Coarctation of the Aorta

Coarctation of the aorta is a narrowing of the aorta between the aortic arch and the iliac bifurcation commonly around the point of insertion of the ductus arteriosus. Coarctation of the aorta is typically congenital and the clinical presentation depends on the age of the patient. Neonates present with heart failure upon the closure of the ductus arteriosus, while children and adults present with hypoperfusion and/or hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension. Classic findings on physical exam include radio-/brachio-femoral delay and decreased blood pressure in the lower limbs. Diagnosis is confirmed by echocardiogram. Patients should be surgically managed as early as possible to avoid complications of hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension. Close follow-up is required as the risk of hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension and re-coarctation remain.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Coarctation of the aorta is a narrowing of the aorta caused by the thickening of the medial layer at a localized point, most commonly near the insertion of the ductus arteriosus.

Coarctation of the aorta-scr

Schematic representation of coarctation of the aorta

Image by Lecturio.

Types

  • Preductal: The narrowing is located proximally to the ductus arteriosus.
  • Postductal: The narrowing is located distally to the ductus arteriosus.
Illustration coarctation of aorta

Types of coarctation of the aorta

Image by Lecturio.

Epidemiology

  • Incidence in the United States: 4 per 10,000 live births
  • Accounts for approximately 6% of all congenital heart disease
  • More common in boys (2:1 men:women ratio)
  • Associated conditions:
    • Up to 15% of girls with coarctation of the aorta have Turner syndrome Turner syndrome Turner syndrome is a genetic condition affecting women, in which 1 X chromosome is partly or completely missing. The classic result is the karyotype 45,XO with a female phenotype. Turner syndrome is associated with decreased sex hormone levels and is the most common cause of primary amenorrhea. Turner Syndrome.
    • Accompanied by bicuspid aortic valve in over 70% of cases

Etiology and Pathophysiology

Etiology

  • Congenital: 
    • Accounts for most cases
    • Caused by intrauterine factors or genetic predisposition altering endothelial development and elasticity of the aorta
    • 2 accepted theories of development:
      • Tissue from the ductus arteriosus extends into the aorta.
      • Underdevelopment of the aortic arch results from reduced intrauterine blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure from the left ventricle (LV) through the aorta to the fetal body.
  • Acquired: This form may be seen in adult patients with aortitis secondary to Takayasu’s arteritis.

Pathophysiology

  • In utero and in neonates, the presence of the foramen ovale and the ductus arteriosus provide a physiological aortic bypass.
  • Heart failure begins to develop when the structures close after birth and the neonate begins to depend on the aorta for systemic circulation Systemic circulation Circulation is the movement of blood throughout the body through one continuous circuit of blood vessels. Different organs have unique functions and, therefore, have different requirements, circulatory patterns, and regulatory mechanisms. Systemic and Special Circulations.
  • The narrowing of the aorta causes increased afterload increasing systolic pressure in the LV and the proximal aorta.
  • In contrast, there is hypoperfusion of the tissues distal to the narrowing.
  • To compensate, the LV undergoes hypertrophy to maintain the ejection fraction.
  • To bypass the narrowing, collateral blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure develops through the inferior intercostal, internal mammary, and scapular arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries.
Collateral circulation in coarctation of the aorta

Collateral circulation composed of the inferior intercostal vessels develops to bypass the coarctation, which results in rib notching.

Image by Lecturio.

Clinical Presentation

Neonates

  • Asymptomatic while there is a patent ductus arteriosus Patent ductus arteriosus The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) ( PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA)
  • When the PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) closes, the patient presents with signs of heart failure (cyanosis, dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, diaphoresis, shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock).
  • In the physical exam:
    • Delayed or absent femoral pulses
    • Cyanotic and/or cold lower extremities
    • Systolic ejection murmur at the left sternal border due to an underlying bicuspid aortic valve 
    • Continuous machinery-like murmur of the infraclavicular location due to PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) or collateral circulation

Children

  • Fainting or near-fainting
  • Claudication, weakness, or chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain on exertion
  • Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive
  • In the physical exam: 
    • Radio-femoral delay/brachio-femoral delay: Femoral pulses are delayed compared to radial or brachial pulses.
    • Higher blood pressure in the upper vs. the lower extremities (difference of > 20 mm Hg)
    • Presence of continuous murmur due to collateral circulation 
    • Presence of systolic ejection murmur due to a bicuspid aortic valve

Adults

  • Hypertension
  • Stroke secondary to intracranial aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms
  • Weak pulses of the lower extremities
  • Higher blood pressure in the upper vs. the lower extremities (difference of > 20 mm Hg)

Diagnosis

Diagnostic test of choice: echocardiogram

Findings:

  • Narrowing of the lumen
  • Any additional cardiac lesions (e.g., bicuspid aortic valve)
  • Doppler: increased velocity and turbulence of blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure through the narrowing

Supportive noninvasive workup

  • Chest X-ray:
    • Neonates: cardiomegaly with pulmonary congestion
    • Older children:
      • Figure 3 sign: formed by the indentation at the coarctation point along the dilated aorta
      • Rib notching: erosion of the lower surface of the ribs due to increased blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure through the collateral intercostal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries
  • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Normal Electrocardiogram (ECG) shows LV hypertrophy.
  • CT and MRI can be helpful when echocardiogram results are deficient or unclear.

Comorbidity screening

  • Genetic testing for women suspected of having Turner syndrome Turner syndrome Turner syndrome is a genetic condition affecting women, in which 1 X chromosome is partly or completely missing. The classic result is the karyotype 45,XO with a female phenotype. Turner syndrome is associated with decreased sex hormone levels and is the most common cause of primary amenorrhea. Turner Syndrome
  • For adults, CT angiography to screen for intracranial aneurysms, abdominal aortic aneurysms Abdominal aortic aneurysms An aortic aneurysm is the abnormal dilation of a segment of the aorta. Abdominal aortic aneurysm is the most common aortic aneurysm, occurring frequently in the infrarenal area. Most aneurysms are asymptomatic, but can cause compression of surrounding structures or rupture, which is a life-threatening emergency. Abdominal Aortic Aneurysms, and atherosclerotic changes to the coronary arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries

Management and Complications

Management

Neonates: 

  • Prostaglandin E1 IV to keep the ductus arteriosus open
  • Surgical management for patients dependent on PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA)

Children and adults:

  • Surgical treatment is indicated in the case of:
    • Heart failure
    • > 20 mm Hg gradient across the coarctation
    • Presence of collateral blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
  • Therapeutic procedures include balloon angioplasty, stent placement, or patch aortoplasty.

Complications

A few long-term complications can develop postsurgical repair:

  • Rebound hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
    • Most common in adults
    • Re-coarctation must be ruled out.
    • Hypertension must be medically managed to reduce the risk of coronary or cerebrovascular disease.
  • Re-coarctation: 
    • Most commonly seen in neonates and children
    • Due to inadequate wall growth
    • Should be suspected in cases where symptoms resurge
  • Aortic aneurysm Aneurysm An aneurysm is a bulging, weakened area of a blood vessel that causes an abnormal widening of its diameter > 1.5 times the size of the native vessel. Aneurysms occur more often in arteries than in veins and are at risk of dissection and rupture, which can be life-threatening. Extremity and Visceral Aneurysms and dissection: mainly in adults at the site of repair

Postoperative follow-up: Annual consult and imaging, such as an echocardiogram, is required to detect complications.

Prognosis

  • When detected in childhood and not treated, death occurs by 20–40 years old due to hypertensive complications such as coronary heart disease Coronary heart disease Coronary heart disease (CHD), or ischemic heart disease, describes a situation in which an inadequate supply of blood to the myocardium exists due to a stenosis of the coronary arteries, typically from atherosclerosis. Coronary Heart Disease or stroke.
  • If surgery performed prior to age 20, 10-year postrepair survival estimate is 90%.
  • Patients may resume all forms of exercise within a year of uncomplicated repair.

Differential Diagnosis

The differential diagnosis of coarctation of the aorta must be considered depending on the age group of the patients.

Neonates

Since patients present in shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock, other causes such as septic shock Septic shock Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Septic shock is diagnosed during treatment when vasopressors are necessary to control hypotension. Sepsis and Septic Shock or hypovolemic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock must be ruled out.

  • Septic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock: organ dysfunction resulting from a dysregulated systemic host response to infection. The etiology is mainly bacterial; pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia is the most commonly known source. Presentation includes fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever, tachycardia, tachypnea, hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, and/or altered mentation. Diagnosis is confirmed during the treatment when vasopressors are necessary to control hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
  • Hypovolemic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock: a life-threatening condition of organ dysfunction resulting from decreased cardiac output due to reduced preload secondary to hemorrhage, gastrointestinal losses, burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns, or polyuria. Presentation includes tachycardia, tachypnea, hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension, decreased capillary refill time, and cold/clammy skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin in the case of compensated shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock. Treatment is based on volume resuscitation.

Children

If a young girl is diagnosed with coarctation, karyotyping for Turner syndrome Turner syndrome Turner syndrome is a genetic condition affecting women, in which 1 X chromosome is partly or completely missing. The classic result is the karyotype 45,XO with a female phenotype. Turner syndrome is associated with decreased sex hormone levels and is the most common cause of primary amenorrhea. Turner Syndrome must be performed as it accounts for 15% of cases.

Turner syndrome Turner syndrome Turner syndrome is a genetic condition affecting women, in which 1 X chromosome is partly or completely missing. The classic result is the karyotype 45,XO with a female phenotype. Turner syndrome is associated with decreased sex hormone levels and is the most common cause of primary amenorrhea. Turner Syndrome: a genetic condition in which 1 X chromosome is partly or completely missing, resulting in karyotype 45,X0. Presentation includes primary amenorrhea Primary Amenorrhea Primary amenorrhea is defined as the absence of menstruation in a girl by age 13 years in the absence of secondary sex characteristics or by the age of 15 years with the presence of secondary sex characteristics. Etiologies can originate in the hypothalamic-pituitary-ovarian (HPO) axis or from anatomic abnormalities in the uterus or vagina. Primary Amenorrhea (characteristic of a woman with short stature), webbed neck, broad chest, and widely spaced nipples. Genetic testing confirms the diagnosis, and treatment is based on hormone replacement.

Adults

A delay in pulse may also be seen in peripheral arterial disease and aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a "false lumen." Aortic dissection is most commonly caused by uncontrolled hypertension. Aortic Dissection.

  • Peripheral arterial disease: obstruction of the arterial lumen resulting in decreased blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure to the distal limbs caused by atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis or thrombosis. Patients may be asymptomatic, have progressive claudication, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin discoloration, ischemic ulcers, or gangrene. Diagnosis is confirmed with ankle-brachial index measurement and imaging studies to localize and assess the disease. Treatment varies depending on disease severity.
  • Aortic dissection: a tear in the tunica intima of the aortic wall allowing blood to flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure into the media and create a “false lumen.” Aortic dissection results from pulsatile pressure shearing stress secondary to uncontrolled hypertension Uncontrolled hypertension Although hypertension is defined as a blood pressure of > 130/80 mm Hg, individuals can present with comorbidities of severe asymptomatic or "uncontrolled" hypertension (≥ 180 mm Hg systolic and/or ≥ 120 mm Hg diastolic) that carries with it a significant risk of morbidity and mortality. Uncontrolled Hypertension. Presentation includes acute “tearing” chest or back pain Back pain Back pain is a common complaint among the general population and is mostly self-limiting. Back pain can be classified as acute, subacute, or chronic depending on the duration of symptoms. The wide variety of potential etiologies include degenerative, mechanical, malignant, infectious, rheumatologic, and extraspinal causes. Back Pain. Computed tomography is the diagnostic modality of choice. Type a dissections require surgery, while Type b dissections can be managed medically with impulse control using beta-blockers and calcium channel blockers Calcium Channel Blockers Calcium channel blockers (CCBs) are a class of medications that inhibit voltage-dependent L-type calcium channels of cardiac and vascular smooth muscle cells. The inhibition of these channels produces vasodilation and myocardial depression. There are 2 major classes of CCBs: dihydropyridines and non-dihydropyridines. Class 4 Antiarrhythmic Drugs (Calcium Channel Blockers).

References

  1. Hoffman, J.I.E. & Kaplan, S. (2002). The incidence of congenital heart disease. doi: https://doi.org/10.1016/S0735-1097(02)01886-7
  2. Kliegman, R.M., St. Geme, J.W., Blum, N.J., Shah, S.S., Tasker, R.C., & Wilson, K.M. (2020). Acyanotic congenital heart disease: Obstructive lesions. Nelson textbook of pediatrics (pp. 238-2393.e1). https://www.clinicalkey.es/#!/content/3-s2.0-B9780323529501004545
  3. Eckhauser, A., South, S.T., Meyers, L., Bleyl, S.B., & Botto, L.D. (2015). Turner Syndrome in Girls Presenting with Coarctation of the Aorta. The Journal of pediatrics, 167(5), 1062–1066. DOI:10.1016/j.jpeds.2015.08.002
  4. Hijazi, Z.M. (2018). Clinical Manifestation and diagnosis of coarctation of the aorta. UpToDate. Retrieved January 5, 2021, from https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-coarctation-of-the-aorta

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