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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

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Answer: C

The ECG revealed ST segment depression in leads C3–C6 and inferior leads highly suggestive of non-ST elevation myocardial infarction (figure 1A). Both transthoracic and transoesophageal echocardiography revealed a fast-growing periprosthetic aortic abscess (figure 2). Urgent coronary angiography disclosed a giant aneurysm of the left sinus of Valsalva (figure 1B,C) causing left anterior descending artery compression (figure 1D) (online supplementary video 1). Coronary slow-flow phenomenon and the progressive narrowing of the lumen were evocative of external compression. Coronary artery spasm is more likely localised while postoperative coronary dissection would have involved the left main artery. Embolisation or plaque rupture would have disclosed an abrupt lesion with no progressive narrowing. Salvage surgery with Bentall procedure was performed and led to relief from extrinsic compression. Penicillin-sensitive S. pneumoniae was isolated from aortic tissue cultures.

Figure 2

(A, B) Transthoracic parasternal short axis at the level of the aortic mechanical prosthesis demonstrating a periprosthetic abscess. (C) A large abscess lateral to the aortic mechanical prosthesis in the transoesophageal aortic short-axis view.

Acute coronary syndrome resulting from compression of epicardial coronary vessels is a rare entity, furthermore in the setting of a septic aneurysm of the sinus of Valsalva. There are very few reported cases that generally carry poor prognostic.1 2 Septic aortic root complications may involve both native and prosthetic valves. Prompt surgery is considered the cornerstone of treatment and 30-day mortality rates are ranging from 19% to 25%.3 4 Common reported risk factors associated with increased mortality include prosthetic valve endocarditis and Staphylococcus aureus infection.5



  • 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.