What are the physical findings in the early presentation of coarctation of the aorta (CoA)?

Updated: Nov 20, 2018
  • Author: Syamasundar Rao Patnana, MD; Chief Editor: Stuart Berger, MD  more...
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Answer

Neonates may be found to have tachypnea, tachycardia, and increased work of breathing and may even be moribund with shock. Keys to the diagnosis include blood pressure (BP) discrepancies between the upper and lower extremities and reduced or absent lower extremity pulses to palpation. However, when the infant is in severe heart failure, all pulses are diminished. Upon treatment for heart failure, prominent brachial pulses with weak or nonpalpable femoral arterial pulses may be discerned. Diminished pulses on examination should never be disregarded, since the digits appreciate the rate of change in BP, which may be diminished in ductally dependent coarctation, although the measured BP may not show discrepancies. In patients with an aberrant origin of the right subclavian artery from the aorta distal to the obstruction, such discrepancies in BP may not be present, although lower extremity pulses are diminished versus the carotid pulses.

Differential cyanosis (pink upper extremities with cyanotic lower extremities) may occur when right-to-left shunt across a patent ductus arteriosus provides flow to the lower body. Although often not obvious to the eye, differential cyanosis may be documented based on preductal and postductal pulse oximetry measurements and careful inspection. However, in the presence of lesions with large left-to-right shunt (eg, VSD), pulmonary artery saturations may approximate aortic saturations with less obvious differential oximetric findings. Reversed differential cyanosis (upper body cyanosis with normal lower-body oxygen saturation) may occur with transposition of the great arteries, patent ductus arteriosus, and pulmonary hypertension, resulting in right-to-left ductal shunting.

In patients with low cardiac output and ventricular dysfunction, pulses may be diminished diffusely, and BP gradients may seem minimal. Thus, in addition to coarctation, the differential diagnosis of perinatal circulatory insufficiency always includes left ventricular (LV) outflow obstruction, including aortic valve stenosis, subaortic stenosis, and supravalvar aortic stenosis, as well as severe mitral stenosis or insufficiency.

The murmur associated with coarctation of the aorta may be nonspecific yet is usually a systolic murmur in the left infraclavicular area and under the left scapula. Additional murmurs that result from the presence of associated abnormalities, such as VSD or aortic valve stenosis, may also be detected. An ejection click may signify the presence of a bicuspid aortic valve, whereas a gallop rhythm may indicate ventricular dysfunction.


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