Case Presentation:
A 62‐year‐old man presented with 1 day of chest pain and shortness of breath. Four months earlier, he had been diagnosed with MRSA endocarditis and had aortic valve replacement surgery. The preoperative evaluation revealed normal coronary arteries and normal systolic function. One month prior to his current presentation he had a non‐ST‐elevation myocardial infarction (MI) with T‐wave inversions in V3 through V5. He had a heart rate of 89 bpm, blood pressure was 104/68 mm Hg; and SaO2 was 97% on room air. He had bibasilar crackles and a systolic murmur at the apex. He had an elevated JVP and bilateral pitting edema, but no ascites. The EKG revealed reversal of the T‐wave inversions but no additional changes; troponin I levels were normal. An echocardiogram showed an ejection fraction of 25% and a new anterior wall motion abnormality. A left‐heart catheterization revealed that the left circumflex artery succumbed to a 90% collapse during systole. Subsequent imaging with CT angiogram of the chest revealed a pseudoaneurysm that enveloped the left main coronary artery from its origin to the bifurcation of the circumflex and left anterior descending artery. The cause of his myocardial ischemia was due to the left ventricular pseudoaneurysm occluding the left coronary artery. An aortic valve replacement and resection of the pseudoaneurysm were performed.
Discussion:
A left ventricular pseudoaneurysm is an abnormal outpouching of the left ventricular wall that arises after damage to the myocardial tissue. Typically, pseudoaneurysms are consequences of myocardial infarction but, as this case illustrates, can be a complication of aortic valve replacement. The coronary vessels are juxtaposed to the aortic ring; inadvertent compression of the vessels during aortic valve replacement surgery, either intraoperatively or from scarring after the surgery, can lead to a pseudoaneurysm. Like the pseudoaneurysm seen following an anterior myocardial infarction, reversal of the T‐wave polarity is a clue to its presence. In our case, clinical suspicion, and the use of newer imaging procedures such as CT coronary angiogram led to the correct diagnosis.
Conclusions:
Access to echocardiographic evaluation has increased, leading to earlier diagnosis of surgically repairable valvular disease. With increased valve surgeries being performed, the hospitalist must be aware of the potential complications of this surgery to prevent life‐threatening complications.
Author Disclosure:
A. Small, none; B. Kunjummen, none; J. Wiese, none.