AKT · Child health/Congenital heart

Coarctation of the aorta

Narrowing of the aorta (typically juxta-ductal) → obstruction; can be duct-dependent in the neonate

Overview

Narrowing of the aortic arch (usually around the duct/just distal to the left subclavian). Critical coarctation presents in the NEONATE with collapse/shock as the duct closes (DUCT-DEPENDENT systemic circulation) → prostaglandin is life-saving. Milder coarctation presents later with hypertension, radio-femoral delay and weak femoral pulses. Associated with Turner syndrome and bicuspid aortic valve.

Recognise

NEONATE (critical): shock/collapse, poor feeding, weak/absent FEMORAL pulses, differential cyanosis/saturations as the duct closes (duct-dependent)
Older child/adult: hypertension (upper limbs), RADIO-FEMORAL DELAY, weak femoral pulses, headaches; rib notching on CXR (collaterals)
Associations: Turner syndrome, bicuspid aortic valve

Red flags

Critical neonatal coarctation presenting as collapse when the duct closes → PROSTAGLANDIN to reopen/maintain the duct + urgent surgery
Severe upper-limb hypertension; aortic complications

Differentials & how to tell them apart

Other duct-dependent collapse (HLHS, critical AS/PS)neonatal collapse on duct closure — echo defines; all need prostaglandin

Sepsisneonatal collapse mimics — but weak femorals/differential saturations point to coarctation

Essential hypertensioncheck femoral pulses/four-limb BP in any hypertensive young person

Investigations

Four-limb BP + pulses (radio-femoral delay, arm>leg BP); echocardiography (the coarctation, associated lesions); CXR (rib notching, '3 sign' in older patients); pulse oximetry screening.

Management

Critical neonate → prostaglandin (keep duct open) + surgery; older → surgical/catheter repair

1In a collapsed neonate, check femoral pulses and saturations; suspect duct-dependent coarctation and start PROSTAGLANDIN (alprostadil) to maintain the duct while arranging urgent surgery. Older children: confirm with four-limb BP/echo, then repair.Gate: A neonate who collapses as the duct closes has DUCT-DEPENDENT circulation → prostaglandin to KEEP the duct OPEN is life-saving (the opposite of closing a PDA); always feel the FEMORAL pulses in a sick neonate
2Surgical repair (resection + anastomosis) or balloon/stent; lifelong BP surveillance (re-coarctation, hypertension); manage Turner/bicuspid valve associations.

PROSTAGLANDIN (alprostadil) — KEEP the duct OPEN — life-saving in critical neonatal (duct-dependent) coarctation while awaiting surgery

Surgical/catheter repair — resection/end-to-end anastomosis or balloon/stent

Key points

Weak/absent femoral pulses + radio-femoral delay (older) or neonatal collapse on duct closure = coarctation. Critical neonatal coarctation is duct-dependent → prostaglandin. Think Turner syndrome and bicuspid aortic valve.

Monitor & prognosis

BP, re-coarctation, associated valve disease.

Good with repair; lifelong hypertension risk.

Source: RCPCH; paediatric cardiology