Aortic root abscess presenting as unstable angina due to extrinsic compression of the left coronary artery

Abstract

Coronary ischaemia in acute endocarditis is usually due to pre-existing coronary disease or occasionally as a result of embolism from vegetations. A 68 year old man with known mixed aortic valve disease presented with a four week history of progressive exertional angina, which became unstable. He was apyrexial with no peripheral signs of endocarditis. Three sets of blood cultures were negative. Transthoracic echocardiography with suboptimal windows confirmed moderate mixed aortic valve disease. Marked reversible ST segment depression with angina recurred at rest. Aortography showed severe aortic regurgitation with a distorted aortic root. Coronary angiography showed severe proximal narrowing of the left anterior descending and circumflex arteries with an unusual long and tapering contour. Emergency surgery revealed a large anterior aortic root abscess which had destroyed the left and right coronary cusps. Aortic root abscess and other rare causes of extrinsic coronary compression are discussed. CASE REPORTA 68 year old man with known mixed aortic valve disease presented with a four week history of progressive exertional angina, which became unstable. A month previously he experienced rigors but spontaneously improved without treatment. He had no risk factors for coronary disease. Examination revealed moderate mixed aortic valve disease and blood pressure 140/70 mm Hg.He was apyrexial with no peripheral signs of endocarditis. The resting electrocardiogram showed left ventricular hypertrophy, left axis deviation, and 1 mm of ST depression in V6. The chest radiograph showed mild cardiomegaly and upper lobe venous diversion. Haemoglobin concentration was 93 g/l, mean cell volume 70 fl, serum iron 0.9 µmol/l, total iron binding capacity 55 µmol/l (45-75), white cell count 10.8 × 10 9 /l, platelets 316 × 10 9 /l, erythrocyte sedimentation rate (ESR) 100 mm/hour, and C-reactive protein 60 mg/dl. Three sets of blood cultures and serial cardiac enzymes were negative. Transthoracic echocardiography with suboptimal windows revealed overall moderate left ventricular systolic function, posterioapical hypokinesis and a calcified, immobile aortic valve. Doppler predicted a peak aortic valve gradient of 60 mm Hg with moderate aortic regurgitation. Despite oral metoprolol, nitrates, intravenous unfractionated heparin and a three unit blood transfusion, marked reversible ST segment depression with angina recurred at rest accompanied by hypotension. Emergency coronary angiography showed severe proximal narrowing of the left anterior descending (LAD) and circumflex arteries with an unusual long and tapering contour (fig 1). Aortography showed severe aortic regurgitation with a distorted aortic root and a peak to peak withdrawal gradient of 45 mm Hg across the aortic valve.Emergency surgery revealed a large anterior aortic root abscess which had destroyed the left and right coronary cusps with penetration into but not through the interventricular septum. The aortic root was replaced with a 25 mm Carbomedics valved conduit with reimp...

Primary percutaneous coronary intervention during ST elevation myocardial infarction in prosthetic valve endocarditis: a case report

“…In our case, an immediate coronary angiogram was performed because ST elevation myocardial infarction, complicated by haemodynamic instability, was evident, while the abscess cavity was only suspected. The hypothesis of external coronary compression due to periannular complication was, indeed, only formulated at the time of the invasive procedure due to the specific angiographic pattern (diffuse narrowing of the coronary arteries with severe stenosis of the proximal segments) along with the peculiar clinical presentation [19]. However, an erosion/perforation of the abscess into left coronary artery, could not be definitely ruled out.…”

Aortic Valve Endocarditis Complicated by ST-Elevation Myocardial Infarction

“…[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] We found 21 unique cases, the earliest from 1987. Only 2 cases involved abscess compression of the right coronary circulation.…”

Postoperative asystole in a vasculopathic man

“…The source can be infection of the aortic root leading to root abscess formation, expanding outward to distort coronary anatomy by direct mass effect [18,19]. In a similar fashion, mediastinal and pulmonary neoplastic processes have been documented to expand to the point of encasement and distortion of all vascular structures, leading to unstable angina from coronary insufficiency despite the absence of atherosclerotic plaque [20].…”

“…Coronary arterial occlusions have been reported resulting from external compression from a variety of abnormal mediastinal structures: acute hematomas from aortic dissections [40,41], sinus of Valsalva aneurysms [4], Teflon pledget granuloma after aortic valve replacement [42], aortic root abscess [19], and dilated pulmonary arteries from both primary and secondary pulmonary hypertension [43][44][45][46]. In fact, compression of the left coronary ostium has been reported secondary to left ventricular pseudoaneurysm formation from prior mitral valve replacement [47] and has previously been implicated as the cause of ostial RCA compression from an aortic pseudoaneurysm subsequent to aortic valve replacement [48].…”