Circulation. 1999;99:1919-1921
(Circulation. 1999;99:1919-1921.)
© 1999 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Non–Q-Wave Infarction and Ostial Left Coronary Obstruction Due to Giant Lambl's Excrescences of the Aortic Valve
George Dangas, MD, ;
Felix G. Dailey-Sterling, MD, ;
Samin K. Sharma, MD, ;
Selvakumar Chockalingham, MD, ;
James R. Albanese, MD, ;
David L. Reich, MD, ;
Jose Meller, MD, ;
John T. Fallon, MD, PhD,
From the Zena and Michael A. Wiener Cardiovascular Institute and the
Departments of Pathology and Anesthesiology, Mount Sinai School of Medicine,
New York, NY.
Correspondence to Dr John T. Fallon, MD, PhD, Zena and Michael A. Wiener Cardiovascular Institute, Box 1194, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029. E-mail falloj01{at}doc.mssm.edu
A75-year-old woman presented with new onset
of angina at rest associated with shortness of breath. The physical
examination was significant for jugular venous distension and rales in
both lungs. The chest radiogram showed bilateral lung congestion. She
had ischemic ECG ST-segment and T-wave changes and serum
creatine kinase-MB enzyme elevation consistent with a
non–Q-wave myocardial infarction. Transthoracic
echocardiography documented severe posterolateral
and mild anteroseptal hypocontractility, with mild
overall left ventricular function and mild aortic
regurgitation. Because the symptoms were refractory to
medical therapy, the patient was referred for cardiac
catheterization. The coronary arteries appeared
angiographically normal. However, the patient experienced severe chest
pain at the end of the procedure. Repeat left coronary
injection revealed a severe stenosis of the left main
coronary artery, and the arterial blood pressure
tracing was damped (Figure 1
);
intracoronary nitroglycerin had no effect. The
patient continued to have severe angina, worse ischemic ECG
changes, and progressive bradycardia and hypotension, warranting
placement of a perfusion balloon in the left main coronary
artery and insertion of an intra-aortic balloon pump and a temporary
pacemaker. She was referred for emergent open-heart surgery with the
presumptive diagnosis of catheter-induced dissection of the left
aortocoronary ostium.
Immediately after induction of anesthesia, a routine
intraoperative transesophageal echocardiogram
demonstrated a highly mobile round mass at the left coronary
cusp of the aortic valve (Figure 2). The
mass appeared to obstruct the left coronary ostium in early
diastole (Figure 2C and 2D). The surgical approach
was altered accordingly. Inspection showed a mass attached to the left
coronary cusp of the aortic valve (Figure 3); the left coronary ostium
appeared normal. The patient underwent aortic valve replacement with a
bioprosthetic valve, and no aortocoronary bypass grafts
were required. Histological examination (Figure 4) showed a papillary fibroelastoma of
the aortic valve, also referred to as giant Lambl's excrescences,
fibroelastic hamartoma, or papilliferous
tumor.
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Figure 2. Round mass in left coronary cusp of aortic
valve: A and C, cross section of valvular plane; B and D,
longitudinal cross section of aortic valve and aorta. Obstruction of
left coronary ostium in early diastole is noted in
C and diminished flow in left main coronary artery in D.
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Figure 4. Cross section of excised mass stained with
hematoxylin and eosin demonstrates gelatinous substance characteristic
of papillary fibroelastoma. A large number of giant excrescences appear
to branch out of central core of tumor.
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Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
