The Department of Emergency Medicine at Carolinas Medical Center is passionate about education! Dr. Michael Gibbs is a world-renowned clinician and educator and has helped guide numerous young clinicians on the long path of Mastery of Emergency Medical Care. With his oversight, the EMGuideWire team aim to help augment our understanding of emergent imaging. You can follow along with the EMGuideWire.com team as they post these monthly educational, self-guided radiology slides or you can also use this section to learn more in-depth about specific conditions and diseases. This Radiology Reading Room pertains to Pediatric and Adult Aortic Coarctation and is brought to you by Jennifer Potter, MD and Elizabeth Olson, MD.

1. Pediatric And Adult Aortic Coarctation
Elizabeth Olson, MD & Jennifer Potter, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD, Faculty Editor
The Chest X-Ray Mastery Project™

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: PEDIATRIC AND ADULT AORTIC COARCTATION.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. CASE #1
11-day-old born at full term
with 2 days of progressive
respiratory distress, grunting
and decreased PO intake.

8. Coarctation Of The Aorta
CASE #1
11-day-old born at full term
with 2 days of progressive
respiratory distress, grunting
and decreased PO intake.

9. CASE #2
5-day-old full term found to
have a heart murmur after
delivery.

10. Coarctation Of The Aorta
CASE #2
5-day-old full term found to
have a heart murmur after
delivery.

11. Coarctation Of The Aorta (CoA)
EARLY detection is IMPORTANT!!
Late repair of CoA is associated with an increased
risk of coronary artery disease in early adulthood.

12. Clinical Presentation of CoA in Neonates/Infants
Signs/Symptoms
• Can present in shock during first
6-8 weeks
• Decreased femoral arterial pulse
compared to right brachial
artery
• Heart murmur
• Cyanosis
Associated conditions
• Bicuspid aortic valve
• VSD
• PDA
• Mitral valve stenosis
• Hypoplastic aortic arch
• Subaortic membrane or stenosis
• Turner’s Syndrome
• Intracranial berry aneurysm
Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the
Neonates and the Infant with Short and Long Term Implications.”

13. Work up of CoA in Neonates/Infants
In the ED
• EKG
• LVH
• Flat ST segment or T waves
• CXR
• Enlarged heart
• Pulmonary venous
congestion
• Its too early to see “classic”
rib notching
Beyond the ED
• Formal Echocardiogram
Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the
Neonates and the Infant with Short and Long Term Implications.”

14. Treatment of CoA in Neonates/Infants in the ED
DOs
• Prostaglandin E1 or E2
• Start at 5.0-15.0 ng/kg/min
• Max 100 ng/kg/min –beware of
increased risk of apnea at higher
doses
• Can be administered via
peripheral access or IO
• Inotropes
• Dopamine, dobutamine, and
epinephrine
• Needs central access
DON’Ts
• Hyperventilation
• High FiO2
• Vasodilators
• Cautious use of fluids
• Consider 5 ml/kg boluses
• Re-evaluate for signs of heart
failure with each bolus
• Do not chase with diuretics as
this can make things WORSE
Joshi, Gitika, et al. “Presentation of Coarctation of the Aorta in the
Neonates and the Infant with Short and Long Term Implications.”

15. Healthy Adult
Patient With
Chest Pain.

16. Healthy Adult
Patient With
Chest Pain.
Why Would A
Patient Have
Cardiomegaly
And Inferior
“Notching” Of
Ribs?

17. Why Would A
Patient Have
Cardiomegaly
And Inferior
“Notching” Of
Ribs?
Coarctation Of The Thoracic Aorta
Healthy Adult
Patient With
Chest Pain.

18. Healthy Adult
Patient With
Chest Pain.
Coarctation Of The Thoracic Aorta

19. Healthy Adult
Patient With
Chest Pain.
Coarctation Of The Thoracic Aorta

20. Coarctation – Stent Graft Placed
Thoracic Endovascular Aortic Repair [TEVAR]

21. 35-Year-Old
Healthy Male
Evaluated After A
Fall.
What do you
notice?

22. 35-Year-Old
Healthy Male
Evaluated After A
Fall.
Cardiomegaly
And Inferior
“Notching” Of
Ribs

23. 35-Year-Old
Healthy Male
Evaluated After A
Fall.
Coarctation Of The Thoracic Aorta

24. 35-Year-Old
Healthy Male
Evaluated After A
Fall.
Coarctation Of The Thoracic Aorta

25. Aortic Coarctation In Adults Can Be An
Incidental Finding In Patients Who Are
Asymptomatic.

26. 42-Year-Old Found To Have Coarctation On An Outpatient Echocardiogram.

27. 42-Year-Old Found To Have Coarctation On An Outpatient Echocardiogram.
Thoracic Endovascular Aortic Repair [TEVAR].

28. 53-Year-Old Found To Have Coarctation On A Preoperative Echocardiogram.

29. 53-Year-Old Found To Have Coarctation On A Preoperative Echocardiogram.
Thoracic Endovascular Aortic Repair [TEVAR].

30. 53-Year-Old Found To Have Coarctation On A Preoperative Echocardiogram.
Thoracic Endovascular Aortic Repair [TEVAR].

31. Why Does Coarctation Cause Rib Notching?
• The descending aorta is stenotic and therefore collateral flow is needed.
• The collateral pathway is via the subclavian artery to the internal
thoracic artery to the anterior intercostal artery to the posterior
intercostal artery and then to the descending thoracic aorta.
• The dilated, tortuous vessels erode the lower rib margins, seen most
commonly in ribs 4 – 8.
• Notching seen in 70% of cases presenting in older children or adults.

32. Coarctation Of The Thoracic Aorta

33. Coarctation Of The Thoracic Aorta

34. Coarctation Of The Thoracic Aorta

35. Coarctation Of The Thoracic Aorta

37. Stout KK. Circulation 2019; 139:e698-e800.
Coarctation Of The Thoracic Aorta In Adults
Clinical Features
 Hypertension in right arm relative to the lower extremities
 Hyperdynamic carotid pulses
 A murmur may be heard over the left intrascapular position
 A continuous murmurs may be hear over parasternal areas
Presenting Symptoms
 May remain asymptomatic if collateral flow is adequate
 Hypertension – discrepant between the upper and lower extremities
 Increased proximal pressure [chest pain, headache, epistaxis]
 Decreased distal pressure [lower extremity claudication]

38. Coarctation Of The Thoracic Aorta In Adults
Chest X-Ray Findings
 Cardiomegaly
 An indentation at the coarctation may produce a “3-sign” beneath the
aortic arch
 Notching under ribs 3-9
ECG Findings
 Left ventricular hypertrophy
 Secondary ST-T changes due to strain
Stout KK. Circulation 2019; 139:e698-e800.

39. Stout KK. Circulation 2019; 139:e698-e800.

40. Stout KK. Circulation 2019; 139:e698-e800.

41. Stout KK. Circulation 2019; 139:e698-e800.

42. If You Have Interesting Cases Of Pediatric And Adult Aortic Coarctation, We
Invite You To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical
History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!