Coronary bilateral ostial enlargement using the saphenous vein in a patient with syphilitic aortitis

Abstract

Syphilis has been succesfully controlled in recent years; involvement of the heart and the aorta have become relatively rare events. The incidence and degree of seriousness of syphilitic aortitis is greater in the initial portion of the ascending aorta involving the coronary ostia and the valvulae of the aortic valve. Heggtveit 1 , in a clinicopathological review of syphilitic aortitis, noted uni or bilateral coronary ostial stenosis with aortic regurgitation in 14% of patients.Several surgical tactics for the correction of coronary ostial stenosis have been reported: endarterectomy 2-5 , aorto-coronary bridging with either arterial 6,7 or venous 4 grafts or both , and ostial reconstruction via the anterior 3,8 or posterior 8,9 approaches.We have performed surgical treatment of a patient presenting with bilateral coronary lesions and aortic regurgitation by ostial amplification via the anterior approach. Along with the aortic valve substitution, we used grafting with autogenous saphenous vein to reconstruct both coronary ostia. Case ReportA forty-eight-year old male Caucasian patient related a history of two months of intense nonirradiating precordial pain unrelated to effort, dyspnea, throbbing and decreased visual accuity. In his past medical history, he reported several episodes of veneral disease but denied the existence of familial heart disease.Upon examination, the patient was in good physical condition, eupneic, with arterial blood pressure of 16/40mm-Hg in the right upper limb and 70/40mmHg in the left upper limb; his left radial and arm pulses were of lower amplitude relative to the right, which showed strong pounding feature. The first heart sound was normal, the second was of decreased intensity, with a protomesodiastolic regurgitative murmur ++/++++ in aortic and accessory aortic areas.The thoracic radiograph revealed aortic ectasia and a normal cardiac area. The electrocardiogram showed a sinusal rhythm, QRS axis AT + 30 o , T wave negative at 4V, flattened at V5 and V6, Dl and the VL with left ventricular hypertrophy. Dopplerechocardiography showed diffuse hypokinesia of the left ventricle and moderate aortic regurgitation with ectasia of the ascending aorta. A cinecoronariographic study showed 70% obstruction of the left coronary ostium, 60% of the right coronary ostium, serious aortic regurgitation and a critical lesion in the left subclavian artery that was treated by percutaneous transluminal coronary angioplasty at the time of diagnosis. Results of routine laboratory tests were normal with the exception of the Venereal Disease Research Laboratory test (VDRL), reactive at 1:64 dilution and positive fluorescent treponemal antibody-absorption test (FTA-ABS).The surgical approach was performed by medial sternotomy, aortic and right atrial cannulation, and extracorporeal circulation under moderate hypothermia at 30 o C. Myocardial protection was afforded by St. Thomas crystalloid solution.The aorta was transversally incised in its anterior wall, a pronounced inflammatory condition being observed. ...

A case of acute myocardial infarction due to cardiovascular syphilis with aortic regurgitation and bilateral coronary ostial stenosis

“…Regarding the treatment of coronary ostial lesions, direct reconstructive ostial surgeries such as endarterectomy [11] and vein patch angioplasty [12] have been reported, but not recommended [5], and CABG has been the main treatment in recent years. Considering the histological characteristics of the aortic wall, there are concerns about proximal anastomotic stenosis of the SVG [5].…”

Syphilitic Coronary Artery Ostial Stenosis Resulting in Acute Myocardial Infarction and Death

“…Croti et al [5 ]report the case of a 48-year-old male with a 2-month history of severe chest pain and dyspnea. Physical exam found asymmetric upper extremity blood pressure and pulses and a diastolic murmur.…”

“…Despite the ease and efficacy of treatment, however, syphilis has not been eradicated and indeed has increased in incidence in the US since 2000 [2]. While admittedly uncommon, a selection of case reports from the past decade demonstrates that syphilitic aortitis and its complications are a challenge to clinicians in both diagnosis and treatment [3,4,5,6,7]. We present here the case of a 32-year-old female who died of myocardial infarction due to coronary artery ostial stenosis secondary to syphilitic aortitis.…”

Re-implant of the right coronary artery: a surgical technique for the treatment of ostial lesions

“…Venous grafts suffer from degeneration and arterial grafts, due to several factors, can not always be used. Coronary ostial reconstruction procedures utilize homogenous [3,4] or autologous [2,3] tissue susceptible to intimal hyperplasia, thrombosis and calcification.…”

“…Surgical techniques for the treatment of ostial lesions of the coronary arteries, with the exception of endarterectomy [1], utilize patches of autologous tissue (bovine pericardium) [2,3] or homologous (saphenous vein [4] or internal thoracic artery [5]) to reconstruct the affected ostium. The utilization of homologous or autologous tissue patches helps intimal hyperplastia, thrombosis and calcification, compromising the immediate and / or late results.…”