Pulsatile flow in descending aorta: Can coarctation of aorta be ruled out by transesophageal echocardiography?

A 5-year-old child with L posed great arteries, large subpulmonic ventricular septal defect (VSD), atrial septal defect (ASD), and a large patent ductus arteriosus (PDA) with mild isthmic narrowing was scheduled for surgical correction. Intraoperatively, it was a case of anatomically corrected malposition of great arteries. Due to abnormal positioning of great vessels, the isthmus was ligated instead of the large PDA. The postoperative transesophageal echocardiography showed pulsatile flow in descending aorta as it was being filled by large PDA, and thus iatrogenic coarctation (CoA) was missed. It was detected in the intensive care unit due to the onset of acidosis on blood gas analysis and the presence of gradient between radial and femoral arterial line pressures. The patient was taken for redo surgery, the PDA was then ligated, resection of the isthmic narrowing and repair by end-to-end anastomosis was done.