**4.3.2 Physical findings**

A clinical diagnosis of CoA is best made by simultaneous palpation of femoral and brachial pulses. The left ventricular impulse may be increased. A thrill is usually felt in the suprasternal notch. The first and second heart sounds are usually normal in isolated aortic coarctation. Since a large percentage (up to 60%) of patients with CoA have associated bicuspid aortic valves, an ejection systolic click may be heard at right upper and left mid sternal borders and apex; this click does not change with respiration. An ejection systolic murmur may be heard at left or right upper sternal borders, but is usually heard best over the back in the inter-scapular regions. Sometimes a continuous murmur may be heard in the left inter-scapular region secondary to continuous flow in the coarcted segment or on the back (secondary to flow in the collateral vessels). Palpation of the brachial and femoral artery pulses simultaneously will reveal delayed and decreased or absent femoral pulses. Blood pressure in both arms and one leg must be determined: a peak systolic pressure difference of more than 20 mmHg in favor of arms may be considered as evidence for coarctation of the aorta (Rao 1995). Involvement of the left subclavian artery in the coarctation or anomalous origin of the right subclavian artery (below the level of coarctation) may produce decreased or absent left or right brachial pulses, respectively, and therefore palpation of both brachial pulses and measurement of blood pressure in both arms are important.

#### **4.3.3 Noninvasive evaluation**

#### **<IP_ADDRESS> Chest x-ray**

Chest roentgenogram may show a normal sized heart or the heart may be mildly enlarged. Other roentgenographic features include a "3" sign on a highly penetrated chest x-ray, inverted "3" sign of the barium filled esophagus and rib-notching (secondary to collateral vessels).

#### **<IP_ADDRESS> Electrocardiogram**

The ECG may be normal or may show left ventricular hypertrophy.

Congenital Heart Defects – A Review 15

Fig. 7. Selected cine frames from aortic arch angiogram in 20-degree left anterior oblique projection demonstrating aortic coarctation with isthmic hypoplasia in an adolescent prior

Fig. 8. Bar graph showing immediate and follow-up results after balloon angioplasty of native aortic coarctation. Peak-to-peak systolic pressure gradients across the coarctation in mmHg (mean + SEM) are shown. Note significant (p 0.001) drop in the gradient following angioplasty (Pre, prior to vs. Post). The gradient increases (p 0.05) slightly at a mean follow-up of 14 mo. However, these values are lower (p 0.001) than those prior to

angioplasty. At late follow-up (LFU), (median 5 years) following balloon angioplasty, blood pressure-measured arm-leg peak pressure difference is lower than catheterization measured peak gradients prior to (p 0.001) balloon angioplasty and those obtained at intermediate-

When surgical option is chosen, resection and end-to-end anastomosis, subclavian flap angioplasty or prosthetic patch angioplasty may be used depending upon anatomy of the aortic arch and coarctation and surgeon's preference. When balloon angioplasty is contemplated, the balloon size should be carefully chosen: the diameter of the balloon

to (A) and immediately following (B) stent implantation.

term follow-up (p 0.01).

#### **<IP_ADDRESS> Echocardiogram**

Echocardiographic studies usually reveal the coarctation in the supra-sternal notch, twodimensional echo views of the aortic arch. Increased Doppler flow velocity in the descending aorta by continuous-wave Doppler and demonstrable jump in velocity at the coarcted segment by pulsed-Doppler technique are usually present. Extension of the Doppler flow signal into the diastole is indicative of significant obstruction. Instantaneous peak pressure gradients across the aortic coarctation can be calculated by employing modified Bernoulli equation in manner similar to that described for PS and AS. Because of higher proximal velocity, coarctation gradients may be more accurately estimated by:

$$
\Delta \, \mathbf{P} = 4 \, (\mathbf{V}\_2^2 - \mathbf{V}\_1^2)
$$

Where, Δ P is peak instantaneous gradient and V2 and V1 are peak Doppler velocities in the descending aorta distal to the coarctation (continuous wave Doppler) and proximal to the coarctation (pulsed Doppler), respectively.

But the calculated gradient is usually an over-estimation, especially if there is no diastolic extension of the Doppler velocity (Rao and Carey 1989).


**4. Discussions**

From the results shown in this work the great potential of using piassava powder as a reinforcement in the COPU matrix for HPCF application was evident. Along with the results of a previous work [39], almost all standard requirements were attained. By comparing the results obtained for impact, abrasive wear and flexural strength with the results from FTIR analysis, there was space to improve the flexural strength of the material by further addition of piassava powder without greater loss of impact resistance and yet maintain the wear resistance at acceptable levels.

Finally, the use of the polyurethane material with approximately 60% volume fraction derived from castor oil (mass proportion use converted to the volume fractions) with a 30 vol% of piassava powder obtained as an industrial waste represented a biocomposite made almost 80% in volume from a renewable source. This alone represented a much greener solution compared to composites made with matrices or reinforcements from the non-renewable sources commonly applied in high-performance floors. Furthermore, the fact that the COPU resin used in this study was biodegradable, as well as the piassava powder, meant an environmentally friendly end-of-cycle alternative for natural materials.

To be used as HPCFs, according to the standard [10], the biocomposites are required to withstand a 10-year-long period. This can be a problem owing to the biodegradable characteristics of this biocomposite. However, the castor oil-derived polyol is reported to be antimicrobial, and the biocomposite itself can be designed to present a good resistance to biodegradability until its end of cycle [19]. Further studies should determine the life cycle times of these materials.


2.2.5. Depression

A patient health questionnaire (PHQ-9) was used to measure symptoms of depression among university students. PHQ-9 consisted of nine items, corresponding to the DSM-IV diagnostic criteria [58,59]. Participants answered questions about how often over the past two weeks they had been bothered by nine depression symptoms, using a Likert-like response scale ranging from 0 = Not at all, to 3 = Nearly every day. The PHQ-9 scores may be interpreted as normal between 0–4, mild major depressive disorder between 5–9, moderate between 10–14, moderately severe between 15–19, and severe between 20–27 [58]. At a score of 10 or above, it is recommended to screen for a major depressive disorder [58,60,61]. In this study, the Cronbach's α for the PHQ-9 was 0.85.