Coarctation of the aorta (CoA) is often associated with bicuspid aortic valve (BAV). Both count as the most frequent congenital heart diseases and predispose to progressive valvular and aortic damage, leading to a higher morbimortality in undiagnosed patients. Rare cases of adult aortic coarctation lead to severely left ventricular impairment function so early diagnosis is crucial for prognosis improvement.

The objective of this case report is to highlight a rare form of late diagnosis of aortic coarctation discovered during heart failure with reduced ejection fraction (HFrEF) assessment.

A 60-year-old male presented to us with New York Heart Association functional class III dyspnea and atypical chest pain. On physical examination, he was found to have lower limbs pulse delay associated with asymmetrical blood pressure measurement between the upper and lower limbs. The echocardiography revealed severe heart failure with reduced ejection fraction (HFrEF), a type 1 left right bicuspid aortic valve (BaV) with moderate aortic stenosis (Fig. 1), and severe coarctation of the aorta located in the aortic isthmus. The diagnosis was confirmed using computed tomography angiography, which allowed for a precise evaluation of the location and anatomy of the aorta. A pre-operative coronary angiography revealed a smooth epicardial coronary artery tree. HFrEF secondary to long-term high afterload was diagnosed and treated with optimal medical therapy, and scheduled for percutaneous balloon angioplasty of the aortic stenosis.

Despite the low prevalence of aortic coarctation among patients with adult congenital heart diseases, it should be screened in patients presenting with refractory heart failure symptoms or persistent high blood pressure despite optimal medical treatment.