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(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@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.

View larger version (85K): [in this window] [in a new window]   Figure 1. Damped arterial pressure tracing.

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 . . . [Full Text of this Article]