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Hi. Hello. Good afternoon, everyone. And I hope, I hope this is working and I hope you've not had the same tech issues that we have. Oh, there are people here. Great. Fantastic. Oh, thank you so much for joining us. I'm ju I'm a consultant cardiologist. Um and I work in Oxford and specialize in adult congenital heart disease. And then I'm really grateful to be joined by my wonderful colleague Jackson, who's one of our cardiac physiologists. We've had a really classic time because at 415 we did a test log on and we could not get on. So we've both had to jump on our bikes and cycle home to log on via the home Wi Fi in order to be able to be here today. So we're both feeling really relieved that we're here and that you're here and you can hopefully um hear what's going on. Um If you can't, please do say so in the chat because um we wanna hear from you. Um Right. So Oh, yes, and it will be recorded. Yes. Ok. Someone says waiting for the screen to come up still blank. Yes, we can. Brilliant. Ok. So um we promised beginner's AD HD echo. And so I always um start with what is um ach D I'm sure lots of, you know, this but just to kind of go back to basics. So 1% of the population born with a congenital heart defect and that can be something simple here. Um like a a VSD ventriculoseptal defect or something super complex here, like hyperplastic left heart and 6070 years ago, Children born with more complex disease would not survive. But now thanks to all the amazing advances in surgery, anesthetics, diagnostics, cardiology and so on. We now these Children do survive and they need lifelong specialist care, which is provided by adequate congenital heart disease services. Um because in the majority of cases, the surgery is corrective but not curative. And the reason that we do this teaching is because we need you. The ach d community needs you all of you. Um because as the population grows, it's no longer what, it's just not feasible for these patients to be cared for exclusively by, you know, in in tertiary centers and they will crop up everywhere as you know. So we really, we really need people who know how to look after them. But we also recognize that it is really hard and indeed frankly terrifying sometimes if you are not used to looking after ad HD patients when they look up on your list and so on. So the purpose of this teaching series today is to debunk some of the complexity and to provide you all with some simple tools and frameworks so that you can approach these patients with confidence and competence um when, when you meet them. So that's why we're here now, housekeeping things. So as you have noticed, we have moved over to this new platform mer which is an amazing platform. Um Now, some of you may be having tech issues like we have and I'm really sorry if that's the case. But the reason we do this is because last time when we did it for ours, my amazing colleague, Catherine Townsend at the end had to go through 12 spreadsheets and generate 500 individual certificates um for all these lovely people. And so that was, and she did it all in her own time and totally unpaid and she's amazing, but obviously that's not really fair and was not sustainable. Um But med all is amazing and it will do that bit for us. So that's why we've moved over. So if you are having tech issues, I'm really sorry, do let me know afterwards and we can put you in touch with the support team who are great and hopefully sort it out. Um So it started out as something small and we could all talk and sadly, we can't do that as the numbers have grown. But please do use the chat function because um we really want to hear from you and Jackson will interrupt me. So if you want me to go back to a particular picture or whatever, just put it in and then Jackson will shout out and we can sort that out for you. At the end, there will be a link to a feedback form, a short feedback form and then you fill that in and then you will be sent a certificate via medal straight afterwards, which is great. Um And thank you for doing the feedback and particularly thank you to all the, all the old timers because it is a weird thing. Um Sometimes I think talking into one's computer screen and you kind of sometimes wonder if anybody's out there or what you're doing it for. But then when you know, to get the feedback, it and or emails, it's really nice to hear from you and makes it all worthwhile. So thank you for taking the time to do that. And the other great thing about med all is that hopefully there will be a video recording. This session is recorded and then if you follow us on med, all you will then have access to that recording for a few months afterwards. So that's where we are. Um And then we're gonna talk about coarctation. So I'm gonna make this smaller for a moment and just check. Is there anything in the chat or? Oh, no, great. Ok, cool. So let's keep going. So I'll make this bigger again and we're gonna talk about coarctation today. And the way I do with all these lesions is we start off the first part, you'll be like, where's the echo? Because I spend the first part talking about the anatomy and physiology. And then the second part is the echo. So we're gonna talk anatomy physiology. And at the end, I hope you'll be able to appreciate that coarctation should be regarded not as an isolated lesion but as part of a more generalized arteriopathy with important associations. We will talk about treatment um treatment options and complications and hopefully you'll be able to go out for knowing how to do a comprehensive assessment on transthoracic echo, the native coarctation and the patients who've had a coarctation repair and or stent and the pictures. Um again, this is the value of the feedback. So because of the it was asked for and the feedback, we now have a website Oxford ad HD echo.org where the key slides you can access them all for, for free afterwards. So that will be it. So to kind of focus our minds. Let's imagine that you're doing your regular list or you pick up a request for something like this, either um an 18 year old with hypertension query coarctation or perhaps a request for an 18 year old with a history of coarctation repair under surveillance. So have a think now maybe about what, what you're looking for on the Echo, how you're gonna answer these questions and all these thoughts in your mind as you go through. But let's start with what is a coarctation? So, coarctation means narrowing, growing in and it's a narrowing at the aortic isthmus. What is the isthmus? Well, here's a refresher of our aortic arch anatomy. So, in a left sided normal arch, we've got this branch here. The first one, the brachiocephalic artery, which gives rise to the right subclavian and the right common carotid arteries, left common carotid and left subclavian artery. I mean, isthmus is the bit between the left subclavian origin and the ligamentum arteriosum here. What on earth is that you might ask this, the ligamentum arteriosum is the remnant of the ductus arteriosus. What is that? Well, in fetal circulation, the pink blood comes into the right side of the baby's heart from the mother. And then it obviously needs to cross over into the left side of the baby's heart. And it does that either through the foramen ovale or through the fra ovale and also through the ductus arteriosis, connecting the pulmonary artery and the aorta. And after birth in most people that duct shuts and we're left with this ligament, the ligamentum arteriosum here and so coarctation and narrowing of the isthmus this bit here between the left subclavian artery and the ligamentum arteriosum. Now, there's lots of sort of variations, different flavors of coarctation and we can classify it according to its location relative to the ductus. So you might have heard these terms, preductal, juxtaductal or postductal, we can talk about the morphology of the narrowing. So some narrowings might be diffuse or tubular or sometimes will have a discrete ridge. And then we can also classify according to the, the severity of the narrowing. And it's important here to introduce these guys in the coarctation family, which you might also have heard of. So there's aortic atresia and interrupted arch. So here we've got coarctation narrowing here, we've got anatomical continuity, but functional discontinuity. So this is aortic Atresia where the blood to the descending aorta is having to come here through a patient doctors. And then here we've got anatomical discontinuity and functional discontinuity. So completely separate here, the aortic arch and the descending aorta completely separate. So this is interrupted arch, they're all part of the same family. So simple terms, cooptation narrowing and then we can classify it in these different terms. Yeah. No. What the other thing which is important to sort of bear in mind when we're talking about coarctation is that it's commonly seen in association with other lesions. Now, whenever you go to congenital talks, we always put up slides like this and say these are the associated lesions. And I think it's really hard to remember this like this. So the important thing is to pick out themes. And the key theme for coarctation is, as I said, already, it's part of this generalized arteriopathy. So the key associated lesions are, it can be associated with abnormalities of the arch. For example, a gothic arch or a hypoplastic arch. There is a strong association with bicuspid aortic valve. So 85% of patients with co op have bicuspid aortic valve and of course, with bicuspid aortic valve. There also comes the association with bicuspid aortopathy and then also super important is an association with hypertension. And this persists even if you have the best cooptation and repair in the world, there is still this life and predisposition to hypertension. And there's various theories about that relation to reduced arterial compliance, abnormal arch geometry, neurohormonal factors in factors, lots of theories. But, but this is a well recognized association and obviously that puts people at risk of cerebrovascular disease, coronary disease further down the line. And there is also an association between coarctation and intracranial aneurysms. So when you look at coarctation, it's not enough just to be like great coarctation tick by, you've gotta be thinking about all these other sort of features of the generalized arteriopathy. And then if you're going for the gold star, you can remember some of these other ones as well. So there is an association with syndromes and the really important one is Turner Syndrome because Turner Syndrome associated with coarctation, bicuspid valve bicuspid aortopathy and risk of dissection. And women with Turner Syndrome have short stature. And so what looks like in absolute terms, a normal size, ascending aorta, um may not actually be a normal size, ascending aorta for a woman with Turner syndrome. So you have to index it to body surface area. So, association with syndromes association with shunt lesions. These ones. And we do also see coarctation as part of what we call a shown complex where you can have serial left heart obstruction. So, mitral stenosis, aortic stenosis, coarctation. So just keep these things in mind. We'll come back to this again later. So, physiology. Ok. Oh, I'm just gonna pop back to the chat and check everything's oh, everybody's ok. All right here. Nothing, everyone. OK, everyone. Ok. Cool. OK. Thanks Jackson. OK. So, physiology. So, um as we go through this series, you'll see, these are the questions I normally think about when we're talking about any cooptation, any um congenital lesion. And I think first of all, where's the blood going and in coarctation, you know, the blood is all going where we would expect it to go in a normally connected heart. But we've got this narrowing here and the effect of this on the heart is that it's going to exert a pressure, pressure load on the left ventricle. And then I would think about, well, what are the effects of this abnormality on the systemic circulation? Is the body getting enough blood? And this is, you know, we're thinking here about a coarctation in its most sort of basic vanilla form um with nothing else going on. And what whether or not, the, the body is getting enough blood. We can see that the upper body should be getting enough blood, but the lower body may not be getting enough blood. So that's the basic starting point. And then the precise physiology in each individual will depend on the interplay between all these factors here. So, we've talked already about the severity of their narrowing. It will depend on whether or not the arterial duct is open. Whether or not we have collateral vessels, pulmonary vascular resistance and associated anomalies. And in the majority of cases, coarctation presents in the neonatal stage. And the presentation can be quite dramatic because as we've seen before the ductus here, that is open when the baby's in the uterus. And so when the baby's first born, even if we've got quite a severe narrowing here from the coarctation, we will have maintained lower body perfusion because the blood here, the blue blood coming through, the pulmonary artery can cross over through the ductus and perfuse the lower body. So we will mainly see that the lower body is perfused, but we might see that the lower limbs are cyanosed cos they're getting blue blood um relative to the upper limbs, which will be pink. So they call this differential cyanosis. So in the early days after birth, the baby may be fine. But then as the doctor shuts, then we lose lower body perfusion and get circulatory collapse. Um with lower body hypoperfusion acidosis ventricular dysfunction, and that's all very bad. So, with severe coarctation and those pictures we looked at earlier with aortic atresia interrupted arch, we call this duct dependent systemic circulation because these babies need to be maintained on prostaglandin to keep the duct open in order to maintain the perfusion of the lower body. And whilst you, you know, the pediatric cardiologist plan for repair, so that's kind of coarctation in the newborn. But we do also see cooptation presenting in older Children and adults. And this is often quite a different, more insidious presentation. And as we said before, because of the narrowing here, we get this pressure load on the left ventricle and we get compensatory, left ventricular hypertrophy and pres preservation of the LV function. But we do get this pressure gradient here across the coarctation. And so what you see typically is upper body hypertension um and presenting with things sometimes like epistaxis, nose bleeds, um headaches and then they may also have lower body hypotension, low BP in the limbs. So that might present with claudication. So, pains in the legs when you walk abdominal angina, cold feet, and then when we sometimes we examine these patients and you find that their BP in their upper limbs is higher than that in their lower limbs. So it can be more insidious presentation in older Children and adults. And the presentation can also be complicated by the development of collateral vessels. So, collaterals develop in any vascular system where you've got a difference in pressure. And what we get is the, where these small arteries which are bridging, the higher and the lower pressure components in large and blood sort of diverts through these bridging vessels and dilates them and bypasses the, the narrowing and with coarctation, it's typically the internal mammary and intercostal arteries most frequently which form these collateral vessels. And so, if you've got well developed plaque drugs, again, you may actually be able to maintain reasonable lower body perfusion and, and there may not be a major difference in blood pressures. And sometimes coarctation is just diagnosed incidentally when, when we find in young people with hypertension. So in simple terms, coarctation, pressure load on the left ventricle. And then we need to think about all these other different factors which will determine how a particular individual presents in their physiology. Now, when talking about assessment, I think it's always good to think about when you would intervene, cos that informs the assessment and we intervene for um cot where there is hemodynamic and or anatomical significance. And we talk about and hypertension importantly. So we talk about hemodynamic significance as being coarctation where we have a pressure gradient, a pressure difference of 20 millimeters of mercury. And that might be, we might measure that um on noninvasively, upper and lower limb blood pressures or invasively on cardiac catheter. And we talk about anatomical significance as being er where we have a narrowing of greater than 50% of the aorta relative to the diameter of the aorta at the diaphragm. And then we're also looking for the presence of hypertension. And so when we assess these patients and clinically, we're looking for hypertension, we're measuring up a lower in blood pressures. And on echo, we're gonna talk about the key sort of thing that would show us this is significant coarctation. And then these patients will also have, you know, CT or MRI and some of them will also have cardiac catheter. What kind of interventions are available. So, they're surgical or percutaneous. Sorry. My writing is a bit smaller on this slide. Um These are some of the surgical repair techniques you may have heard of. So end to end anastomosis where we cut out the coarctation and we not we not me um where the surgeons cut out the, the coarctation and then join the two ends together. Um And then you're also probably heard of this one subclavian flap repair where they use a subclavian artery, they ligate the subclavian artery and then use that to, to patch the coarctation. Then sometimes this one sort of rarer, sometimes you might see one, someone who's had an interposition graft or one where um a dacron patch has been used to patch the coarctation. These ones have quite high rate of aneurysms, so they're not really um done for it anymore. Um And generally the surgical results are good low morbidity. But there are, um, rates of, you know, we do see later complications, rec cooptation, aneurysm. So we'll come back to that in a bit. And so that's the surgical options. And then there is also the option to stent coarctations. And this is a, this is a nice picture taken from this paper here by Soad and Hijazi and this shows here. So someone is there where they're putting in a they're putting dilating and then stenting a coarctation. Now, typically, oh, sorry, get back. Um Typically for infants and Children surgery or balloon dilatation tend to be first eye management because obviously the problem with stenting an infant is then the infant grows into an adult and then you have an adult with an infant size stent which is a problem. Um But in adults and adolescents then balloon dilatation and stent implantation are our first choice if the anatomy is appropriate. Ok. Now we come on to the echo bit. So I'm gonna again, just make this smaller one, just see if there's anything, any questions or anything in the chat. Not yet. Ok. Do you please? Um Yeah, chime in if you would like to. Ok, let me come back to this. Here we go. So what are we looking for? So these are the three questions I think you need to be thinking about when you're scanning these patients. Number one, is there a coarctation? Number two. Is it hemodynamically significant And number three, is there anything else going on? Are you, are there any, is this coarctation having any effects, local effect on the heart? And are there any other associated lesions of the sort that we mentioned before? And remembering in particular, thinking about left heart obstructive lesions? The arch geometry is there a bypass for the aortic valve? But because of the autopathy and is the patient hypertensive? So, and then we were also thinking about what effects the coarctation could be having locally. So it might have local effects, aneurysm rupture dissection. Hopefully, we're not going to see those things um effects on the heart. So we've talked about left ventricular hypertrophy cos we've got the pressure load and then in some patients, it's very severe and untreated. Maybe we get LV dysfunction, heart failure, premature coronary disease. And then we've mentioned also those kind of systemic effects associations as well. So you start with, is there a coarctation? And and really hear the and that so sorry, that was for um assessment of a native coarctation. But the questions are really the same. Also, if we're assessing a patient who's had a stent or an operation, is there a coarctation? Ie is there a restenosis. Um and those who've had end to end repair, there is slightly higher rate of restenosis. Again, is it is hemodynamically significant and again, is there anything else going on? So, you know, thinking particularly somebody might have had a great coarctation repair, but you need to be walked in the bicuspid aortic valve and the ascending aorta for aneurysm. And then looking for local consequences of that coarctation repair. Um aneurysm as we said earlier, pretty bad for patch repair. So, same questions really for whether this is native coarctation or a repaired or stented coarctation. And it's really quite, this is all quite straightforward. And the, the first you starting place is obviously gonna be the arch and this is your money shot. And I would really encourage you to take the time to set this up properly because I think sometimes I, you guys scan under such pressure. I know and it's, it, it's really hard, really hard to scan in the time slots that you have. But I, although it might feel like it takes a lot of time, you're a, it's actually a lot less time than if we end up having to bring the patient back cos we haven't got the, the right picture. So when you're setting up for this, you know, all this, but put the patient flat, put that funny bumpy thing, which isn't a pillow behind their neck and really get them to extend their neck beautifully. So you can get a really nice, nice picture and, and, you know, set yourself up for success and you're gonna take the two D picture of the arch and characterize that isthmus area. You're gonna put color across it, you're gonna do PWCW Doppler and you're gonna look for any local complications like aneurysm. And here's a reminder again of that arch anatomy and these are all the things we're gonna do. So, as we said, two D color and then the PW and CW dopplers and I really hope these play, they're playing for me. I really hope they're playing for you. Here's just a few examples. So this is um, a nice arch picture here showing there's the ascending, here's a, a very hypoplastic arch here. Do you see it's quite thin? And then we've got this narrow ridge here, the coarctation here and we can see that there's flow acceleration across there in that region. And then here let these ones warm up cos it'll probably take a while to get through my wifi and then to your wifi. This is an adult patient here. So here's the arch. This is a, a zoomed in picture of the arch showing those branches. Nice. He said brachycephalic left con left common subclavian, left Subclavian. And then we see there's this kind of ridge here and then some flow acceleration here. So we're trying to get nice zoomed in pictures here of, of the art and of this region like so and then the question is if there is narrowing is this significant and this is where the, the Doppler come in. And yes, what are we actually looking for? We all do these traces, right? But what are we actually looking for now, when we're doing, you know, assessing gradients and things across aortic valves, we convert the velocity, don't we get a velocity? And we convert it to a peak systolic gradient using the Beno equation. But this alone is not enough to determine whether or not the patient has significant coarctation because these velocities can be affected by many other factors. So for example, we know if you think back to your PSA exams from years ago, perhaps, um we know, but no, he's not reliable for long tubular lesions. And we know it can be affected by aortic compliance, pre and post coarctation segment. And we know compliance is often abnormal in cart patients. And we also know that, you know, if you've got anything else going on that might reduce it's proximal velocity such as a regurgitation, collaterals reduced LV function, then we might underestimate the true gradient. So what we're really interested in with coarctation is the diastolic philosophies and specifically this business of the diastolic tail, do we have continuous antegrade diastolic flow? Because this is a really good marker of significant coarctation. And here's just a sort of bit of schematic. So there we see a normal, you know, pulsatile flow through and isthmus without coarctation about 1 m per second with severe coarctation. We do see elevation of the the peak systolic velocity. But more importantly, see this tail, this continuous antegrade diastolic flow here like we've seen very nicely here and then sometimes we might have a patient who's got a mild coarctation where we do see an increase in the velocities, but we don't see this diastolic tail and that tells us that it's unlikely to be hemodynamically significant. Now, sometimes I spent ages looking at these things and going. Is there a tale? Is there not a tale? I think in this kind of example, I think it's quite clear there's always a tale, but I sometimes find it helpful to have kind of parameters for the borderline cases which ii find helpful. You may may or may not, but you can measure the diastolic. So there is some, there's some papers which say that um diastolic velocity, if you measure at the end of the T wave of greater than 100 and 93 um centimeter per second is considered significant or, and or diastolic systolic velocity ratio of greater than 0.5. So just to sort of show you that in practice, you can measure the diastolic velocity and the systolic velocity ratio here clearly greater than naught 0.5 so significant. Um But in other examples, we'll see um it's it, you know, it's not, it's not significant. So that, that I sometimes find that those numbers useful if I can't quite decide. Um Here's an example of a patient who had a repaired interrupted arch, followed by a stent to the area and you can see the stent hopefully here and there's the color. So this is an example where there is flow acceleration through this stent. So about 3.8 m per second but clearly no diastolic tail here. So we'd say this is somebody who's got a small stent. But you know, we're not worried from the hemodynamic perspective with this patient. Um we're just monitoring and so this fits more in the rounds of that sort of mild coarctation pattern here. And then if you do that ratio thing again here, you can see that the diastolic systolic velocity ratio is like less than um naught 0.5. Now, really important here cos I do see this happening sometimes here's a beautiful picture of an arch and this is a patient who's had a coarctation stent down here. This is a great picture. But what's then happens sometimes is that people, oh is that people who are perhaps not so experienced in this? Um might you put their Doppler across here and go? Ok. Well, there is an increased velocity but there's no diastolic tail. But do you see how putting the cursor across here? We're not actually putting the cursor through that cooptation site. And then when someone's come back and has kind of swung it around to make sure it's properly aligned, you can see that actually there is recoarctation here and there is a diastolic tail. So again, I think it comes back to this thing of setting yourself up for success and really taking the time to get those nice pictures and to make sure your cursor are aligned for when you do the, your dopplers. And I know it's difficult sometimes and sometimes I sort of say to the patient, you know, turn your head to the left, turn your head to the right and it's nothing really particularly scientific about. It's just trying to kind of try different things until you can, can get, it can get it right. But again, do take the time because otherwise you might provide falsely reassuring data and miss the fact that there is coarctation going on here. So that is the arch. And then the other thing which might be new for some people is to study the abdominal aorta. And this is fun and, and I encourage you to think about this um because we're gonna come back to this in other sessions and you might, if you've seen some pediatric or congenital echos, you might, and you're a, a general echo person, you might have seen this picture cropping up at the beginning of scans and think what on earth is going on here and this is what we call um your situs shot and this is an abdominal uh subcostal view. So you start with the patient lying flat and then, whereas normally you kind of go down and you scoop up, don't you for your subcostal view of the heart? But here you're just pointing straight down. So sort of straight down through to the patient's back with a notch at three o'clock. And then what you're trying to do is bring up the AORTA and the IVC in cross section and then the spine at the back. So this is aorta with pulsatile flow, the vein with lamin aha flow and then the spine at the back. And you put the color on the top to demonstrate this is the AORTA on the patient's left and the vein on the IVC on the patient's right. And then what you can do is turn round, spin your cursor so that the notch is now pointing up towards the patient's head. And then if you tilt right, you'll bring in the IVC or in this case, what you wanna do is tilt left slightly and you can bring up your aorta in long axis like. So, so you start here like this. So that's straight down notch at three o'clock, rotate round. So the notches at 12 o'clock and then angle towards the patient's left and there's your aorta in long axis. And this is cool because now you can put a Doppler through here. You want, you want to get it as vertical as possible. So to do that, you often have to kind of drop the tail quite far down and then you can put a Doppler in here and AP W Doppler and then what you're looking for. So this is a normal trace which shows nice pulsatile flow about 1 m per second. But if somebody's got a significant coarctation, then you would see blunting of that systolic flow and more kind of con er continuous flow profile like this. It's taken from this paper here. And if you see that, then that is also a good indicator that there may well be a hemodynamically significant cooptation going on here. Now, sometimes it can be falsely reassured there are some caveats. So if, for example, there's other things going on. So if you've got um for example, a patent ductus arteriosis with a um and high and pulmonary hypertension. And if your lower body is being perfused through that ductus, then you might see a normal, you know, flow profile, well, sort of normalish looking here as in this case, here we go. So in a case here, you might have severe coarctation but because the blood is coming here through the pulmonary artery and perfusing the lower body, then you might still get nice kind of pulsatile flow in the abdominal aorta. So if it's normal, it doesn't necessarily mean there isn't a coarctation. But if it's abnormal, then that is a useful, a useful sign. So do have a play with that and try it out cos we're gonna come back to it, as I said in, in later sessions. So that's what we're looking for. Normal pulsatile systolic flow as opposed to coarctation, low velocity flow with minimal variation. So that's where I would start with. And then you go on and do the rest of the study. And this is really to say, is there anything else going on? Are there any consequences of this coarctation that we need to think about? So, is there L VH, are there regional wall motion abnormalities? Is there pulmonary hypertension? And then are there any associations, is there a bypass valve? What's the aortic root doing? Are there any other left heart obstructive lesions? And you guys all know how to do this? Right. So then you just get one with your study. So that's it. Really. And as I said, when you're looking at patients with operated authentication, again, it's all just the same, the same deal really? It is not hard. So I thought I now just share some cases and you can have a, have a look at these and, and sort of with the questions in mind as to which we said about before. So is there a coarctation? Is it significant? And is there anything else going on? So this is a picture I showed before we've got this hypoplastic arch and a per patient here and then the patient went on to have a repair. So you can have a look at this and then think is there coarctation of their restenosis? Is it significant? And I see that we've got a nice looks really nice, doesn't it? No flow acceleration around here? And then here's a Doppler which is well aligned and we've got a nice pulsatile flow. So, coarctation. Yes. No. 01 more. I feel like he's, that abdominal aortic is getting a bit mental. But that's the, the um your name, the, you know what's doing that? We've got the um Doppler here in the abdominal aorta. So again, nice pulsatile systolic flow. So this is the point where we're being interactive. I get people to put their hands up and say um cooptation, no cooptation. But hopefully you can all agree. This is a great, this is a great repair. Oh, there are some questions I've just seen. Hello. OK. What is the reason for premature coronary disease? Uh Thank you very much. So largely related to hypertension. Um would be the answer and then normal dimensions for the arch and descending aorta for the AD HD is an index as well to height. So no, wouldn't normally index unless um in internal syndrome. As I said, important to index the ascending aorta. Thanks. Thanks for asking these questions just quickly. Yeah, there was a question for indexing and turn is, is it BSA or height? Only? Great question? Great question. So it has traditionally been BSA and the cut off would be 25 millimeters per meter squared. But my colleague who's an expert interna says that it is changing now and there are new guidelines regard it and it's more it's gonna be changed to height. I haven't read those and I'm not up to date on that. But yes, but I still do the B SA but I think it will change to height. A great question. Thanks. Um OK, I'm gonna go and show next example. So yeah, so hopefully we can all agree. This is a great repair and we do not have significant ation here. OK. This is another case that we have to remind myself. Oh, yes. So this is an adult who presented um with a BP of 200/100 and impalpable peripheral pulses and chest pain. So again, let's just, I'll just show some images here and decide if we think this is cart or not cult and if this is significant or not. And I think that's all I've got for that one. Yeah. Oh You let's go back. So hopefully we all agree like this is cooptation. Let me see this significant flow acceleration here. And then this really like beautiful classic profile here with the diastolic tail. This patient had a severe coarctation. This is one diagnosed in adulthood and then they went on to have a stent. And this again looks really nice, doesn't it? I'm not sure if I've got the the doctor profile here. So this is one of those ones where there is a bit of flow acceleration. So the the beat loss is about, you know, two and a bit meters per second, but no diastolic tail. So this is a a really nice result from a stent in adult. Um, I got a question here, Jo. Oh, yes. Great. How can differentiate between pseudocoarctation from true coarctation? I don't know. I don't know about pseudo. What, what do we mean? I don't know about Pseudoarc. He let me come out of that stuff. Let me come down and have a look then. Ok. 00, this is great. This is so nice. Seeing track. And James Bradley Wats. Hello, James Bradley Watson. Great turn brilliant. James James Bradley Watson up to date on the Turners guideline. Brilliant. Thank you. Um, great and yes. Yes, absolutely. So, Mummy, tell me, what do you mean by pseudocoarctation? Oh, I'll let you, I'll let you type something in the chat while we go on to the next one. But that's a good. Um, but yeah, no, we're interested to hear cos I'm not familiar with that term. So, no, thank you, um, for asking it and do type more in the chat. And so this and I'll just carry on with this one here. So this is an adult hypertensive adult here. So here's the art pictures and some color. Yeah. So what do we think about this one? So this one's kind of a little bit borderline, isn't it? And this, I think we call it this. Oops, here we go. So we've got this. So here's the arch is this kind of ridge like coarctation and, but it's not too severe. Is it you can see sticks out a bit here, but it's not, not, doesn't look more than 50% and there's a bit of flow acceleration, but we don't and a little bit of diastolic flow, but we don't have that typical, that classic um tail pattern there. So this one is what we call it a mild coarctation. We've had quite a lot of discussion about this patient and decided not for intervention at the moment and we're just managing the BP medication, but one that we're kind of keeping an eye on. So that's a bit of a borderline one. And then this one. Mm. Oh, yes. So this is one who has had a stent, someone who's had a coc patient stent and again, some sort of a slight increase in the systolic velocity about give me just a second but no diastolic tail. The so you think, ok, good result from the stent. But this is just a one of those reminders about thinking about what else is going on. And you can see here that you've got a bicuspid aortic valve which is reasonably well functioning at the moment with just a mild regurgitation and the ascending aorta looks ok. But one where we need to keep an eye, not just on that stent region, but keep an eye on the, on the valve and think about what else is going on. And then sometimes actually the coarctation is, you know, we, we see these in the setting of more complex congenital lesions. So this is a patient who had a coarctation repair and that you see that kind of gothic sort of arch shape and a good repair. Um But this patient has and I'll just show you all the pictures. Here we go. So this patient had coarctation as part of a a shown complex. So they had a, a significant mitral stenosis for which they've had a mechanical mitral valve replacement. Let me see here and you can see there's a a pretty big gradient across that mechanical valve and pulmonary hypertension. So again, just a reminder of thinking not just about the coarctation but about what else, what else is going on? So that's it really. And so I hope now if you think back to those initial requests as to what to do if you get those kinds of requests about, you know, has this patient got coarctation or this patient's got coarctation repair? Hopefully you'll have a better idea about what you're looking for and how to, how to define it. Remember you're asking those three questions? Number one, is there a coarctation or restenosis? Number two, is it hemodynamically significant? Number three, is there anything else going on and remember, set yourself up for success with the art? Make sure you get those Doppler really nicely aligned. Look for the diastolic tail, try taking some pictures of interest in all your patients. If you have time of the, see the the abdominal aorta and you're looking for blunting of the systolic flow there which could indicate significant cart and then remember to think, are there any consequences of this coarctation? Does the patient have L VH, does the patient have coronary disease, regional wall motion abnormalities? And then are there any important associated lesions going on that? I need to think about like the pa the root and left heart obstructive lesions. So that's that I hope that all make sense. So I will now a couple of questions. Yes, great. Yes. Um One from Mark, is there a clear definition for hyperplastic aorta? Oh, that's a good one, isn't it come across patients with tiny aortas without coarctation where I wonder whether the small dimension in the aorta could result in future complications? Yeah. Yeah. Interesting. So that's, that's a great question. So I there probably are pediatric definitions for it. I don't think we, I'm not aware of any in adulthood, but I'm happy to be corrected. But I think that's interesting. I and I'm I'm not sure I would think that there would be if they, I think if so if I, if I were to find someone who did have a small aorta, then yes, I would be thinking about you. What is this someone who is at risk of um of hypertension? I would probably be monitoring for that. And I would be thinking, why does this patient have a hyperplastic aorta? Is there anything else going on Um And again, thinking about left heart obstructive lesions and so on. So that, so that's a good question. That's really interesting. One and normal values for aortic dimensions is sending aorta. Oh Niki, that's a great question. And do you know what? I don't even have those on the top of my head. So I'm afraid I can't, I don't have those. Maybe I should put that in the slide. I normally just refer to the PSE to the BSE guidelines. And then, and then I think also the other thing for me is that I'm also tend to be thinking about is it, we do see a lot of big. So with B we do what we know and all these people, we do see big aortas. But II think the key thing in my mind is normally the cut offs for the, for the intervention. And so, you know, generally it sort of five, that's when I start to be worried. But, and before that, then I'm looking at, at changes, but in terms of the absolute normal values, I'd have to refer to the BSE guidelines. I'm sorry, I don't have that to hand um screening for cerebra. That is a great question and we don't do it because I think the trouble is if it in patients who are asymptomatic, you potentially are opening up a massive can of worms. Because if you do start scanning these people routinely and then you find things, but then you've gotta decide what you're gonna do with that information and that causes obviously a whole lot of anxiety and investigation and so on for the patients. So we don't routinely screen for them. But if somebody's symptomatic, then yes, absolutely. Image them and then thinking, you know, particularly about whether there could be aneurysms um in association with this and Richard's got a definition of a pseudoarc. Thank you, Richard. Um I will, I will have to go and look that up, but thank you. I presume you have done. Thank you. That's very helpful. And yes, in the first Z scores we got. Yes. So I think, yes. So in peds again, they tend to use Z scores. We don't tend to use them so much in adults though. And then what is the accepted peak velocity for flow a bit after a stent? So, yeah, I mean, that's a great one. So there's not really, um um an absolute because it's really, as I've sort of tried to emphasize, it's not so much about the peak velocity. The more important thing is whether or not there is the diastolic tear or not. So you think back to some of the pictures I showed before, you know, we've got patients where they've got a stent, we do have patients who've been stented in childhood and where it's small. And so they do end up with high velocities. But if we can see that the stent is open and if there's no diastolic tail, then we would, you know, we wouldn't intervene on that necessarily. But I think if you're somebody, I, I'm not sure if you're a doctor or a, or a, a physiologist, but if you're reporting it, I think the important thing is to report the peak velocity and then to report the presence or absence of a diastolic tale and to report whether or not there's blunting of the systolic flow in the descending abdominal aorta and report whether or not there's LVH. So I think those are the, the key things. And then clinically, we would look at the those findings in particular, the diastolic tail, we'd be measuring the BP and seeing there's a BP differential and then we would be doing some cross sectional imaging as well. So it's kind of the, there's not really an absolute cut off of what is OK or not. OK. It's more about the other parts of the, of the puzzle and the diastolic town in particular. Oh Fiona. Thank you. That is a really interesting question. So we, no, we don't and we treat the BP aggressively in these patients. And so yeah, so if you said you run into complications, lowering BP, is it a necessary adaptation? And no, I haven't. And then this is talking about in adulthood. So I'm not talking about, you know, pediatrics that's different, but certainly in adults in adulthood, we just, we treat the BP quite aggressively aiming for less than 100 and 30/80. And we normally just use, you know, standard nice guidelines in terms of agents and we get them to do home monitoring or 24 hour monitoring. Um you know, every year and treat it really aggressively. Um Oh, thanks, Mark. That's nice. And then how frequent do we follow up patients with coarctation repair with zero echo? So I think it depends slightly on the type of repair and how good the repair has been. So, I'd say maybe on average annually mainly for the BP. But if I've got someone who's got good BP control and they've got a great result and they've had, you know, an MRI or a CT done in the past few years, then you might stretch out to 18 months, two years. They, they do all need cross sectional imaging every few years as well because although the echo's, you know, great, you sometimes, you know, when picking up aneurysms and things like that can be hard on an echo so that we do do cross section on every few years. Thank you, Hasib. That is really nice. Thank you so much Jackson. Have I covered all of the main questions to the best of my abilities? I could not answer them all. Um Do you have a preference for antihepatitis? If no, just go according to nice guidelines and yeah, thanks Emma. Thank you. So Jackson. Well, I'm going to try and figure out how to share the feedback thing. You tell me if there is anything else questions or indeed, anything you'd like to correct or anything else, anyone would like to answer? No, that's fine. I saved some for Q and A at the end, but um you've covered them all now. So thank you. OK. So now we come to the bit where now going to attempt to share the feedback form. Here we go. And then really, we all have to just like pray that we are then going to this is going to work. Um, copy link. Here we go. Let's try this. Oh, thank you, Emma. Thank you. Oh, that was so nice. Thank you so much. That's lovely. So I'm gonna put this in here and then I'm gonna hope for the best and hope that this works. I really hope it does. Um And yeah, I really hope to see you all again. And as I said, that's do get in touch with any questions and there's the pictures on the, on the website. Oh, hi, Abby. Hi. That's so nice to see these nice names. Hello? Oh, ok, great. Ok. I, I'll stay on for a few minutes and then if maybe, I don't know Jackson, maybe you can test the feedback and the certificate thing and then just see if it um works. Really hope it does. Let's see. Ok. Ok. Um Just going through it now, Joe. Thank you. Yeah. Oh, there is, there is a feedback response that if somebody has successfully completed it and I really hope they will get a certificate. Thank you. I'm not quite sure what I'm gonna do if it doesn't work, but at least we'll all be in it together. Fingers crossed.