Chain pain following cardiac surgery in a 35-year-old man

Heart. 2019 Feb;105(3):234-243. doi: 10.1136/heartjnl-2018-313577. Epub 2018 Aug 18.

Abstract

Clinical introduction: A 35-year-old man with multiple cardiovascular risk factors presented with a recent history of fever and acute heart failure. His initial echocardiogram showed evidence of severe aortic regurgitation due to ongoing infective endocarditis. Preoperative coronary angiography revealed no coronary abnormalities. Urgent aortic valve replacement was performed and a 29 mm St Jude mechanical valve was implanted. While blood and resected valvular tissue cultures were negative for bacteria, a PCR-based analysis revealed the presence of penicillin-sensitive Streptococcus pneumoniae. Echocardiographic follow-up study at day 3 showed excellent mechanical valve function with no persistent signs of endocarditis. Eight days after surgery, our patient presented with severe chest pain. The ECG is shown in figure 1A and coronary angiography was performed for diagnostic confirmation (figure 1B-D and online supplementary video 1).DC1SP110.1136/heartjnl-2018-313577.supp1Supplementary file 1 heartjnl;105/3/234/F1F1F1Figure 1(A) 12-lead ECG. (B, C) Selective angiogram of the left main, left anterior descending artery and circumflex artery. (D) Aortic root angiography.

Question: Which of the following is most likely the diagnostic?Occlusion of the left anterior descending coronary arteryDissection of the left anterior descending coronary arteryValsalva aneurysm presenting as an acute coronary syndromeLeft anterior descending coronary artery spasmLeft main coronary aneurysm.

Keywords: acute coronary syndrome; sinus of Valsalva aneurysm.

Publication types

  • Case Reports
  • Video-Audio Media

MeSH terms

  • Adult
  • Aortic Aneurysm* / diagnosis
  • Aortic Aneurysm* / etiology
  • Aortic Aneurysm* / physiopathology
  • Aortic Valve / diagnostic imaging
  • Aortic Valve / surgery
  • Aortic Valve Insufficiency* / diagnosis
  • Aortic Valve Insufficiency* / etiology
  • Aortic Valve Insufficiency* / physiopathology
  • Aortic Valve Insufficiency* / surgery
  • Chest Pain* / diagnosis
  • Chest Pain* / etiology
  • Coronary Angiography / methods
  • Diagnosis, Differential
  • Echocardiography / methods
  • Electrocardiography / methods
  • Endocarditis, Bacterial* / complications
  • Endocarditis, Bacterial* / diagnosis
  • Endocarditis, Bacterial* / physiopathology
  • Heart Valve Prosthesis
  • Heart Valve Prosthesis Implantation* / adverse effects
  • Heart Valve Prosthesis Implantation* / methods
  • Humans
  • Male
  • Pneumococcal Infections* / complications
  • Pneumococcal Infections* / diagnosis
  • Pneumococcal Infections* / physiopathology
  • Postoperative Complications* / diagnosis
  • Postoperative Complications* / etiology
  • Postoperative Complications* / physiopathology
  • Reoperation / methods
  • Sinus of Valsalva* / diagnostic imaging
  • Sinus of Valsalva* / pathology
  • Streptococcus pneumoniae / isolation & purification
  • Treatment Outcome