Singapore Med J 2013; 54(1) : e5 C ase R eport INTRODUCTION Compared to the use of balloon angioplasty alone, endovascular treatment of aortic coarctation in adults with the use of stents has shown favourable results and a reduction in complications. (1) Thanopoulos et al recently reported sustained results of up to fve years in selected adult patients. (2) However, few studies have addressed the dif fculties in the management of older patients with coarctation who are likely to have advanced disease with complications such as hypertension and concomitant coronary artery disease, and who are more likely to be at risk for inferior outcomes following treatment. In addition, unfavourable anatomy in these patients may hinder successful surgical or percutaneous management. CASE REPORT A 65-year-old Caucasian woman with a history of coarctation of the aorta presented in December 2007 with chest and shoulder pain associated with significant elevation of troponin I level, and was diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI). She had not been previously told that she needed treatment for coarctation and was thus not on regular follow-up. Her left arm blood pressure was 180/90 mmHg and she had a grade 3 ejection systolic murmur heard over the aortic region, which radiated posteriorly. Lower limb pulses were not palpable. Despite treatment with atenolol 100 mg, losartan 100 mg, frusemide 40 mg and methyldopa 500 mg twice daily, her systolic blood pressure remained persistently elevated. Cardiac catheterisation following this acute presentation showed normal coronaries, but a significant peak-to-peak gradient of 60 mmHg across a highly calcifed coarctation site was found. The patient had undergone multiple orthopaedic surgeries on both knees as well as repeated surgeries for iritis, one of which was complicated and required enucleation of the left eye. She also had severe subcapsular cataracts from chronic steroid therapy for her joint pains. Her past medical history includes a right carotid to right subclavian bypass in 1994 (no details were available), thyroidectomy for papillary carcinoma and treated pulmonary tuberculosis. Transthoracic echocardiogram revealed a trileaflet aortic valve with features of concentric left ventricular hypertrophy and preserved ventricular ejection fraction. Cardiac magnetic resonance (MR) imaging and computed tomography (CT) confirmed the diagnosis of coarctation, showing a long and calcifed lesion (Figs. 1 & 2) with a minimum diameter of 4 mm. This case was extensively discussed among congenital cardiologists and cardiac surgeons, and it was decided that percutaneous treatment was indicated, given the severity of the lesion, poorly controlled hypertension and high surgical risk. However, the Challenges in the management of aortic coarctation in the elderly: native coarctation complicated by severe calcifcation Edgar LW Tay 1,2 , MBBS, Namal Wijesinghe 1 , MD, Jonathan Avrom Leipsic 1 , MD, Ronald Carere 1 , MD 1 St Paul’s Hospital, University of British Columbia, Vancouver, Canada, 2 National University Health System, Singapore Correspondence: Dr Edgar Tay, Consultant Cardiologist, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore 119228. Edgar_Tay@nuhs.edu.sg ABSTRACT Although the treatment of aortic coarctation in adults with the use of stents has shown favourable results and reduced complications, there have been few studies involving elderly patients. We highlight the clinical challenges faced in the management of such patients, with attention to severe calcifcation at the coarctation site. The midterm results were good in our patient, showing an improvement in blood pressure control and maintenance of stent patency. Keywords: adult congenital heart, coarctation, hypertension Singapore Med J 2013; 54(1): e5–e8 Fig. 1 MR angiography with gadolinium shows the coarctation site (white arrow).