscapular region.
Other system reveals no abnormality.
Provisional diagnosis- Coarctation of aorta

8. Diagnostic workout



CXRP/A view- no cardiomegaly, no rib
notching.
LAO view- normal.
ECG- normal.
Echo- 2D & M modeLVIDd- 42mm, LVIDs-27mm, EF-62%,
IVST- 10mm, PWT- 10mm, LA- 33mm,
AO- 38mm, ACS- 16mm.

9. Echo (cont….)
DescriptionLA, RA, RV, PA- Normal
LV- mild concentric hypertrophy.
AO- dilated.
IAS, IVS- intact.
MV- normal in appearance.
AV- Bicuspid with mild reduction in cusp separation.
A constriction suggestive of Coarctation of aorta seemed to
be present distal to left subclavian artery.
Impression1) Coarctation of aorta
2) Bicuspid aortic valve.
3) Mild concentric LV hypertrophy
4) Fair LV systolic function

10. Photograph of Echo

11. CXR P/A View

12. CXR lateral view

13. CXR LAO View

14. Cardiac catheterization
(Sheldinger)
PressureArch- 162/87mmHg
Descending aorta- 101/76mmHg.
Arch- There is a coarctation distal to the origin of
left subclavian artery. No PDA seen.
Descending aorta- Post stenotic dilatation. Both
renal arteries are normal.
Impression- Coarctation of aorta distal to left
subclavian artery.

15. Cardiac catheterization

16. Biochemical investigations
1)
2)
3)
4)
5)
6)
7)
8)
CBC- within normal limit.
RBS- 6.2mmol/L
Blood urea- 29mg%
S. creatinine- 1.0mg%
S. cholesterol- 137mg%.
LDL- 75mg%
HDL- 43mg%
S. Triglyceride- 10mg%.

17. Confirmed diagnosis
Coarctation of Aorta.

18. Surgery was done on 11/4/2007 under
G/A.
Incision- Left postero-lateral thoracotomy through 4 th
ICS.
Identification of coarctation (just distal to left
subclavian artery).
Dissection and control of aorta proximal and distal
to coarctation as well as left subclavian artery.
PDA was found distal to coarctation. Multiple ligation
of PDA done (after reducing B.P with
nitroprusside).
Aortotomy, excision of posterior shelf and
aortoplasty was done using PTFE onlay patch.

19. Patient position

20. Incision

21. Left lateral thoracotomy

22. Dissection and mobilization

23. Mobilization and control

24. The procedure ( internet)

25. Post operative CXR

26. Post operative periods
1)
2)
Uneventful
Hypertension was controlled by GTN.
Outcome1) Immediate appearance of lower limb pulses.
2) Improvement of symptoms.
3) Reduction of anti-hypertensive drug doses.
4) Reduction of brachiocephalic hypertension.

27. She is
Her happiness is our satisfaction
happy

28. THANK
YOU
ALL