In June 2015, a 67-year-old female with a long-standing history of asymptomatic critical AS was referred for AVR after new onset of shortness of breath. A preoperative transesophageal echocardiogram showed aortic valve area of 0.6 cm2 with 2+ mitral regurgitation. Cardiac catheterization revealed no significant coronary artery disease and well-preserved left ventricular ejection fraction. She underwent insertion of a 19 mm St. Jude Biocor bioprosthetic aortic valve. Postoperatively patient did well. She was started on warfarin and discharged home. In May 2016, patient experienced shortness of breath with moderate exertion, which was new. She underwent a nuclear stress test (Cardiolite), which was abnormal. Repeat coronary angiography revealed 99% narrowing of the left main coronary artery (LMCA).The left anterior descending artery, left circumflex and right coronary artery (RCA) did not reveal any discrete stenosis. After consultation with the cardiac surgeon and the family, the patient underwent urgent primary stent deployment of LMCA.
A 91-year-old male presented to our office in July 2015 with a complaint of a new-onset substernal burning pain of six weeks’ duration. He had been following up with us regularly in the past for his valvular heart disease (AS), hypertension and dyslipidemia. This pain was worse with exertion and was relieved by rest. The patient would have pain on walking, even around 100 yards. Prior to six weeks, he could walk a distance of about two street blocks on level ground without any shortness of breath or chest pain. Patient denied any history of radiation or referral of pain. It was not related to breathing or positional changes. On examination, blood pressure was 140/90 mm Hg and pulse was regular at 60 beats per minute. Cardiovascular exam revealed a Grade 4/6 ejection systolic murmur best heard in the right second intercostal region radiating bilaterally to the neck.