Compression of the right coronary artery by an aortic pseudoaneurysm after infective endocarditis: an unusual case of myocardial ischemia

Abstract

A 61-year-old male with a prosthetic St Jude aortic valve size 24 presented with heart failure symptoms and minimal-effort angina. Eleven months earlier, the patient had undergone cardiac surgery because of an aortic root dilatation and bicuspid aortic valve with severe regurgitation secondary to infectious endocarditis by Coxiela burnetii and coronary artery disease in the left circumflex coronary artery. Then, a prosthesis valve and a saphenous bypass graft to the left circumflex coronary artery were placed. The patient was admitted to the Cardiology Department of Hospital Universitario de Canarias, Tenerife, Spain and a transthoracic echocardiography was performed that showed severe paraprosthetic aortic regurgitation and an aortic pseudoaneurysm. The 64-slice multidetector computed tomography confirmed the pseudoaneurysm, originating from the right sinus of Valsalva, with a compression of the native right coronary artery and a normal saphenous bypass graft. On the basis of these findings, we performed surgical treatment with a favorable postoperative evolution. In our case, results from complementary cardiac imaging techniques were crucial for patient management. The multidetector computed tomography allowed for a confident diagnosis of an unusual mechanism of coronary ischemia.

Extrinsic Circumflex Coronary Artery Compression and Occlusion by Mycotic Aneurysm of Left Aortic Sinus

“… 4 Acquired aneurysms are much less common than congenital and may be spontaneous due to cystic medial necrosis, postsurgical status, trauma, Takayasu's arteritis, or endocarditis. 5 , 10 , 11 , 12 , 13 Unruptured SVA may be discovered as an incidental finding 10 or cause symptoms related to right ventricular outflow obstruction, left ventricular outflow obstruction, complete heart block, or ventricular tachycardia. Ruptured aneurysms may present with heart failure due to left-to-right shunt.…”

“…They have been described as being due to severe pulmonary artery dilation in patients with pulmonary hypertension, 2 anomalous origin of left coronary artery from right aortic sinus with interarterial course, 3 congenital aortic sinus of Valsalva aneurysms (SVAs), 4 pseudoaneurysm following ascending aortic replacement surgery, 5 and submitral left ventricular aneurysms. 6 Aortic valve endocarditis can be complicated by a variety of subaortic ( Figure 1 ) 7 , 8 , 9 and periaortic ( Figure 2 ) 10 , 11 , 12 , 13 structural complications. In this report, we describe a case of aortic valve endocarditis that presented with acute lateral wall myocardial infarction due to extrinsic compression of left main (LM) and occlusion of the circumflex coronary artery by a mycotic aneurysm of the left aortic sinus of Valsalva ( Figure 2 I).…”

Extrinsic compression of coronary and pulmonary vasculature

“…Compression of coronary arteries from an enlarged pulmonary artery (PA) (1), unruptured left sinus of Valsalva aneurysm (SVA) (2,3), aortic root abscess (4), prosthetic pulmonary valve placement (5), stent placement in a PA conduit (6), metastatic cardiac tumor (7), parasitic infections (8), and ventricular pseudoaneurysm (9) (amongst others) have been described as etiologies of this potentially life-threatening condition that may lead to refractory angina, persistent myocardial dysfunction and sudden cardiac death. Cases of compression of the right coronary artery (RCA) and left anterior descending coronary artery (LAD) have been described as a result of aortic root pseudoaneurysms and SVAs (10)(11)(12). Extrinsic compression of pulmonary vasculature is a rare but important etiology of chest pain and dyspnea that may be encountered in various clinical scenarios including chest wall deformities such as pectus excavatum and malignant infiltration and/or compressive narrowing of PA and veins.…”

Dual Coronary Compression: An Exceedingly Rare Complication Secondary to Annuloaortic Ectasia

“…Similarly, RCA compression by aortic root abscess/pseudoaneurysm and sinus of Valsalva aneurysm has been described previously. 1,2 This report describes a case of extrinsic compression of both the RCA and LMCA secondary to annuloaortic ectasia. In addition, the dilated aortic root causing effacement of the retrosternal fat with resultant near-total compression of the ostioproximal RCA against the sternum is a hitherto undescribed entity.…”