Article Text

Download PDFPDF
Image challenge
Chain pain following cardiac surgery in a 35-year-old man
  1. Benjamin Marchandot1,
  2. Bogdan Radulescu1,
  3. Olivier Morel1,2
  1. 1 Department of Cardiology, Hôpitaux Universitaires de Strasbourg–NHC, Strasbourg, France
  2. 2 UMR 1260 INSERM, Nanomédecine Régénérative, Faculté de Pharmacie, Université de Strasbourg, Illkirch, France
  1. Correspondence to Dr Benjamin Marchandot, Pôle d’Activité Médico-Chirurgicale Cardiovasculaire, Nouvel Hôpital Civil, Strasbourg 67091, France; benjamin.marchandot{at}


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).

Supplementary file 1

Figure 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?

  1. Occlusion of the left anterior descending coronary artery

  2. Dissection of the left anterior descending coronary artery

  3. Valsalva aneurysm presenting as an acute coronary syndrome

  4. Left anterior descending coronary artery spasm

  5. Left main coronary aneurysm


  • acute coronary syndrome
  • sinus of Valsalva aneurysm

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors All three authors are responsible for patient management. All authors contributed significantly to the submitted work as follows: BM: drafting of the manuscript. BR: data collection (angiography) and interpretation. OM: drafting of the manuscript and revision.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.