Stenting of critical aortic coarctation in adult patient with low ejection fraction and pulmonary hypertension: a clinical case

Introduction. Coarctation of the aorta (CoAo) occurs in approximately 2–5 per 10,000 births and currently accounts for about 30% of congenital heart defects. When diagnosing CoAo in adults, the cardiac team often deals with decompensated comorbid patients at high surgical risk with reduced cardiac contractility, pulmonary hypertension (PH), and congestive heart failure. In such a situation, the endovascular correction method, consisting of CoAo stenting, may be the only possible treatment method that gives a chance for patient survival. At the same time, the issues of reversibility of the processes of pathological remodeling of the myocardium and PH during the correction of CoAo in adulthood have not been fully studied and are of high scientific and practical interest. Aim: To demonstrate the results of stenting of critical coarctation of the aorta in an adult patient at high surgical risk with low ejection fraction and pulmonary hypertension and to evaluate the degree of reversibility of pathological cardiac remodeling and pulmonary hypertension. Material and Methods. Patient M., 27 years old, consulted a cardiologist on an outpatient basis with complaints of pain in the left half of the chest, an increase in abdominal volume, and attacks of cardiac asthma at night after suffering an acute respiratory illness. Critical coarctation of the aorta in a typical location and bicuspid aortic valve insufficiency were diagnosed. Taking into account the clinical status, a pronounced decrease in cardiac contractility (ejection fraction 32%), high pulmonary hypertension (systolic pressure in the pulmonary artery 90 mmHg), the patient was considered inoperable for open surgery. Therefore, the cardiac team chose treatment tactics in favor of aortic stenting in the coarctation zone. Results. In this case, CoAo stenting became the only possible treatment method for an inoperable young patient. In the postoperative period, regression of complaints of chest pain and cardiac asthma was noted, and normalization of blood pressure was achieved while receiving therapy. Positive changes in the echocardiographic picture consisted of an increase in LVEF from 32 to 66%, a decrease in the average pressure in the pulmonary artery from 58 to 22 mm. rt. art., reducing the end systolic volume of the left ventricle from 147 to 72 ml. When examining the patient after 6 months. after CoAo stenting, a satisfactory clinical effect and normalization of the echocardiographic picture remained in the form of a further increase in LVEF and complete regression of high PH. The minimally invasive nature of the intervention, rapid rehabilitation and low risk of developing infectious and neurological complications made this method even more justified. Conclusions. The results obtained demonstrated that CoAo stenting in an adult patient of very high surgical risk was the only possible safe and effective method of correction, which had a pronounced positive effect on cardiac remodeling and eliminated PH. CoAo stenting can be considered as the first stage of treatment towards surgical correction of concomitant aortic valve disease, allowing the decompensated patient to be stabilized, transferred from a very high to a low surgical risk group.