An infant presents with cardiac failure. Examination reveals a weaker femoral pulse when compared to the radial pulse. What is the probable diagnosis?
Ref: Nelson's Textbook of Pediatrics. 19th Edition.Explanation:Weak femoral pulse is indicative of Coarctation of aorta. Normally, the femoral pulse occurs slightly before the radial pulse. Weak femoral pulse or femoral pulse felt after radial pulse is a characteristic feature of COACoarctation of aorta (COA)Constrictions of the aorta of varying degrees may occur at any point from the transverse arch to the iliac bifurcation, hut 98% occur just below the origin of the left subclavian artery at the origin of the ductus arteriosus i juxtaductal coarctation).The anomaly occurs twice as often in males as in females.Coarctation of the aorta may be a feature of Turner syndrome and is associated with a bicuspid aortic valve in more than 70% of patients.Mitral valve abnormalities (a supravalvular mitral ring or parachute mitral valve) and subaortic stenosis are potential associated lesions.When this group of left-sided obstructive lesions occurs together, they are referred to as the Shone complex.Clinical ManifestationsMostly asymptomaticSome children or adolescents complain about weakness or pain in the legs after exerciseSilent hypertension diagnosed on routine physical examination.Disparity in pulsation and blood pressure in the arms and legs.The femoral, popliteal, posterior tibia], and dorsalis pedis pulses are weak (or absent in up to 40%' of patients), in contrast to the bounding pulses of the arms and carotid vessels.The radial and femoral pulses should always be palpated simultaneously for the presence of a radial-femora] delay.Normally, the femoral pulse occurs slightly before the radial pulse. A radial-femoral delay occurs when blood flow to the descending aorta is dependent on collaterals, in which case the femora] pulse is felt after the radial pulse.In normal persons, systolic blood pressure in the legs obtained by the cuff method is 10-20 mm Hg higher than that in the arms.In coarctation of the aorta, blood pressure in the legs is lower than that in the arms.The precordial impulse and heart sounds are usually normal.The presence of a systolic ejection click or thrill in the suprasternal notch suggests a bicuspid aortic valve (present in 709c of cases).A short systolic murmur is often heard along the left sternal border at the 3rd and 4th intercostal spaces.In older patients with well-developed collateral blood flow, systolic or continuous murmurs may be heard over the left and right sides of the chest laterally and posteriorly. (SUZMAN SIGN)In these patients, a palpable thri 11 can occasionally be appreciated in the intercostal spaces on the back.DiagnosisCardiac enlargement and pulmonary congestion are noted in infants with severe coarctation.The enlarged left subclavian artery commonly produces a prominent shadow in the left superior mediastinum.Notching of the inferior border of the ribs from pressure erosion by enlarged collateral vessels is common by late childhood.In most instances, the descending aorta has an area of poststenotic dilatation.
PDA
COA
Aorto-illiac vasculitis
VSD
C.V.S.