Myocardial Infarction in a Patient With Severe Aortic Stenosis and Normal Coronary Arteriograms-Involvement of the Circumferential Subendocardial Wall of the Left Ventricle-

Abstract

yocardial ischemia, particularly of the circumferential subendocardial region, commonly occurs in patients with severe aortic stenosis during hemodynamic stress, even in the setting of angiographically documented normal coronary arteries. 1 The mechanism responsible for this type of ischemia is myocardial oxygen demand that exceeds supply and myocardial necrosis can even occur. 2 Even if the occurrence of myocardial infarction is extrapolated from the myocardial ischemia, the myocardial necrosis would be located in the circumferential subendocardial wall of the left ventricle. In other words, when infarcts are located in the circumferential subendocardium, they are thought to be caused solely by aortic stenosis. 3 Subendocardial necrosis caused by severe aortic stenosis often leads to left ventricular dysfunction and overt congestive heart failure. 4 There have been only a few documented case of acute myocardial infarction caused solely by severe aortic stenosis, 5 although silent ischemic necrosis has often been observed. 6 In the present patient, who had marked left ventricular hypertrophy secondary to severe aortic stenosis and normal coronary arteriograms, the acute phase of myocardial infarction involving the circumferential subendocardial wall of the left ventricle was clearly documented by detection of a transient rise in the biochemical markers of myocardial necrosis and an abnormal accumulation of infarct-avid imaging agent in the irreversibly damaged myocardium. Case ReportA 58-year-old man was admitted to hospital because of prolonged chest pain and loss of consciousness. He had a 2-year history of chest pain and shortness of breath during exertion. Two hours before admission, he had experienced these symptoms while watching television in excitement, and subsequently became unconscious.On admission, he had regained consciousness, but his chest pain persisted. Physical examination revealed a systemic blood pressure of 170/110 mmHg and a pulse rate of 100 beats/min. On auscultation, a grade IV/VI systolic ejection murmur was heard best at the upper right sternal Circ J 2003; 67: 891 -894 (Received November 30, 2001; revised manuscript received April 15, 2002; accepted April 18, 2002

Subendocardial Infarction in Severe Bicuspid Aortic Stenosis without Coronary Stenosis Confirmed by Contrast-enhanced Computed Tomography and Autopsy

“…Myocardial ischemia, particularly of the circumferential subendocardial region, commonly occurs in cases of severe AS, even with normal coronary vessels (1). However, only a few cases of myocardial infarction solely caused by severe AS have been reported (1)(2)(3). Some are accompanied by a high degree of myocardial enzyme elevation (2,3).…”