Clinical introduction

A 49-year-old man presented to the emergency department with sudden-onset left-sided precordial chest discomfort after cycling home from work. He usually cycled up to 60 miles per week and did not report any history of antecedent anginal symptoms. Fourteen years previously, he underwent a bioprosthetic aortic valve replacement (29 mm Carpentier-Edwards, Edwards LifeSciences) with re-implantation of the left coronary artery. Of note, he had recently reported transient loss of vision that was attributed to ocular migraines. On clinical examination, he appeared systemically well and ECG demonstrated sinus rhythm with no S-T changes suggestive of ischaemia. Serum blood analysis revealed an elevated high-sensitivity troponin I, 865 ng/L (normal reference range <40 ng/L). A coronary CT angiogram was performed (figure 1).

Figure 1

Axial views at the level of the right pulmonary artery (A), bioprosthesis (B) and mid left ventricular cavity (C). Reconstructed views of the bioprosthetic…

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