Coarctation of the aorta and ventricular septal defect.

he patient was a 27-year-old Negro woman who was T adtl~itted to thr l~ ( rp i t r l for cartliilc n,alaation. A cardiac CommentS by tnrtrmur h i~d heen discovered at the titne of her first pregnilncy four and one-half years earlier, and it was thought to Robert C. Schlant, M.D.* represent a ventricr~lar septal defect. The patient had not had orthopnea, paroxysmal noch~rnal tlyspnea, cyanosis or chest This patient presents the problem of an asyn~ppain. Sire was aMe to do 11cr own housework anti wa.; not tomatic 27-year-old black mother of two who has a Ii~nitcbtl in her physical activities. It is of note, however, that coarctation of the aorta with a 64-72 mm HE sllv Ilatl also been hypertensive since her first pregnancy, ant1 11;1tl transitmt ankle edema at that time and again with her second pregnancy three ancl one-half years ago. Since then, she had received ~ncdication with adequate cwntrol of her I)I(n)d pressure. There was no history of rheumatic fever. Physical examination revealed a well-developed, slender Negro woman who was cotnfortahle at rc,st. Pulse rate was 90 per minute; blood pressure was 1 6 2 / 0 in the left artn ant1 160/84 in the right arm. Frtndrtscopic examination disclosed slight silver wiring and arteriolar narrowing. There was no jugular venous distention. Her chest was clear to percussion and ar~scr~ltation. Her PSI1 was in the fifth intercostal space in the midclavicrtlar line. There was a systolic thrill along the left stcrnal hortler at the third and for~rth intercostal space. A grade I\'/VI holosystolic mrrrmur was heard in this area. It radiated widely and was heard in the back as well. The sc.cond heart sor~nd split widely but closecl with expiration. Thc liver was not palpable. There was no cyanosis, clr~hbing or citlem;l of her extremities. Femoral, popliteal, dorsalis petlis, ancl posterior tihial pulses colrld not be palpated. Clinical impression was that of congenital heart disease with a ventricrrlar sept'tl defect ancl possibly with ass t~ia ted cu~arctation of the aorta. Resrllts of lalmratory tests inclr~tletl nomial CBC, ttrinalysis, VDRL, prothrombin time, platclet count, BUN, semm creatinine and electrolytes. Her electrocardiogram also was nortnal. Cardi;~c flr~oroscopy revealed some left ventricular t.nlargement. Chest roentgenogram showed some pr~llnonnry venous distention, particularly in the rlpper lung fields, but no findings sr~ggestive of coarctation of the aorta cortltl he itlc~ntific~tl. IZiglit and left heart catheterization rcvealed nortnal right ;itrial, right ventricrtlar and prtlmonary artery pressures. Alcan pulmonary capillary wedge pressure was 8 mrn Hg. -rllc.rt. was no pressure gradient fol~ncl across the aortic valve. Drtring simr~ltancor~s pressure recordings in the ascending ;lntl tlrasc~*ntling ;lorta, however, a pressrtre gradient of 64 to 72111111 Hg W ~ I S tloted across a coarctation of the aorta which was at the Irvel of the take-off of the left sr~l>clavi;in wtery. I.cft \.entriculr cineangiograms ;tlso rrvealrtl a high ventricrlI;ir scspt;~l tlcfect with an ;issoci;~tctl ilnihrlrysm of the vent r ic .~~l ;~r s rp tun~ . I'r~lmonary vasclrlar resistance was normal. 'I'Irt, p;~ticnt's cartlinc o~ttprtt w;ls 5.8 L/min with prtlmonary flow of 9.4 L/min, giving a left-to-right ventricu1;lr shrtnt of .'3,[j L . / ~ l r i t ~ , -~ . -