Coarctation of the aorta in adults — practice case: recoarctation before pregnancy

Presentation

Practice case (not a real patient). A 30-year-old woman had coarctation of the aorta repaired with a patch in childhood and has not been seen in a cardiology clinic for years. She plans a pregnancy next year.^[1][7] Her right-arm blood pressure is raised, the systolic difference between her right arm and leg is 30 mmHg, and her femoral pulses are delayed. She has no cardiac symptoms.^[1]

Step 1 — What is going on?

Discussion:

• ESC 2020: an increased systolic gradient (≥20 mmHg) between upper and lower extremities indicates re-coarctation and warrants invasive assessment for confirmation and treatment; radiofemoral pulse delay also indicates significant coarctation.^[1]
• Patch repairs are at particular risk of repair-site aneurysms (ESC 2020), and ACC/AHA 2025 lists re-coarctation, aneurysms or pseudoaneurysms at the repair site, and dissection among the vascular complications of repaired coarctation.^[1][2]
• Hypertension at rest or during exercise is common even after successful treatment, and recurring or residual coarctation may induce or aggravate it (ESC 2020).^[1]

Step 2 — Investigations

Discussion:

• ACC/AHA 2025: in adults with repaired coarctation, periodic cross-sectional imaging is recommended to screen for recurrent coarctation, aortic root or ascending aneurysms and vascular complications of repair (COR 1, LOE B-NR); CMR is preferred because it avoids radiation.^[2]
• ESC 2020: CMR and CCT depict the site, extent and degree of narrowing, the arch and head and neck vessels and collaterals, and detect aneurysms, false aneurysms, restenosis or residual stenosis.^[1]
• Right-arm ambulatory blood pressure should be considered for the diagnosis of hypertension (ESC 2020 table footnote); ACC/AHA 2025 calls ambulatory measurement reasonable to diagnose hypertension and monitor treatment (COR 2a, LOE B-NR).^[1][2]
• Echocardiography shows LV function and hypertrophy and associated abnormalities (ESC 2020); a bicuspid valve should be sought, since ACC/AHA 2022 says it coexists in at least 50% of cases.^[1][4]

CMR shows a severe recoarctation at the repair site without an aneurysm, and catheterisation confirms a peak-to-peak gradient of 32 mmHg; stenting is technically feasible.^[2][1]

Step 3 — Treatment before pregnancy

Discussion:

• ESC 2024: coarctation or re-coarctation repair is indicated in patients with hypertension with an increased non-invasive gradient confirmed with invasive measurement (peak-to-peak >20 mmHg), with a preference for stenting when technically feasible (Class I, Level C).^[3]
• ACC/AHA 2025: surgical or transcatheter stent therapy is recommended for anatomically and hemodynamically significant native or repaired coarctation to prevent irreversible LV dysfunction from chronic pressure overload (COR 1, LOE B-NR).^[2]
• Pregnancy: ACC/AHA 2025 Table 10 lists severe native coarctation or recoarctation as significantly high risk for maternal complications, and ESC 2025 Table 12 advises pre-pregnancy CMR and treatment of residual lesions.^[2][7]
• ACC/AHA 2022: after a previous open repair, an endovascular approach to recoarctation, aneurysm or pseudoaneurysm avoids reoperation, assuming adequate iliofemoral access and no involvement of the supra-aortic trunks.^[4]

Step 4 — Pregnancy and follow-up

Discussion:

• ESC 2025 Table 12 for coarctation: close blood pressure monitoring, also early post-partum; treat hypertension; vaginal delivery preferred unless aneurysm, heart failure or severe hypertension.^[7]
• It lists a higher complication risk with residual obstruction (gradient >20 mmHg, aortic lumen <12 mm), clinical signs of heart failure, LVEF <40% or NYHA class >1, a higher miscarriage rate, and pre-term birth and low birth weight in 9%.^[7]
• After the stent, CT angiography rather than CMR should be used for imaging because of stent artefacts on CMR (ACC/AHA 2025), and ESC 2024 recommends lifelong follow-up in native or repaired coarctation, including regular CCT/CMR of the aorta every 3–5 years adapted to clinical status and previous imaging findings (Class I, Level B).^[2][3]
• If hypertension persists without hemodynamically significant coarctation, GDMT is recommended to maintain controlled resting and ambulatory blood pressure (ACC/AHA 2025, COR 1, LOE B-NR).^[2]

Learning points

• A raised upper-to-lower limb gradient after repair points to re-coarctation and needs invasive confirmation (ESC 2020).^[1]
• Severe recoarctation is high risk in pregnancy, so the residual lesion is treated before pregnancy (ACC/AHA 2025 Table 10; ESC 2025 Table 12).^[2][7]
• After a stent, image with CT angiography (ACC/AHA 2025).^[2]