Repaired Congenital Heart Disease in Older Children and Adults: Up-to-Date Practical Assessment and Characteristic Imaging Findings

Because of a recent increase in survival rates and life expectancy of patients with congenital heart disease (CHD), radiologists are facing new challenges when imaging the peculiar anatomy of individuals with repaired CHD. Cardiac computed tomography and magnetic resonance are paramount noninvasive imaging tools that are useful in assessing patients with repaired CHD, and both techniques are increasingly performed in centers where CHD is not the main specialization. This review provides general radiologists with insight into the main issues of imaging patients with repaired CHD, and the most common findings and complications of each individual pathology and its repair.

Beating heart thoracic aortic surgery under selective myocardial perfusion for patients with congenital aortic anomalies

OBJECTIVE

We evaluated beating heart thoracic aortic surgery (BHTAS) using selective myocardial perfusion (SMP) in patients with aortic anomalies with complex surgical needs.

METHODS

Between 2012 and 2018, 27 infants with aortic anomalies underwent BHTAS using SMP.

RESULTS

Median body weight was 3.5 kg (range 2.6-5.2). In total, 15 cases of aortic coarctation, 7 cases of hypoplastic left heart syndrome, and 5 cases of interrupted aortic arch were included. An extended aortic arch anastomosis maneuver was used in 7 cases and aortic arch reconstruction compensated with an autologous pericardium patch was used in 6 cases. A Norwood-type procedure was used in 11 cases. The median Aristotle comprehensive score was 13.9 (7.0-20.0). BHTAS cases were not inferior in postoperative CK-MB/CK ratio (12.4 ± 2.8 in BHTAS vs 13.9 ± 3.6 in CTAS, p = 0.09), and there were no instances of myocardial ischemia. Two late deaths occurred due to shunt obstruction (n = 1) and valve malfunction (n = 1). Freedom from aortic reintervention was not inferior to conventional thoracic aortic surgery. BHTAS cases exhibited shorter cardiac arrest time than that of conventional thoracic aortic surgery in similar surgical procedures [CoA/VSD cases: 48.0 ± 8.0 min in the BHTAS cases and 65.7 ± 10.8 min in the CTAS cases (p = 0.0122), simple CoA/re-CoA cases: 0 min in the BHTAS cases and 20.1 ± 3.6 min in the CTAS cases].

CONCLUSIONS

BHTAS reduced cardioplegic arrest time while maintaining postoperative CK-MB/CK ratio, mid-term death, and aortic reintervention rates.

Subject-specific simulation for non-invasive assessment of aortic coarctation: Towards a translational approach

We present a multi-scale CFD-based study conducted in a cohort of 11 patients with coarctation of the aorta (CoA). The study explores the potential for implementation of a workflow using non-invasive routinely collected medical imaging data and clinical measurements to provide a more detailed insight into local aortic haemodynamics in order to support clinical decision making. Our approach is multi-scale, using a reduced-order model (1D/0D) and an optimization process for the personalization of patient-specific boundary conditions and aortic vessel wall parameters from non-invasive measurements, to inform a more complex model (3D/0D) representing 3D aortic patient-specific anatomy. The reliability of the modelling approach is investigated by comparing 3D/0D model pressure drop estimation with measured peak gradients recorded during diagnostic cardiac catheterization and 2D PC-MRI flow rate measurements in the descending aorta. The current study demonstrated that the proposed approach requires low levels of user interaction, making it suitable for the clinical setting. The agreement between computed blood pressure drop and catheter measurements is 10  ±  8 mmHg at the coarctation site. The comparison between CFD derived and catheter measured pressure gradients indicated that the model has to be improved, suggesting the use of time varying pressure waveforms to further optimize the tuning process and modelling assumptions.

Coarctation Stenting in a Rare Case with Congenitally Corrected Transposition of the Great Arteries and the Bicuspid Aortic Valve

Congenitally corrected transposition of the great arteries (cc-TGA) is a rare congenital abnormality that occurs in 1 per 33000 live births. This abnormality comprises nearly 0.05% of all congenital heart defects, with at least 90% of cc-TGA patients having associated cardiac defects; some of these associated defects are, however, very rare. In this case report, we describe a 22-year-old man who referred to our hospital for the evaluation of hypertension and cardiac murmurs. Via echocardiography and catheterization, the patient was finally diagnosed with cc-TGA, bicuspid aortic valve, and coarctation of the aorta. He underwent successful percutaneous transarterial coarctoplasty without any complications at early and 6 months' follow-up visits.

Safety and efficacy of stenting for aortic arch hypoplasia in patients with coarctation of the aorta

Background

Despite a successful repair procedure for coarctation of the aorta (CoA), up to two-thirds of patients remain hypertensive. CoA is often seen in combination with abnormal aortic arch anatomy and morphology. This might be a substrate for persistent hypertension. Therefore, we performed endovascular aortic arch stent placement in patients with CoA and concomitant aortic arch hypoplasia or gothic arch morphology. The goal of this retrospective analysis was to investigate the safety and efficacy of aortic arch stenting.

Methods

A retrospective analysis was performed in patients who underwent stenting of the aortic arch at the University Medical Center Utrecht. Measurements collected included office blood pressure, use of antihypertensive medication, invasive peak-to-peak systolic pressure over the arch, and aortic diameters on three-dimensional angiography. Data on follow-up were obtained at the date of most recent outpatient visit.

Results

Twelve patients underwent stenting of the aortic arch. Mean follow-up duration was 14 ± 11 months. Mean peak-to-peak gradient across the arch decreased from 39 ± 13 mm Hg to 7 ± 8 mm Hg directly after stenting (p < 0.001). There were no major procedural complications. Mean systolic blood pressure decreased from 145 ± 16 mm Hg at baseline to 128 ± 9 mm Hg at latest follow-up (p = 0.014).

Conclusion

This retrospective study shows that stenting of the aortic arch is successful when carried out in a state-of-the-art manner. A direct optimal angiographic and haemodynamic result was shown. No major complications occurred during or after the procedure. At short- to medium-term follow-up a decrease in mean systolic blood pressure was observed.

A delayed diagnosis of aortic coarctation

Coarctation of the aorta is most often diagnosed in early childhood, with infrequent recorded presentations of previously undiagnosed adults. We present a young female hospitalized with hypertensive emergency who was then diagnosed with a stenotic bicuspid aortic valve requiring surgical intervention. Subsequent preoperative coronary angiogram led to discovery of an undiagnosed coarctation of the aorta, which is commonly a forgotten cause of secondary hypertension.

Balloon angioplasty of aortic coarctation in critically ill newborns using axillary artery access

Balloon angioplasty may be performed as the first treatment of aortic coarctation to stabilize newborns too sick for immediate surgery. The issue of vascular access is the key to the successful treatment of critical newborns. In our study, we argue that the lesser-known axillary access route is the safest and most effective route of vascular access for balloon angioplasty in infants with aortic coarctation. To support this argument, we present the case of eight unstable newborns with complex heart diseases, who were successfully treated with percutaneous intervention through the axillary artery. This case series is followed by an analysis of the greater efficacy of this technique compared to the more conventional femoral and carotid routes. We conclude by acknowledging the substantial advantages of this lesser-known vascular access and advocate its more widespread clinical implementation in the treatment of critical newborns.

Chetham-platinum-covered stent, aortic coarctation, and left subclavian artery: sometimes is there one too many?

A new approach was used in the percutaneous treatment of two patients with severe recoarctation involving the origin of the left subclavian artery. A tiny handmade fenestration was created in a NuMED-covered Cheatham-platinum stent before its implantation to avoid left subclavian artery occlusion. The stent placement was performed using a two-guidewire technique in which the different stiffness helped a proper positioning of the stent. After the stent deployment, the fenestration was enlarged performing a balloon angioplasty to improve flow in left subclavian artery.

The Diastolic and Systolic Velocity-Time Integral Ratio of the Aortic Isthmus Is a Sensitive Indicator of Aortic Coarctation in Fetuses

BACKGROUND

Prenatal diagnosis of coarctation of the aorta (CoA) is challenging and is affected by high false-positive and false-negative rates. The aim of this study was to identify sonographic criteria to improve the identification of fetal CoA.

METHODS

A retrospective review was conducted of subjects with prenatal suspicion for CoA who also had postnatal follow-up. Sixty-nine fetuses were identified with possible CoA, and 47 normal fetuses were selected as control subjects. Retrospective measurements of right ventricular/left ventricular ratio, pulmonary artery/aorta ratio, aortic isthmus (AOI) Z score, diastolic velocity-time integral (VTI_D), and systolic velocity-time integral (VTI_S) at the AOI were recorded. Receiver operating characteristic curve analysis identified the parameter most predictive of postnatal CoA.

RESULTS

When comparing subjects with (n = 31) and without (n = 38) CoA, significant differences were detected for the AOI Z score, VTI_D, VTI_D/VTI_S ratio, and VTI_D/(VTI_D + VTI_S) ratio (P < .001). The areas under the receiver operating characteristic curve were 0.92, 0.92, 0.78, 0.74, 0.71, and 0.68 for the VTI_D/VTI_S ratio, VTI_D/(VTI_D + VTI_S) ratio, VTI_D, AOI Z score (sagittal view), AOI Z score (three-vessel tracheal view), and pulmonary artery/aorta ratio, respectively. There was a 25% (95% CI, 14%-35%) improvement in the area under the curve after adding the VTI_D/VTI_S ratio to the basic model (AOI Z score [sagittal view]), and this ratio (after transformation) showed significantly better discrimination and reclassification ability for determining CoA. The pulmonary artery/aorta ratio, VTI_D, VTI_D/VTI_S ratio, and VTI_D/(VTI_D + VTI_S) ratio were stable throughout the normal fetal developmental period in this study.

CONCLUSIONS

In cases with suspected prenatal diagnosis of CoA, evaluation of spectral Doppler measurements, such as the VTI_D/VTI_S ratio, may enhance the accuracy of diagnosis with fetal echocardiography.

Emergency Pulmonary Artery-to-Systemic Artery Shunt to Break the Positive Feedback Loop of a Pulmonary Hypertensive Crisis after Neonatal Coarctation Repair

A 2.5-kg neonate with coarctation of the aorta and a small left ventricle experienced a severe pulmonary hypertensive crisis. An emergency pulmonary artery-to-systemic artery shunt was placed to break the positive feedback loop caused by pulmonary hypertension and functional mitral stenosis. This shunt provided immediate relief of suprasystemic pulmonary hypertension and the resultant low cardiac output.

Evaluation of 4D flow MRI-based non-invasive pressure assessment in aortic coarctations

Severity of aortic coarctation (CoA) is currently assessed by estimating trans-coarctation pressure drops through cardiac catheterization or echocardiography. In principle, more detailed information could be obtained non-invasively based on space- and time-resolved magnetic resonance imaging (4D flow) data. Yet the limitations of this imaging technique require testing the accuracy of 4D flow-derived hemodynamic quantities against other methodologies. With the objective of assessing the feasibility and accuracy of this non-invasive method to support the clinical diagnosis of CoA, we developed an algorithm (4DF-FEPPE) to obtain relative pressure distributions from 4D flow data by solving the Poisson pressure equation. 4DF-FEPPE was tested against results from a patient-specific fluid-structure interaction (FSI) simulation, whose patient-specific boundary conditions were prescribed based on 4D flow data. Since numerical simulations provide noise-free pressure fields on fine spatial and temporal scales, our analysis allowed to assess the uncertainties related to 4D flow noise and limited resolution. 4DF-FEPPE and FSI results were compared on a series of cross-sections along the aorta. Bland-Altman analysis revealed very good agreement between the two methodologies in terms of instantaneous data at peak systole, end-diastole and time-averaged values: biases (means of differences) were +0.4 mmHg, -1.1 mmHg and +0.6 mmHg, respectively. Limits of agreement (2 SD) were ±0.978 mmHg, ±1.06 mmHg and ±1.97 mmHg, respectively. Peak-to-peak and maximum trans-coarctation pressure drops obtained with 4DF-FEPPE differed from FSI results by 0.75 mmHg and -1.34 mmHg respectively. The present study considers important validation aspects of non-invasive pressure difference estimation based on 4D flow MRI, showing the potential of this technology to be more broadly applied to the clinical practice.

The effects of age at correction of aortic coarctation and recurrent obstruction on adolescent patients: MRI evaluation of wall shear stress and pulse wave velocity

Background

Coarctation patients before curative reconstruction are exposed to abnormal flow patterns which potentially could cause wall deterioration. This study evaluated the effect of age at correction on the pulse wave velocity (PWV) and peak wall shear stress (WSS) in adolescent patients with corrected coarctation. Effects of valve morphology and presence of reobstruction were also evaluated.

Methods

Twenty-one patients aged 13.7 ± 2.6 years (mean ± standard deviation) were included (bicuspid aortic valve, n = 14; reobstruction, n = 9). Mean age at correction was 1.0 ± 1.8 years. PWV was determined from two high-temporal through-plane phase-contrast magnetic resonance imaging (MRI) acquisitions, for two segments: ascending aorta plus aortic arch and descending aorta. WSS was determined from four-dimensional flow MRI. Peak WSS over five systolic phases was determined for ascending aorta, aortic arch, and descending aorta.

Results

Patients with tricuspid aortic valve showed a significant correlation between the age at correction and descending aorta PWV (r_s = 0.80, p = 0.010). Significant differences were found between patients without and with reobstruction for peak WSS in the aortic arch (3.9 ± 1.3 Pa versus 6.5 ± 2.2 Pa, respectively; p = 0.003) and descending aorta (5.0 ± 1.3 Pa versus 6.7 ± 1.1 Pa, respectively; p = 0.005).

Conclusions

A prolonged period of abnormal haemodynamic exposure may result in increased aortic wall stiffening. The increased peak WSS as results of a reobstruction possibly promotes different disease progression, which endorse longitudinal follow-up examination of corrected coarctation patients.

Complicated coarctation repair: The importance of three-dimensional cross-sectional imaging in late postoperative assessment

Coarctation of the aorta (CoA) represents 5%–8% of congenital heart disease patients and is one of the most common causes of neonatal surgical intervention. These patients require close lifelong follow-up due to frequent long-term complications. Although transthoracic echocardiography is the first-line technique for its diagnosis and follow-up, cross-sectional imaging with cardiovascular magnetic resonance (CMR) gives excellent anatomical and functional information, especially in complex CoA. We present the case of a 17-year-old patient who underwent complicated neonatal CoA repair and demonstrate how CMR and thorough operative records helped to define the exact anatomy of repair many years after surgery. Furthermore, we conclude that keeping surgical drawings in the patient records can be of great importance, especially in complicated cases.

Incomplete Form of Shone Complex in an Adult Congenital Heart Disease Patient

Shone complex is a rare congenital disorder that involves 4 obstructive lesions of the left heart, as follows: parachute mitral valve, supravalvular mitral ring, subaortic stenosis, and coarctation of the aorta. Incomplete forms with 2 or 3 of these lesions in adult patients have been rarely reported in the literature, meaning that insufficient general data exist concerning the surgical strategy and clinical follow-up. Herein, we report the case of a 31-year-old woman with a diagnosis of incomplete form of Shone complex with parachute mitral valve and coarctation of the aorta who underwent successful single-stage surgical repair.

Right aortic arch with an aberrant left subclavian artery and aortic coarctation including a descending aortic aneurysm

BACKROUND

The right aortic arch and aortic coarctation are rare congenital anomalies with the incidence of 0.1% and 0.03-0.04%. We present a case report of a 51-year-old woman with the right aortic arch with aberrant left subclavian artery and coarctation of the aorta with post-stenotic aneurysm.

CASE PRESENTATION

Resection of the coarctation and aneurysm with replacement by tubular prosthesis was performed on partial cardiopulmonary bypass via femoral vessels.

CONCLUSION

Partial cardiopulmonary bypass is an applicable method for ensuring the perfusion of the distal part of the body and an aberrant left subclavian artery is not a contraindication of this technique.

Extracorporeal membrane oxygenation in a low-weight infant after cardiac surgery

A neonate was diagnosed with ventricular septal defect and aortic coarctation. Bilateral pulmonary artery banding was performed at 9 days of age (weight 1472 g). Because of ductal shock, emergency extracorporeal membrane oxygenation was initiated after surgery. Fine adjustment of the bilateral pulmonary artery banding sites using hemoclips was carried out to facilitate weaning from extracorporeal membrane oxygenation, and staged delayed sternal closure was achieved. Arch repair, ventricular septal defect closure, and tricuspid annuloplasty were undertaken when the patient was 4-months old (weight 1.8 kg). She was discharged at 11 months of age (3.0 kg).

Patient-specific non-invasive estimation of pressure gradient across aortic coarctation using magnetic resonance imaging

BACKGROUND

Non-invasive estimation of the pressure gradient in aortic coarctation has much clinical importance in assisting the diagnosis and treatment of the disease. Previous researchers applied computational fluid dynamics for the prediction of the pressure gradient in aortic coarctation. The accuracy of the prediction was satisfactory but the procedure was time-consuming and resource-demanding.

METHOD

In this research a magnetic resonance imaging (MRI)-based non-invasive modeling procedure is implemented to predict the pressure gradient in 14 patient cases of aortic coarctation. Multi-cycle patient flow and pressure data are processed to produce the flow and pressure conditions in the patient cases. Bernoulli equation-based friction loss model combined with the inertial effect of the blood flow in the vessel segments are applied to model the pressure gradient in the aortic coarctation. The model-predicted pressure gradient data are then compared with the catheter in vivo measurement data for validation.

RESULTS

The MRI-based model prediction technique produces results that are consistent with those from the catheter measurement, based on the criteria of both the cycle-averaged instantaneous pressure gradient and the peak-to-peak pressure gradient.

CONCLUSION

This study suggests that the MRI-based non-invasive modeling procedure has much potential to be applied in clinical practice for the prediction of the pressure gradient in aortic coarctation patients.

Characterization and estimation of turbulence-related wall shear stress in patient-specific pulsatile blood flow

Disturbed, turbulent-like blood flow promotes chaotic wall shear stress (WSS) environments, impairing essential endothelial functions and increasing the susceptibility and progression of vascular diseases. These flow characteristics are today frequently detected at various anatomical, lesion and intervention-related sites, while their role as a pathological determinant is less understood. To present-day, numerous WSS-based descriptors have been proposed to characterize the spatiotemporal nature of the WSS disturbances, however, without differentiation between physiological laminar oscillations and turbulence-related WSS (tWSS) fluctuations. Also, much attention has been focused on magnetic resonance (MR) WSS estimations, so far with limited success; promoting the need of a near-wall surrogate marker. In this study, a new approach is explored to characterize the tWSS, by taking advantage of the tensor characteristics of the fluctuating WSS correlations, providing both a magnitude and an anisotropy measure of the disturbances. These parameters were studied in two patient-specific coarctation models (sever and mild), using large eddy simulations, and correlated against near-wall reciprocal Reynolds stress parameters. Collectively, results showed distinct regions of differing tWSS characteristics, features which were sensitive to changes in flow conditions. Generally, the post-stenotic tWSS was governed by near axisymmetric fluctuations, findings that where not consistent with conventional WSS disturbance predictors. At the 2-3 mm wall-offset range, a strong linear correlation was found between tWSS magnitude and near-wall turbulence kinetic energy (TKE), in contrast to the anisotropy indices, suggesting that MR-measured TKE can be used to assess elevated tWSS regions while tWSS anisotropy estimates request well-resolved simulation methods.

Exercise Capacity in Asymptomatic Adult Patients Treated for Coarctation of the Aorta

A reduced exercise capacity is a common finding in adult congenital heart disease and is associated with cardiovascular morbidity and mortality. However, data on exercise capacity in patients after repair of coarctation of the aorta (CoA) are scarce. Furthermore, a high rate of exercise-induced hypertension has been described in CoA patients. This study sought to assess exercise capacity and blood pressure response in asymptomatic patients long-term after CoA repair in relation to left ventricular and vascular function. Twenty-two CoA patients (age 30 ± 10.6 years) with successful surgical repair (n = 12) or balloon angioplasty (n = 10) between 3 months and 16 years of age with a follow-up of > 10 years underwent cardiopulmonary exercise testing at a mean follow-up of 23.9 years. Exercise capacity (peak oxygen uptake; VO_2peak) and blood pressure response were compared to age- and gender-matched reference values. Left ventricular function and volumetric analysis was performed using cardiovascular magnetic resonance imaging. CoA patients showed preserved exercise capacity compared to the healthy reference group, with a VO_2peak of 41.7 ± 12.0 ml/kg/min versus 44.9 ± 6.7 ml/kg/min. VO_2peak/kg showed a significant association with age (p < 0.001) and male gender (p ≤ 0.001). Exercise-induced hypertension occurred in 82% of CoA patients, and was strongly related to left ventricular mass (p = 0.04). Of the 41% of patients who were normotensive at rest, 78% showed exercise-induced hypertension. No significant correlation was found between peak exercise blood pressure and age, BMI, age at time of repair, LVEF, or LV dimensions. Exercise capacity is well preserved in patients long-term after successful repair of coarctation of the aorta. Nevertheless, a high number of patients develop exercise hypertension, which is strongly related to systemic hypertension. Regular follow-up, including cardiopulmonary exercise testing, and aggressive treatment of hypertension after CoA repair is strongly advised.

Computational fluid dynamics in the numerical simulation analysis of end-to-side anastomosis for coarctation of the aorta

Background

Based on CT image data, a computational fluid dynamics (CFD) model of the aortic arch was established. We aimed to investigate the hemodynamic features associated with end-to-side anastomosis (ESA) surgery for coarctation of the aorta (CoA) by CFD model.

Methods

The data of enhanced CT two-dimensional medical images obtained through clinical practice were processed using medical image post-processing software. The three-dimensional model of the aortic arch was obtained through the geometric model and boundary condition. This was subsequently transformed into a CAD model, which can be used for simulation calculation.

Results

The CFD model accurately reflected the shape of the aortic arch, and produced the hemodynamic results before and after ESA for CoA.

Conclusions

The CFD model provides a virtual execution platform for the scientific research of aortic arch disease and will be helpful to evaluate the operation plan, even to determine the best surgical procedure. Hemodynamic analysis may be helpful to evaluate the therapeutic effects of other aortic diseases.

Role of dexamethasone in the para-vertebral block for pediatric patients undergoing aortic coarctation repair. randomized, double-blinded controlled study

BACKGROUND

Surgery for aortic coarctation requires special care during anesthesia due to severe pain during the lateral thoracotomy incision, intraoperative hemodynamic instability and the need for large doses of intra- and postoperative analgesics and vasodilators. Additionally, the postoperative care of patients is very important.

AIMS

We aimed to compare ultrasound-guided paravertebral block performed using bupivacaine alone and bupivacaine with dexamethasone in terms of the intra- and postoperative analgesic requirements and hemodynamics, postoperative complications and ICU stay.

STUDY DESIGN

This was a prospective, randomized, controlled, double-blinded study.

METHODS

Fifty patients aged four to 12 months scheduled for aortic coarctation surgery were randomly divided into two equal groups (n = 25). Patients in group D (dexamethasone) received 0.5 mg/kg bupivacaine 0.25% mixed with 0.1 mg/kg dexamethasone diluted with isotonic saline and those in group C (control) received 0.5 mg/kg bupivacaine 0.25% diluted with isotonic saline (total volume 15 ml in each group). Intraoperative fentanyl consumption and hemodynamics (heart rate, arterial blood pressure) at baseline, 1 min after induction, at skin incision, after 30 min, after clamping, after declamping and at the end of the surgery were recorded, along with the objective pain score (OPS) immediately postoperatively and at 4 h, 8 h, 12 h and 24 h postoperatively and the time to the first request for pethidine. The intra- and postoperative vasodilator doses, time to extubation, ICU stay duration and postoperative complications were also recorded.

RESULTS

The postoperative OPS was significantly lower at 12 and 24 h in group D than in group C. The time to the first request for analgesia was significantly longer in group D than in group C (3.9 ± 2.23 vs 8.6 ± 0.69). Additionally, the time to extubation was significantly shorter in group D.

CONCLUSION

The use of dexamethasone as an adjuvant in ultrasound-guided paravertebral block in paediatric patients undergoing surgery for aortic coarctation increased the duration of postoperative analgesia with a prolonged time to the first request for analgesics It was also associated with a decreased incidence of postoperative complications.

TRIAL REGISTRATION

Trial registration number: NCT03074773 . (Prospectively registered). The initial registration date was 9/3/2017.

Aortic coarctation endarteritis: The importance of a systematic echocardiographic study

Aortic coarctation determines a favorable anatomical condition for the development of endocarditis-endarteritis due to the presence of an alteration in blood flow dynamics that favors the appearance of endothelial damage and the adhesion of microorganisms. At present, endarteritis of aortic coarctation is a rare entity due to early detection and surgical treatment of patient carriers of aortic coarctation. We present a case of a patient affected with a previously unknown aortic coarctation, who developed infective endarteritis with secondary formation of mycotic aneurysm. The echocardiography techniques proved determinant in establishing the diagnosis of aortic coarctation, as well as the associated infectious complications. <Learning objectives: In this paper we show an infrequent case of vascular infection nowadays, as a complication of a congenital heart disease. Physical examination and echocardiography were clues for an early diagnosis, and should emphasize the performance of a complete echocardiography that includes the suprasternal view.>.