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EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic Coarctation

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Pediatric And Adult Aortic Coarctation
Elizabeth Olson, MD & Jennifer Potter, MD
Department of Emergency Medicine
Carolina...

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Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Prog...

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Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental ed...

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EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic Coarctation

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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.

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.

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EMGuideWire's Radiology Reading Room on Pediatric Adult Aortic Coarctation

  1. 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. 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. 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. 4. Visit Our Website www.EMGuidewire.com For A Complete Archive Of Chest X-Ray Presentations And Much More!
  5. 5. Airway Bones Cardiac Diaphragm Effusion Foreign body Gastric Hilum
  6. 6. It’s All About The Anatomy!
  7. 7. CASE #1 11-day-old born at full term with 2 days of progressive respiratory distress, grunting and decreased PO intake.
  8. 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. 9. CASE #2 5-day-old full term found to have a heart murmur after delivery.
  10. 10. Coarctation Of The Aorta CASE #2 5-day-old full term found to have a heart murmur after delivery.
  11. 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. 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. 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. 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. 15. Healthy Adult Patient With Chest Pain.
  16. 16. Healthy Adult Patient With Chest Pain. Why Would A Patient Have Cardiomegaly And Inferior “Notching” Of Ribs?
  17. 17. Why Would A Patient Have Cardiomegaly And Inferior “Notching” Of Ribs? Coarctation Of The Thoracic Aorta Healthy Adult Patient With Chest Pain.
  18. 18. Healthy Adult Patient With Chest Pain. Coarctation Of The Thoracic Aorta
  19. 19. Healthy Adult Patient With Chest Pain. Coarctation Of The Thoracic Aorta
  20. 20. Coarctation – Stent Graft Placed Thoracic Endovascular Aortic Repair [TEVAR]
  21. 21. 35-Year-Old Healthy Male Evaluated After A Fall. What do you notice?
  22. 22. 35-Year-Old Healthy Male Evaluated After A Fall. Cardiomegaly And Inferior “Notching” Of Ribs
  23. 23. 35-Year-Old Healthy Male Evaluated After A Fall. Coarctation Of The Thoracic Aorta
  24. 24. 35-Year-Old Healthy Male Evaluated After A Fall. Coarctation Of The Thoracic Aorta
  25. 25. Aortic Coarctation In Adults Can Be An Incidental Finding In Patients Who Are Asymptomatic.
  26. 26. 42-Year-Old Found To Have Coarctation On An Outpatient Echocardiogram.
  27. 27. 42-Year-Old Found To Have Coarctation On An Outpatient Echocardiogram. Thoracic Endovascular Aortic Repair [TEVAR].
  28. 28. 53-Year-Old Found To Have Coarctation On A Preoperative Echocardiogram.
  29. 29. 53-Year-Old Found To Have Coarctation On A Preoperative Echocardiogram. Thoracic Endovascular Aortic Repair [TEVAR].
  30. 30. 53-Year-Old Found To Have Coarctation On A Preoperative Echocardiogram. Thoracic Endovascular Aortic Repair [TEVAR].
  31. 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. 32. Coarctation Of The Thoracic Aorta
  33. 33. Coarctation Of The Thoracic Aorta
  34. 34. Coarctation Of The Thoracic Aorta
  35. 35. Coarctation Of The Thoracic Aorta
  36. 36. 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]
  37. 37. 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.
  38. 38. Stout KK. Circulation 2019; 139:e698-e800.
  39. 39. Stout KK. Circulation 2019; 139:e698-e800.
  40. 40. Stout KK. Circulation 2019; 139:e698-e800.
  41. 41. 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!

Editor's Notes

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