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(Circulation. 2001;104:1984.)
© 2001 American Heart Association, Inc.

Images in Cardiovascular Medicine

Ischemic Pain in Aortic Regurgitation

Satoshi Saito, MD, PhD; Madhava J. Naik, FRCS, MS; Stephen Westaby, PhD, FRCS, MS

From the Department of Cardiothoracic Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK.

Correspondence to Stephen Westaby, PhD, FRCS, MS, Department of Cardiac Surgery, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. E-mail swestaby@AHF.org.uk

A 53-year-old man presented with acute retrosternal chest pain and electrocardiographic changes sufficient to warrant thrombolysis with tissue plasminogen activator (TPA). When he developed pulmonary edema and signs of severe aortic regurgitation, a clinical diagnosis of acute aortic dissection was considered. Transesophageal echocardiography ruled this out but showed aortic root dilatation with free aortic regurgitation. Left ventricular enlargement suggested a chronic process. A spiral computer tomographic (CT) scan confirmed the echocardiographic findings (Figure 1). Emergency surgery was performed after measures to reverse the effects of thrombolysis. The findings provided an explanation for the ischemic pain. The right coronary artery originated posteriorly from the left coronary sinus (type 2A) and took an intramural course around the 10 cm root aneurysm (Figure 2). Aortic root replacement was performed with mobilization and reimplantation of the coronary ostia. Because of the anomalous origin and slit-like intramural course, the right coronary artery was reimplanted higher and more posteriorly than normal on the Dacron graft. The postoperative course was uneventful. Histopathologic examination of the aortic wall showed cystic medial necrosis.

View larger version (122K): [in this window] [in a new window]   Figure 1. A, CT scan showing the aortic root aneurysm. B, CT scan showing the dilated and hypertrophied left ventricle resulting from chronic aortic regurgitation.

View larger version (118K): [in this window] [in a new window]   Figure 2. Photograph at surgery showing the dilated aortic root and a type 2A1 anomalous right coronary artery. The intramural course is highlighted. RCA indicates right coronary artery; LCA, left coronary artery.

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department . . . [Full Text of this Article]