Adult aortic coarctation presenting with refractory heart failure and pulsation below the bilateral clavicle

Adult aortic coarctation is often asymptomatic and this condition can be detected because of a murmur or unexplained hypertension. Here, we report an adult case of aortic coarctaion with heart failure and a characteristic finding of pulsation below the bilateral clavicle.　 A 58-year-old man with refractory heart failure due to unknown reasons was referred to our hospital. Auscultation presented no murmur and high blood pressure had been treated with medicine. Interestingly, precise physical examination revealed the bilateral pulsation at the midclavicular line from the 2nd to the 5th intercostal areas. Echographic examination revealed the dilated vessel and arterial blood flow 1-2 cm in depth from the body surface at the midclavicular 2nd intercostal areas. Contrast-enhanced computed tomography showed thoracic aortic coarctation and a well-developed collateral circulation via the bilateral internal thoracic arteries and epigastric arteries. The cause of heart failure was diagnosed as aortic coarctation. Palliative revascularization was performed and his blood pressure was lowered. When we see the patients with refractory heart failure due to unknown reasons, pulsation below the bilateral clavicle may give us a clue to diagnose the "hidden" aortic coarctation. <Learning objective: We must consider adult aortic coarctation when we see patients with refractory heart failure. Although the present case did not show a cardiac murmur characteristic of aortic coarctation, we found out the very unique sign of pulsation below the bilateral clavicle. When we see patients with refractory heart failure due to unknown reasons, pulsation below the bilateral clavicle may give us an important clue to diagnose the "hidden" aortic coarctation.>.