Case Presentation

Presenter-

Dr. Hriday Ranjan Roy

Assistant Professor, Surgery

Rangpur Medical College Hospital

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.

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.

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.

General examination on admission

Appearance – normalNo anemia, jaundice or cyanosis. No edema or dehydration. No clubbing or koilonychias. Neck glands- not palpable. JVP- not raised.Pulse- 80/minB.P- 185/95mmHG ( in arm)

Leg- not recordable.

CVS examination

Pulses Right Left

Radial + +

Brachial + +

Axillary + +

Carotid + +

Femoral - -

Popliteal - -

Post. Tibial - -

Dorsalis pedis - -

Precordium

Inspection- NormalPalpation- 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

Diagnostic workout

CXR- P/A view- no cardiomegaly, no rib notching.

LAO view- normal. ECG- normal. Echo- 2D & M mode-

LVIDd- 42mm, LVIDs-27mm, EF-62%, IVST- 10mm, PWT- 10mm, LA- 33mm, AO- 38mm, ACS- 16mm.

Echo (cont….)Description-

LA, RA, RV, PA- NormalLV- 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.

Impression- 1) Coarctation of aorta2) Bicuspid aortic valve.3) Mild concentric LV hypertrophy4) Fair LV systolic function

Photograph of Echo

CXR P/A View

CXR lateral view

CXR LAO View

Cardiac catheterization (Sheldinger)

Pressure-

Arch- 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.

Cardiac catheterization

Biochemical investigations

1) CBC- within normal limit. 2) RBS- 6.2mmol/L3) Blood urea- 29mg%4) S. creatinine- 1.0mg%5) S. cholesterol- 137mg%.6) LDL- 75mg%7) HDL- 43mg%8) S. Triglyceride- 10mg%.

Confirmed diagnosis

Coarctation of Aorta.

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.

Patient position

Incision

Left lateral thoracotomy

Dissection and mobilization

Mobilization and control

The procedure ( internet)

Post operative CXR

Post operative periods

1) Uneventful

2) Hypertension was controlled by GTN.

Outcome- 1) Immediate appearance of lower limb pulses.

2) Improvement of symptoms.

3) Reduction of anti-hypertensive drug doses.

4) Reduction of brachiocephalic hypertension.

She is happy

Her happiness is our satisfaction

THANK YOU ALL