This patient most likely has aortic valve stenosis. The systolic ejection click at the left sternal border suggests a bicuspid aortic valve. The quality and location of the systolic ejection murmur suggest associated aortic stenosis. A bicuspid aortic valve is present in more than 50% of patients with aortic coarctation, and more than 70% of patients with a bicuspid valve will require surgical intervention for a stenotic or regurgitant valve or aortic pathology over the course of a lifetime.

Ascending aortic aneurysms occur in up to 50% of patients with aortic coarctation. Aneurysms are generally clinically silent and require imaging to confirm their presence. Ascending aortic aneurysm that results in dilation of the annulus will be associated with the murmur of aortic regurgitation (diastolic murmur), not aortic valve stenosis as seen in this patient.

Mitral valve regurgitation is not an expected sequela of coarctation repair. In addition, the clinical features in patients with mitral valve regurgitation include a holosystolic murmur, heard best at the apex, that radiates to the axilla.

Recurrent aortic coarctation occurs in about 20% of patients with previous coarctation repair. Clinical features include hypertension that is difficult to control with medical therapy. This patient has hypertension that is controlled with medical therapy, which occurs in up to 75% of patients with repaired coarctation. Other features of recurrent coarctation not demonstrated in this patient include a radial artery–to–femoral artery pulse delay and a systolic murmur over the left anterior or posterior chest.