syphilitic infections include aortitis, aortic root dilation, aneurysm formation, aortic regurgitation, and coronary ostial stenosis.1 Coronary ostial lesions have been ...
Images in Cardiovascular Medicine
Bilateral Coronary Ostial Lesions in Cardiovascular Syphilis Treated by Means of Percutaneous Coronary Stenting
Ravindranath K. Shankarappa, DM Nagaraja Moorthy, DM Arunkumar Panneerselvam, DM Satish Karur, DM Ramesh Dwarakaprasad, DM Manjunath Cholenahalli Nanjappa, DM
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39-year-old man presented with a 6-month history of stable angina that had recently worsened to unstable angina. He had no conventional risk factors for coronary artery disease. His medical history included a painless ulcer on his penis when he was 18 years old. Cardiovascular examination revealed moderate aortic regurgitation that was confirmed on echocardiograms (Fig. 1). An electrocardiogram showed ST depression in the inferior and anterolateral leads. Results of routine biochemistry tests and a fasting lipid profile were within normal ranges. A rapid plasma reagin card test and Treponema pallidum hemagglutination test were strongly positive. Coronary angiograms showed critical ostial stenosis of the left main coronary artery (LMCA) with Thrombolysis in Myocardial Infarction (TIMI)-I flow (Fig. 2A) and critical ostial stenosis of the right coronary artery (RCA) (Fig. 3A). Aortic root angiograms showed moder-
Fig. 1 Transesophageal echocardiogram (3-chamber view) shows moderate aortic regurgitation and an aortic root with normal dimensions.
Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute at St. Luke’s Hospital, 6624 Fannin St., Suite 2480, Houston, TX 77030
Click here for real-time motion image: Fig. 1.
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From: Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 560069 Bangalore, India Address for reprints: Nagaraja Moorthy, DM, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, 560069 Bangalore, India E-mail: drnagaraj_moorthy@ yahoo.com
© 2013 by the Texas Heart ® Institute, Houston
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Fig. 2 Left coronary angiograms show A) critical left main coronary artery ostial stenosis with Thrombolysis in Myocardial Infarction (TIMI)-I flow before treatment, and B) TIMI-III flow with no distal lesions after ostial stenting.
Click here for real-time motion image: Fig. 2A.
Syphilitic Bilateral Coronary Ostial Lesions
Click here for real-time motion image: Fig. 2B.
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ate aortic regurgitation with no evident root dilation or ascending aortic aneurysm (Fig. 4). The patient underwent percutaneous transluminal coronary angioplasty (PTCA). Engaging the guide catheter in the coronary arteries was difficult because of displaced, deformed, critical aorto-ostial stenosis secondary to syphilitic aortitis with possible cicatrization and fibrosis. After the LMCA lesion was predilated and a 4 10-mm drug-eluting stent was deployed in the ostium, angiograms showed TIMI-III flow (Fig. 2B). In the RCA ostium, PTCA and a 4 13-mm drug-elut-
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Fig. 4 Aortogram shows a normal-sized ascending aorta with moderate aortic regurgitation.
Click here for real-time motion image: Fig. 4.
ing stent yielded TIMI-III flow (Fig. 3B). A year later, the patient was asymptomatic, and an exercise stress test induced no ischemia.
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Fig. 3 Right coronary angiograms show A) critical right coronary artery ostial stenosis before treatment, and B) Thrombolysis in Myocardial Infarction (TIMI)-III flow with no distal lesions after ostial stenting.
Click here for real-time motion image: Fig. 3A. Click here for real-time motion image: Fig. 3B.
Texas Heart Institute Journal
Well-known cardiovascular manifestations of tertiary syphilitic infections include aortitis, aortic root dilation, aneurysm formation, aortic regurgitation, and coronary ostial stenosis.1 Coronary ostial lesions have been detected in as many as 26% of patients with syphilitic aortitis2; however, bilateral coronary ostial stenosis is rare.3 The elective stenting of unprotected LMCA lesions was once considered to be contraindicated; however, several studies have validated its safety, acceptable shortand intermediate-term success, and feasibility as an alternative to coronary artery bypass grafting (CABG).4 Stenting in cases of syphilitic aorto-ostial stenosis is rarely mentioned in the literature, probably because the condition is rare in the era of stenting. Although cardiovascular syphilis is rarely reported, it should be considered in the differential diagnosis in patients who have bilateral coronary ostial lesions but no conventional risk factors for atherosclerosis. In the case of these nonatherosclerotic lesions, PTCA with stenting can be a safe and effective alternative to CABG.
References 1. Kennedy JL, Barnard JJ, Prahlow JA. Syphilitic coronary artery ostial stenosis resulting in acute myocardial infarction and death. Cardiology 2006;105(1):25-9.
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2. Heggtveit HA. Syphilitic aortitis. Circulation 1964;29:34655. 3. Bruenn HG. Syphilitic disease of the coronary arteries. Am Heart J 1934;9(4):421-36. 4. Seung KB, Park DW, Kim YH, Lee SW, Lee CW, Hong MK, et al. Stents versus coronary-artery bypass grafting for left main coronary artery disease. N Engl J Med 2008;358(17): 1781-92.
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