AIMS:The growing population of adults with congenital heart disease (ACHD) has prompted global initiatives to define standards of care, training pathways, and institutional requirements for catheter-based interventions. High-quality care and effective training rely on specialized, multidisciplinary centres integrating paediatric and adult cardiologists, surgeons, and anaesthesiologists with congenital expertise, supported by advanced catheter labs and hybrid theatres. This work outlines essential elements for optimal ACHD catheterization training, emphasizing a structured, competency-based curriculum covering theory, procedural skills, and post-procedural care. METHODS AND RESULTS:Collaboration between paediatric and adult cardiologists is highlighted as vital for comprehensive care. To meet national and regional needs, a two-tier model of 'level 1' and 'level 2' centres-each with specific capacities-is proposed. Scientific societies play a key role in establishing guidelines, certifications, and facilitating trainee mobility and international collaboration. Emerging tools such as augmented reality and virtual case libraries can improve accessibility and quality of training. The framework also addresses global equity, considering regional and socio-economic differences. Proctorships and partnerships with industry are integral for introducing innovations and maintaining skills in evolving techniques. CONCLUSION:By fostering collaboration, harmonized standards, and multidisciplinary expertise, this model aims to improve ACHD training and meet growing patient needs.

To assess temporal changes in the timing of pulmonary valve replacement (PVR) among patients with tetralogy of Fallot and to determine whether temporal shifts toward earlier PVR were accompanied by differences in ventricular volumes, ventricular function and exercise capacity after PVR. The timing of PVR was evaluated in a national, retrospective cohort using the Aalen-Johansen method to estimate cumulative incidence while accounting for death as competing risk. Trends in ventricular volumes, ventricular function and exercise capacity were assessed in patients with prior PVR, who underwent cardiac imaging and exercise testing in a cross-sectional study using robust linear regression. Among 463 potential candidates for PVR in the retrospective cohort, estimated time from repair to PVR was 34 years, 22 years and 16 years in patients born in 1940–1976, 1977–1999, and 2000–2021, respectively (p < 0.001). In total, 153 patients with prior PVR born between 1942 and 2009 were examined in the cross-sectional study. Estimated right ventricular end-systolic volume index was lower by 5.43 mL/m2 per decade (p = 0.02), estimated right ventricular ejection fraction increased by 2.08 Overview of temporal changes in the timing of pulmonary valve replacement and impact on outcomes. The median time from repair to pulmonary valve replacement for each birth era was based on a nationwide cohort of patients with tetralogy of Fallot and estimated using the cumulative incidence function. The temporal trends in ventricular volumes, ventricular function and exercise capacity were estimated based on the results from patients who underwent cardiac magnetic resonance imaging, transthoracic echocardiography and cardiopulmonary exercise testing as part of a national multicentre cross-sectional study and estimated using robust regression methods

BACKGROUND:Iatrogenic postsurgical ventricular septal defect (VSD) is a rare complication of surgical aortic valve replacement (SAVR). CASE SUMMARY:A patient presented with left-sided heart failure due to an initially missed postoperative VSD after redo SAVR. A moderate shunt in the perimembranous area was discovered. During the initial closure attempt, an intracardiac echocardiography catheter caused dislodgment of a ventricular pacing lead. A later closure attempt was successful with a discrete residual defect and improved patient status. DISCUSSION:Postsurgical VSD is considered exceedingly rare after SAVR and presents a therapeutic challenge because of patient frailty during postsurgical recovery. Key device closure considerations include defect geometry, rim sufficiency, and avoidance of oversizing. TAKE-HOME MESSAGES:Rare postoperative VSD after SAVR is a potential cause of prolonged recovery and heart failure symptoms. The preferred treatment alternative is percutaneous device closure. Use of intracardiac echocardiographic guidance generally increases safety but may rarely cause complications.

Pulmonary valve replacements (PVR) with bioprosthetic pulmonary valves (BPV) increases. This study aimed to assess BPV durability as time to dysfunction and failure, risk factors for reduced durability, and impact on mortality. Data from a Danish nationwide cohort who underwent surgical or transcatheter PVR with a BPV between 1976 and 2021 were obtained. Bioprosthetic valve dysfunction was categorized into (i) structural valve deterioration (SVD) as moderate [pulmonary stenosis (PS) with peak velocity >3 m/s = PG ≥ 36 mm Hg or >mild pulmonary regurgitation] or severe (>4 m/s = PG ≥ 64 mm Hg or severe regurgitation), (ii) patient-prosthesis mismatch (PPM) (PG ≥ 20 mm Hg on the last echocardiography ≤90 days), and (iii) infective endocarditis (IE). Bioprosthetic valve failure (BVF) was defined as redo PVR. 680 PVRs were performed in 439 patients. Median follow-up was 14 years [Inter-quartile range (IQR): 8–21]. Median time to moderate SVD was 6 years (IQR: 1–17), to severe SVD 21 years (IQR: 17-NA), and to BVF 17 years (IQR: 15–18). PPM occurred in 41%. Cumulative incidence of IE was 17% after 25 years. PS was the leading cause of moderate (62%) and severe SVD (54%), then regurgitation (32% and 43%) and combined disease (6% and 3%). Younger age at PVR and PPM was associated with increased risk of SVD and BVF, while PPM and redo-interventions increased risk of IE. SVD was not associated with mortality (P = .08 for moderate, P = .56 for severe SVD). Moderate dysfunction occurred early after PVR, but takes years to progress to severe dysfunction or failure. Younger age and PPM increased SVD and BVF risk. PPM and redo-interventions increased IE risk. SVD was not associated with mortality.

BACKGROUND:As the hospitalisation rate for adults with congenital heart disease (ACHD) increases, information regarding the outcome of these hospitalisations is needed. METHOD:This retrospective cohort study utilized the Danish National Patient Registry to identify ACHD patients who reached 18 years old ≥1st Jan 1995 and followed them to either death or 31st Dec 2018. Each patient was matched 1:10 to controls. Mortality was estimated as the mortality rate per 100 patient-years (/100PY) and the association of hospitalisation burden and mortality was examined. RESULTS:7830 ACHD patients were included (50.5 % female, 64.7 % mild ACHD, 28.1 % moderate ACHD and 7.2 % severe ACHD) and followed for a median of 8.6 years. When not having any hospitalisation in the past one year, the mortality rate for all ACHD patients was 0.04/100PY[95 % confidence interval: 0.02;0.05]. Having any hospitalisation in the past year increased the mortality rate by 5.2-fold to 0.55/100PY[0.42;0.72]. In mild ACHD, the mortality rate increased by 10.7-fold. In moderate ACHD, it increased by 4.8-fold, while in severe ACHD, no significant increase in mortality was observed. Compared to the matched controls, mild ACHD patients also had an increase in excess mortality from 0.8-fold when having no hospitalisation to 1.6-fold when having any hospitalisation in the past year. This increase in excess mortality was however not observed in moderate and severe ACHD. CONCLUSION:Hospitalisation in the past year has a greater impact on mortality in mild ACHD patients than in other ACHD severities. This indicates a greater gap in the follow-up care needed by patients with mild ACHD.

BACKGROUND:As more patients with congenital heart disease (CHD) survive into adulthood, the population of adults with CHD is expanding. This trend is accompanied by an increasing incidence of complications, including arrhythmias. However, the long-term risk of arrhythmias remains sparsely investigated. METHODS:In this observational cohort study, all Danish patients with CHD born from 1977 to 2024 were identified using registries and followed from date of birth until the occurrence of arrhythmia, emigration, death, or end of follow-up (March 2024). The risk of arrhythmias was assessed among patients with CHD and compared to age- and sex-matched controls from the background population. RESULTS:A total of 45,820 patients with CHD (50.9% men) were identified and matched with 183,280 controls from the background population. During a median follow-up of 21.5 years, 2.6% of patients with CHD and 0.2% of controls developed arrhythmias-corresponding to incidence rates (IR) of 1.2 (95% CI 1.2-1.3) and 0.1 (95% CI 0.1-0.1) per 1,000 PY, respectively, and a hazard ratio (HR) of 16.4 (95% CI 14.4-18.7). The most common arrhythmias in patients with CHD were advanced atrioventricular block (IR 0.4 [95% CI 0.4-0.4] per 1,000 PY) and atrial flutter/fibrillation (IR 0.5 [95% CI 0.5-0.6] per 1,000 PY). Patients with malformations of the heart chambers, transposition of the great arteries, tetralogy of Fallot, and atrioventricular septal defect were at the highest risk of arrhythmias. Moreover, the risk of arrhythmias among those with ASD was not negligible. In patients with CHD, arrhythmia was associated with a significantly higher risk of death (HR of 6.9 [95% CI 5.9-8.1]). CONCLUSIONS:Patients with CHD are at significantly higher risk of arrhythmias than the background population, and those with complex CHD are at particularly high risk. In patients with CHD, arrhythmia is associated with an increased risk of death. Additional studies are warranted to investigate how we can improve the diagnosis and management of arrhythmias in CHD.

BACKGROUND Robust data on changes in pulmonary valve replacement (PVR) procedural volume and predictors of bioprosthetic pulmonary valve (BPV) durability in patients with tetralogy of Fallot (TOF) are scarce. OBJECTIVES This study sought to assess temporal trends in PVR procedural volume and BPV durability in a nationwide, retrospective TOF cohort. METHODS Data were obtained from patient records. Robust linear regression was used to assess temporal trends in PVR procedural volume. Piecewise exponential additive mixed models were used to estimate BPV durability, defined as the time from implantation to redo PVR with death as a competing risk, and to assess risk factors for reduced durability. RESULTS In total, 546 PVR were performed in 384 patients from 1976 to 2021. The annual number of PVR increased from 0.4 to 6.0 per million population (P < 0.001). In the last decade, the transcatheter PVR volume increased by 20% annually (P < 0.001), whereas the surgical PVR volume did not change significantly. The median BPV durability was 17 years (Q1: 10-Q3: 10 years -not applicable). There was no significant difference in the durability of different BPV after adjustment for confounders. Age at PVR (HR: 0.78 per 10 years from <1 year; 95% CI: 0.63-0.96; P = 0.02) and true inner valve diameter (9-17 mm vs 18-22 mm HR: 0.40; 95% CI: 0.22-0.73; P = 0.003 and 18-22 mm vs 23-30 mm HR: 0.59; 95% CI: 0.25-1.39; P = 0.23) were associated with reduced BPV durability in multivariate models. CONCLUSIONS The PVR procedural volume has increased over time, with a greater increment in transcatheter than surgical PVR during the last decade. Younger patient age at PVR and a smaller true inner valve diameter predicted reduced BPV durability. (c) 2024 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

Background The congenital heart disease (CHD) population is growing and aging. We aim to examine the impact by describing the temporal trend and causes of lifetime hospitalization burden among the CHD population. Methods and Results From the Danish National Patient Registry, 23 141 patients with CHD and their hospitalizations from 1977 to 2018 were identified, excluding patients with extracardiac malformation. Patients with CHD were categorized into major CHD and minor CHD, and each patient was matched with 10 controls by sex and year of birth. The rate of all‐cause hospitalization increased over time from 28.3 to 36.4 hospitalizations per 100 person‐years (PY) with rate difference (RD) per decade of 2.5 (95% CI, 2.0–3.1) hospitalizations per 100 PY for the patients with CHD, compared with the increase from 10.8 to 17.0 per 100 PY (RD per decade, 2.0 [95% CI, 1.8–2.2] per 100 PY) for the control group (RD for CHD versus control, P =0.08). The all‐cause hospitalization rate remained constant for the major CHDs (RD per decade, −0.2 [95% CI, −1.2 to 0.9] per 100 PY) but increased for the minor CHDs (RD per decade, 5.2 [95% CI, 4.3–6.0] per 100 PY). For all patients with CHD, the cardiovascular hospitalization rate remained constant over time (RD per decade, 0.2 [95% CI, −0.3 to 0.6] per 100 PY) whereas the noncardiovascular hospitalization rate increased (RD per decade, 2.1 [95% CI, 1.6–2.7] per 100 PY). The length of all‐cause hospital stays for all patients with CHD decreased from 2.7 (95% CI, 2.6–2.8) days per PY in 1977 to 1987 to 1.6 (95% CI, 1.6–1.7) days per PY in 2008 to 2018. Conclusions Compared with previous decades, patients with CHD have an increasing hospitalization rate, similar to the general population, but a decreasing length of hospital stay. The increase in hospitalization rate was driven by noncardiovascular hospitalizations, with the patients with minor CHD being the key contributor to the increasing rate.

The percutaneous treatment of structural, valvular, and non-valvular heart disease (SHD) is rapidly evolving. The Core Curriculum (CC) proposed by the EAPCI describes the knowledge, skills, and attitudes that define competency levels required by newly trained SHD interventional cardiologists (IC) and provides guidance for training centres. SHD ICs are cardiologists who have received complete interventional cardiology training. They are multidisciplinary team specialists who manage adult SHD patients from diagnosis to follow-up and perform percutaneous procedures in this area. They are competent in interpreting advanced imaging techniques and master planning software. The SHD ICs are expected to be proficient in the aortic, mitral, and tricuspid areas. They may have selective skills in either the aortic area or mitral/tricuspid areas. In this case, they must still have common transversal competencies in the aortic, mitral, and tricuspid areas. Additional SHD domain competencies are optional. Completing dedicated SHD training, aiming for full aortic, mitral, and tricuspid competencies, requires at least 18 months. For full training in the aortic area, with basic competencies in mitral/tricuspid areas, the training can be reduced to 1 year. The same is true for training in the mitral/tricuspid area, with competencies in the aortic area. The SHD IC CC promotes excellence and homogeneous training across Europe and is the cornerstone of future certifications and patient protection. It may be a reference for future CC for national associations and other SHD specialities, including imaging and cardiac surgery.

Robust data on changes in pulmonary valve replacement (PVR) procedural volume and predictors of bioprosthetic pulmonary valve (BPV) durability in patients with tetralogy of Fallot (TOF) are scarce. This study sought to assess temporal trends in PVR procedural volume and BPV durability in a nationwide, retrospective TOF cohort. Data were obtained from patient records. Robust linear regression was used to assess temporal trends in PVR procedural volume. Piecewise exponential additive mixed models were used to estimate BPV durability, defined as the time from implantation to redo PVR with death as a competing risk, and to assess risk factors for reduced durability. In total, 546 PVR were performed in 384 patients from 1976 to 2021. The annual number of PVR increased from 0.4 to 6.0 per million population (P < 0.001). In the last decade, the transcatheter PVR volume increased by 20% annually (P < 0.001), whereas the surgical PVR volume did not change significantly. The median BPV durability was 17 years (Q1: 10 years-Q3: not applicable). There was no significant difference in the durability of different BPV after adjustment for confounders. Age at PVR (HR: 0.78 per 10 years from <1 year; 95% CI: 0.63-0.96; P = 0.02) and true inner valve diameter (9-17 mm vs 18-22 mm HR: 0.40; 95% CI: 0.22-0.73; P = 0.003 and 18-22 mm vs 23-30 mm HR: 0.59; 95% CI: 0.25-1.39; P = 0.23) were associated with reduced BPV durability in multivariate models. The PVR procedural volume has increased over time, with a greater increment in transcatheter than surgical PVR during the last decade. Younger patient age at PVR and a smaller true inner valve diameter predicted reduced BPV durability.

Abstract Introduction Non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat pain, fever, and inflammation, but they can increase the risk of recurrent myocardial infarction (MI), ischemic stroke, atrial fibrillation, and death in patients with MI. Consequently, the European Society of Cardiology warns against using NSAIDs in patients with manifest cardiovascular disease and in high-risk individuals, such as those with dyslipidemia. However, no study has investigated whether NSAID-associated cardiovascular risks differ according to patients’ low-density lipoprotein cholesterol (LDL-C) levels. Purpose To examine whether LDL-C levels influence the cardiovascular risk associated with NSAID use after first-time MI. Methods Using Danish health registries, we conducted a population-based cohort study of all adult patients with a first-time MI hospitalization during 2010–2020 with an LDL-C value before discharge. Based on the latest LDL-C value, we categorized patients into a low and high LDL-C group (<3 vs. ≥3 mmol/L). We used multivariate Cox regression to compute adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for the association between NSAID use (modelled in time-varying manner) and a major adverse cardiovascular event (MACE), defined as a composite of recurrent MI, ischemic stroke, and all-cause death. We repeated the analysis by changing the cut-off value for LDL-C to 1.8 and 1.4 mmol/L. Results We followed 50,573 patient with a first-time MI for a mean of 3.5 years (66% males, median age of 68 years. During NSAID use, 521 patients experienced a MACE: 312 in the low LDL-C group and 209 in the high LDL-C group. The HRs for MACE comparing NSAID use with non-use were 1.21 (1.11–1.32) overall, 1.19 (1.06–1.33) in the low LDL-C group, and 1.23 (1.07–1.41) in the high LDL-group. The HRs in the low and high LDL-C groups were 1.09 (0.88–1.34) vs. 0.94 (0.74–1.19) for recurrent MI, 0.97 (0.66–1.41) vs. 1.27 (0.86–1.87) for ischemic stroke, and 1.22 (1.07–1.39) vs. 1.54 (1.30–1.83) for all-cause death. Changing the cut-off value for LDL-C to 1.8 and 1.4 mmol/L showed consistent results. Conclusion In patients with a first-time MI, NSAID use was associated with an increased risk of MACE. The LDL-C level did not influence the association between NSAID use and MACE, but it might influence the association between NSAID use and all-cause death. Thus, healthcare providers should be mindful of the increased cardiovascular risk associated with NSAID use in patients with previous MI, regardless of LDL-C values.

Abstract Introduction Comorbidity scores are often used to adjusted for confounding by comorbidity burden in population-based research as they increase statistical efficiency in smaller study populations. However, there is currently no comorbidity index available for predicting infective endocarditis prognosis. This gap in the literature hinders the ability to accurately adjust for confounding in studies investigating the prognosis of infective endocarditis, highlighting the need of validating existing comorbidity indices for this purpose. Purpose To validate the discriminatory ability of the Danish Comorbidity Index for Acute Myocardial Infarction (DANCAMI), the Charlson Comorbidity Index (CCI), and the Elixhauser Comorbidity Index (ECI) for predicting in-hospital, 1-year, and 10-year all-cause mortality after infective endocarditis. Methods We used nationwide Danish health registries to identify all patients with a first-time inpatient, primary or secondary diagnosis for infective endocarditis between 1995 and 2021 and their comorbidities. When identifying the comorbidities, we used all in and outpatient hospital information in the 10 years before the infective endocarditis diagnosis. Based on the presence of comorbidities, we estimated the DANCAMI, the CCI, and the ECI scores for each patient. Using a logistic regression model, we calculated area under the receiver operating curves (AUCs) for a baseline model including age and sex and for models including the scores from the comorbidity indices plus age and sex for in-hospital, 1-year, and 10-year all-cause mortality. The AUC describes the probability that for a pair of random patients, the model will assign a greater predicted risk to the patient dying. Results Overall, we identified 12,530 patients with infective endocarditis. The median age was 71 years and 35% were females. For the individual analyses, we had complete follow-up on 12,493 patients when predicting in-hospital mortality, 11,587 when predicting 1-year mortality, and 5,880 patients when predicting 10-year mortality. For in-hospital mortality, the AUCs were 0.62 for the baseline model, 0.65 for the DANCAMI, 0.64 for the CCI, and 0.65 for the ECI. For 1-year mortality, the AUCs were 0.66 for the baseline model, 0.71 for the DANCAMI, 0.70 for the CCI, and 0.70 for the ECI. For 10-year mortality, the AUCs were 0.76 for the baseline model, 0.82 for the DANCAMI, 0.81 for the CCI, and 0.81 for the ECI. Conclusions After accounting for sex and age, adding either the DANCAMI, the CCI, or the ECI did not increase the discriminatory ability for predicting in-hospital all-cause mortality after infective endocarditis but did increase the discriminatory ability for predicting 1-year and 10-year all-cause mortality. Consequently, comorbidity scores might be beneficial in reducing confounding by comorbidity burden when predicting 1-year or 10-year infective endocarditis mortality, depending on their association with the exposure of interest.

Journal Article Intra-cardiac echocardiography in diagnosis of subvalvular right-sided atrioventricular valve stenosis Get access Cheuk Bong Ho, Cheuk Bong Ho The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark Corresponding author E-mail: bongii2001@gmail.com https://orcid.org/0000-0001-9481-6390 Search for other works by this author on: Oxford Academic PubMed Google Scholar Niels Grove Vejlstrup, Niels Grove Vejlstrup The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark Search for other works by this author on: Oxford Academic PubMed Google Scholar Michael Rahbek Schmidt, Michael Rahbek Schmidt The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark Search for other works by this author on: Oxford Academic PubMed Google Scholar Lars Sondergaard Lars Sondergaard The Heart Center, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal - Cardiovascular Imaging, Volume 24, Issue 2, February 2023, Page e35, https://doi.org/10.1093/ehjci/jeac256 Published: 23 December 2022

Protein-losing enteropathy (PLE) is a severe Fontan complication. This is a case report of the first hybrid treatment of PLE in Denmark of an 11-year-old Fontan patient with severe symptoms (diarrhoea, fatigue and swelling) and low albumin level. Diagnostics included intranodal and intrahepatic dynamic contrast magnetic resonance lymphangiography. The hybrid intervention consisted of selective lymphatic duct embolisation and innominate vein turn-down to treat PLE. The interventions went well, and two months after discharge the patient was relieved from PLE symptoms, the albumin level was normalised, and the patient felt more energetic.

Abstract Background The dose dependency of the adverse effects of diclofenac remains poorly understood. Purpose To examine the dose-related cardiovascular risks associated with diclofenac initiation Methods We used Danish nationwide health registries (1999–2018) to conduct a series of emulated trials (n=285). Eligible adults had no recent NSAID fillings, contraindications, or conditions with low adherence. Individuals eligible for inclusion were ≥18 years with (1) ≥90 days continuous prescription records prior to diclofenac initiation (baseline); (2) no NSAID prescriptions ≤90 days before enrollment, and (3) no exclusion criteria. Exclusion criteria reflected likelihood of low adherence to treatment (dementia, schizophrenia, or antipsychotic drug use) and labeled contraindications (ulcer disease/anti-ulcer drugs, gastrointestinal bleeding, inflammatory bowel disease, thrombocytopenia, or heart failure). Initiators of diclofenac were compared to healthcare-seeking non-initiators, but also head-to-head for initiators of high (≥75 mg pills as proxy for ≥150 mg/daily) vs. low dose (≤50 mg pills as proxy for <150 mg/daily). Cox proportional-hazards regression was used to compute the intention-to-treat hazard ratio, as measure of the incidence rate ratio (IRR), of major adverse cardiac and cerebrovascular events (MACCE) within 30 days from initiation. Results Among 3,177,484 diclofenac initiatiors, 31% used high and 69% used low dose. Compared with non-initiators, diclofenac initiatiors had a 70% increased rate for MACCE (IRR 1.70, 95% CI: 1.55–1.86), reflecting for the individual MACCE components an increased IRRs of 1.66 (95% CI: 1.54–1.79) for myocardial infaction, 1.32 (1.20–1.45) for ischemic stroke, and 1.69 (1.54–1.86) for cardiac death. The effect for MACCE did not differ between initiators of high (IRR 1.73, 95% CI: 1.51–1.97) and low dose (IRR 1.68, 95% CI: 1.52–1.86) (Figure 1). When comparing high and low dose diclofenac head-to-head, we found no meaningful difference in the IRR for MACCE (1.03, 95% CI: 0.89–1.19), MI (0.99, 0.87–1.11), ischemic stroke (0.95, 0.81–1.11) or cardiac death (1.04, 0.90–1.21) (Figure 2). Conclusion Initiation of low- and high-dose diclofenac was associated with a consistent and comparable increase in cardiovascular risk. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Foundation

A man in his mid-30s was admitted with a thunderclap headache. He was conscious and hypertensive. A decade earlier, severe hypertension had been diagnosed and extensively investigated without revealing an underlying cause. Brain imaging showed subarachnoid haemorrhage caused by a ruptured pericallosal aneurysm. Endovascular occlusion was attempted, but as the sheath could not pass the aortic arch, it was converted to surgical aneurismal clipping. Intraoperative blood pressure measurement revealed a peak-to-peak gradient of 100 mm Hg across the aortic arch and an ankle/brachial index of 0.46 (normal range 0.9–1.2). Aortic coarctation was suspected, and angiographic imaging and echocardiography confirmed the diagnosis. Subacute direct stenting was performed, which normalised the peak-to-peak gradient and ankle/brachial index. To minimise the risk of severe complications, early diagnosis of aortic coarctation is important and can be facilitated by ankle/brachial index and echocardiography in the suprasternal view.