Patient Presentation
A 47-year-old male patient was presented to the emergency department with acute chest pain in October 2022.The patient was hemodynamically stable at arrival. Upon arrival, the heart rate was 90 beats/minute and blood pressure was 145/80 mmHg. Cardiac auscultation reported rhythmic heart sounds and a grade II/IV systolic murmur in the mitral area. Pulmonary examination was normal, and there were no signs of peripheral edema or ankle swelling.
Past Medical History
As a child, he was diagnosed with an aortopulmonary window (APW), severe subaortic stenosis, and anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA).At the age of eight, he underwent surgery that involved resection of the subaortic membrane, repair of the APW, and reimplantation of the right coronary artery into the aorta. At fifteen years old, he underwent aortic valve replacement with a mechanical prosthesis due to severe aortic regurgitation. At twenty-seven, he was found to have a 62-mm abdominal aortic aneurysm (AAA), for which surgery was recommended. However, he declined the procedure and returned to his home country. There, he was managed with antihypertensive drugs for preventing progression and complication of aneurysm.
Examination and Investigations
An electrocardiogram (ECG) performed on presentation reported alterations that are consistent with an anterior wall myocardial infarction. Laboratory investigations showed a significantly elevated troponin level of 553 ng/mL (normal <11 ng/mL).Transthoracic echocardiography reported moderate left ventricular systolic dysfunction with abnormalities in the regional wall motion in the anterior and apical segments. There was also severe functional mitral regurgitation, but no pericardial effusion. Given the patient's complex cardiac history and acute presentation, an urgent chest CT angiography was performed. This revealed a markedly enlarged ascending aortic aneurysm measuring 85 mm, with a Stanford type A dissection. The scan confirmed the patency of both coronary ostia, with no significant obstructive coronary disease. As a result, antiplatelet therapy was withheld. The doctor admitted the patient to the coronary care unit for close monitoring.
Further Evaluation and Management
As the patient was hemodynamically stable, surgery was delayed until passing of the acute phase of the infarction. Cardiac magnetic resonance imaging (MRI) was also performed. MRI showed akinesia in the region supplied by the left coronary artery and non-transmural late gadolinium enhancement involving 40% of the myocardial thickness. Seventy-two hours after admission, the patient experienced an episode of ventricular fibrillation. He required two electric shocks to restore normal rhythm. Once clinically stable, he was taken to the operating room for surgery. During the surgical procedure, mitral annuloplasty was performed. A Dacron prosthetic graft was used to replace the ascending aorta. Anastomosis was made to the existing aortic prosthesis, and the coronary arteries were reimplanted.
Follow-Up
The recovery was uneventful during the postoperative period. A postoperative CT angiography confirmed the success of the surgical repairs. Although echocardiography showed persistent ventricular dysfunction, the function of the mitral and aortic prostheses was good. During outpatient follow-up, his heart failure medications were gradually titrated, and he demonstrated good clinical improvement.
