Author + information
- Received March 26, 2013
- Accepted May 9, 2013
- Published online February 1, 2014.
- Christian Dauvergne, MD∗,†,
- Mario Araya, MD†,
- Julia Valenzuela, MD∗,
- Manuel Meneses, MD∗,
- Rafael Selman, MD∗ and
- Gabriel Maluenda, MD†∗ ()
- ∗Department of Cardiology, Instituto Nacional del Torax, Santiago, Chile
- †Department of Cardiology, Clinica Alemana, Santiago, Chile
- ↵∗Reprint requests and correspondence:
Dr. Gabriel Maluenda, Catheterization Laboratory, Cardiology Department, Clinica Alemana, Avenida Vitacura 5960, Santiago, Chile.
A 50-year-old woman with known bicuspid aortic stenosis (AS) was admitted for cardiac catheterization due to progressive shortness of breath. A transthoracic echocardiogram showed severely calcified AS with a mean gradient of 69 mm Hg and estimated valve area of 0.51 cm2. Coronary angiography demonstrated moderate disease of the mid-left anterior descending artery (LAD) (Online Video 1), and left-heart catheterization confirmed the presence of a mean transaortic gradient of 70 mm Hg. A week later, severe retrosternal chest pain with anterolateral ST-segment elevation developed in the patient (Fig. 1). Urgent coronary angiography showed occlusion of the mid-LAD with the presence of filling defect (Online Video 2). Thrombectomy retrieved white-gray hard material (Fig. 2). Final angiography showed a moderate lesion similar to that in the baseline angiogram (Online Video 3). Intravascular ultrasound confirmed a moderate stenotic lesion (minimal luminal area of 4.2 mm2) without evidence of plaque rupture (Fig. 3); in view of this, stenting was avoided. A post-procedural transesophageal echocardiogram showed severe calcified bicuspid AS with a mobile component in the left leaflet (Online Video 4). Histopathology described amorphous calcified material with a fibrin deposit and giant-cell reaction consistent with embolized valvular tissue (Fig. 4). Two weeks later, patient underwent successful surgical aortic valve replacement.
A coronary artery embolism is an uncommon cause of myocardial infarction (1). Causes of emboli include infective endocarditis, atrial thrombi/myxomas, calcified aortic valves, and valve bioprostheses. Most emboli involve the left coronary system due to the preferential flow into the LAD (2). The possibility of embolism from a calcified aortic valve should be considered in patients with AS presenting with acute coronary syndrome.
For accompanying videos, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 26, 2013.
- Accepted May 9, 2013.
- American College of Cardiology Foundation