Introduction: Coarctation of the aorta is a relative frequently vascular malformation – approximately 5-8% of total congenital cardiac diseases. The most common associated lesion is the aortic bicuspid (13-85%) and the most often complication that comes after those two is high blood pressure.

Case presentation: We present to you the difficulty of managing a patient with a complex congenital car-diovascular pathology, diagnosed at an advanced age. A 57-year-old patient from rural environement, hypertensive, dyslipidemic, former smoker, known with descending aortic coarctation-complete occlu-sion and aortic bicuspid comes to our hospital for dyspnea (medium efforts) and palpitations. We per-formed a transthoracic ultrasound which indicated an aortic valve with tight aortic stenosis, with raphe and LVEF= 35-40%. Also moderate LV systolic dys-function was detected at this paraclinic examination. Biologically, the patient has altered renal status, with CKD (chronic kidney disease) stage G3A, probably secondary to both multiple urine flow disorders and hypertensive nephropathy. After performing the transesophageal ultrasound in the clinic, the patient is diagnosed with the certainty of tight aortic stenosis, aortic bicuspid, but considering the complex vascular morphology and the congenital characteristic of the valvular involvement, the patient is proposed for clas-sic mechanical prosthesis. Given the adaptability and formation of collateral circuits, at this time the aortic coarctation operation is no longer feasible. To complete the preoperative investigations, coronary angiography is performed, which detects permeable epicardical arteries, without lesions. The management of risk factors is a complex one, considering the tension difference between the lower and upper limbs, of about 2mmHG, nondipper grade II hypertension and associated renovascular damage, it is decided to chosen to start therapy with calcium channel blockers and antimineralocorticoid-spironolactone.

Conclusion: We bring to your attention a patient with a complex congenital pathology, severe aortic stenosis – aortic bicuspid and complete descending aortic coarctation, for which the natural adaptability has ended and it is our turn to find therapeutic and interventional solutions to restore the state of his health.