Cardiology>>>>>Adult Congenital Heart Disease and Pregnancy
Question 4#

You receive a letter from a GP asking if a patient requires follow-up in clinic. She is 35 years old and has not been seen since discharge from the paediatric cardiology services. She had a coarctation repair in childhood with no associated lesions. You have the surgical information, which documents a Dacron patch aortoplasty technique with excellent result and no residual stenosis. She is otherwise well with BP 120/80 mmHg. She has normal peripheral pulses and no murmurs. She has had two successful pregnancies.  What should you advise the GP?

A) She should have an echocardiogram and if this demonstrates normal structure and velocities in the descending aorta, based on normal blood pressure and clinical examination she does not require regular follow-up
B) She does not require follow-up but should be referred to the pregnancy clinic if she decides to have more children
C) She does not require any follow-up as surgical repair of coarctation has excellent long-term results
D) She will require long-term follow-up in a specialist clinic; an MRI will be the investigation of choice to document the previous repair and any associated problems
E) She should have an ambulatory blood pressure recording and if there is no evidence of hypertension there is no indication to explore any further; if there is evidence of hypertension she should have a CT scan to look for re-coarctation

Correct Answer is D

Comment:

The Dacron patch aortoplasty technique has been shown to be associated with a risk of late aneurysm formation. Therefore there may not be any evidence of re-coarctation but a risk of aneurysm in this patient. MRI will be the best follow-up modality as it will provide structural and physiological data without radiation. The brain should also be scanned to look for berry aneurysms. If a patient has had a coarctation stent, MRI does not have the resolution of CT in detecting stent fracture and the latter may be preferable depending on the situation. The other common surgical techniques for coarctation repair are end-to-end anastomosis and subclavian flap repair (left sublavian artery is used to augment coarctation site). These can be associated with re-coarctation or pseudo-aneurysm and require long-term follow-up for BP control and the possibility of transcatheter stenting.