Coronary ostial stenosis in a young patient.

A 37-year-old man presented to our department complaining of severe chest pain triggered by the slightest physical exercise. The symptoms appeared 6 months previously and have gradually worsened. His medical history was unremarkable, and he had no cardiovascular risk factors except smoking. A 6-lead ECG at rest was normal, as was the chest x-ray. The ultrasonography examination revealed severe aortic regurgitation and a moderately enlarged left ventricle with normal systolic function. The treadmill test was positive for myocardial ischemia. He subsequently underwent a catheter examination that diagnosed severe right and left main coronary ostial stenoses along with severe aortic valve incompetence (Figure 1A and 1B). A computed tomographic examination confirmed these findings (Figure 1C and 1D), revealing an ascending aorta with a maximum transverse diameter of 3.5 cm, an irregular intima, and a thickened wall (6 mm) (Figure 1C). He was referred for urgent replacement of the aortic valve and triple total arterial coronary bypass. At surgery, the ascending aorta had a hyperemic, inflammatory adventitia that adhered firmly to the surrounding structures. Cross-clamping revealed a markedly thickened wall, with extensive longitudinal wrinkling all the way into the aortic root, deforming and narrowing the coronary ostia (Figure 2). The aortic valve leaflets were thickened and retracted, resulting in severe, central incompetence. Aortic valve replacement with a 25-mm mechanical prosthesis and a triple total arterial coronary bypass with the use of the radial and both internal thoracic