Ans. is 'd' i.e., Boot Shaped Heart Coarctation of Aorta -o Symptoms of coarctation of Aorta occurs due to decrease in blood supply distal to Aortic obstruction.o Narrowing or constriction of lumen in coarctation of Aorta may occur anywhere along its length but is most common distal to the origin of the left subclavian artery but sometimes it occurs above the origin of the left subclavian artery.o In these cases the blood supply to left arm (supplied by left subclavian) is interrupted whereas blood supply to the right arm is normal. This results in pressure difference between two arms.o The main reason for symptoms in coarctation of Aorta is interruption of blood supply to the organs located distally to obstructiono Very little of the left ventricle output reaches the descending Aorta.o The symptoms are weak pulses and lower blood pressure in the lower extremities associated with manifestations of arterial insufficiency (i.e., claudication and coldness).o Physical examination shows delayed or weak impalpable femorals compared to strong brachial arteries.o Collateral circulation develops between the precoarctation arterial branches and the postcoarctation arteries through enlarged intercostal and internal mammary arteries.o This produces the radiologically visible erosions (notching) of the undersurface of ribs.o Initially when the narrowing is not very severe the blood flowing through the obstruction produces mid systolic murmur passing through the anterior part of chest, back and spinous process, But when the lumen is sufficiently narrowed, the blood flowing across it results in, high velocity jet across the lesion throughout the cardiac cycle resulting in continuous murmur.o Although coarctation of Aorta may occur as solitary defect, it is accompanied by Biscuspid aortic valve in 50% cases. The Biscuspid valve produces Aortic regurgitation and this results in diastolic murmur seen in coarctation of Aorta.o In coarctation of Aorta unless the hypertension is very severe or left ventricular failure has ensued, cardiac output responds normally to exercise.o Coarctation of Aorta is characterized by Hypertension.Pathophysiology of Hypertension in Coarctation of Aorta.o In coarctation of Aorta the narrowing is typically found just after the vessels are given off to the left arm.o This leads to diminished blood supply in organs distal to the narrowing.o There is diminished blood supply to the kidney. So the kidney releases renin to compensate for the diminished blood supply. But the renin release leads to hypertension in organs which originally had normal B.P.o In this way heart and brain are subjected to very high pressures caused due low blood supply to kidney. The hypertension produces headache and dizziness.Treatment of coarctation of Aorta:o Coarctations generally require repair. Dilating the segment with balloons is a possibility, particularly in the young.o Surgical removal of the narrowed segment needs to be accomplished. If allowed to persist, the high blood pressure which is induced may become "permanent" even after removal of the narrowed segment, due to changes in some organs which are irreversible.o In coarctation of Aorta constriction of the Aorta occurs distal to the origin of the left subclavian artery.o So the blood supply of the organs supplied by Aortic segment before the constriction is normal where as the blood supply of the organs supplied by portion of Aorta distal to the constriction is reduced.o This causes marked difference in blood supply between the upper and lower parts of the body.o The pulses and the pressure is greater in upper extremities compared to the pressure and pulses in lower extremities.o On physical examination there is delay in the femoral pulse.o The reduced blood supply in lower extremities produces manifestations of arterial insufficiency i.e., claudication and coldness.Murmur in Coarctation of Aortao The blood passing through the narrowed Aorta produces midsystolic murmur which can be heard over the anterior part of the chest back and spinous process.o When the lumen becomes severely narrowed the blood flow through it, turns in to a high velocity jet which produces continuous systolic murmur.The chest radiographNotching of undersurface of ribso Compensatory collaterals develop between the precoarctation arterial branches and postcoarctation arteries through the enlarged intercostal and internal mammary arteries.o These produces the radiologically visible erosions ("notching") of the undersurface of ribs."3" Signo The characteristic "3" sign of the coarctation of Aorta is produced due to indentation or constriction of Aorta at the site of coarctation and pre and post stenotic dilatation of Aorta.