FAIDUTTI, B.

GIRARDET, C.

KALANGOS, A.

PRETRE, R.

RICOU, F.

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Letters to the Editor 351S. J. S. VIRK.C. M. BELLAMY R. A. PERRYThe Cardiothoracic Centre,NHS Trust,Liverpool. U.K.References[1] Piana RN, Moscucci M, Cohen DJet al. Palmaz-Schatz Stenting for thetreatment of focal vein graft stenosis:Immediate results and long-term out-come. J Am Coll CardioF 1994; 23:1296-1304.[2] Chronos NAF, Sigwart U. New tech-nologies in interventional cardiology.Curr Opin Cardiol 1992: 7: 634-41.[3] Strauss BH, Serruys PW, BertrandME « al. Quantitative angiographicfollow-up of the coronary wallstent innative vessels and bypass grafts (Euro-pean experience — March 1986-March1990). Am J Cardiol 1992; 69: 475-81.[4] Hong MK, Popma JJ, Pichard ADet al. Clinical significance of distal em-bolization after transluminal extrac-tion atherectomy in diffusely diseasedsaphenous vein grafts. Am Heart J1994; 127. 1496-1503.[5] Ikari Y, Yamaguchi T, Tamura T,Isshiki T, Saeki F, Hara K. Translumi-nal extraction atherectomy and adjunc-tive balloon angioplasty for restenosisafter Palmaz-Schatz coronary stent im-plantation. Cathet Cardiovasc Diagn1993; 30: 127-30.An atypical aortic valve non-bacterialthrombotic endocarditis in the courseof multiple myelomaNon-bacterial thrombotic endocarditis(NBTE) is characterized by small,sterile and loosely attached vegeta-tions upon valve leaflets that developusually in instances of debilitatingdisease such as metastatic cancer,renal failure, chronic sepsis, etc.''1.Although clinically significant embo-lization may be frequently encoun-tered'21, valvular dysfunction is rare inthe course of NBTE.A 40-year-old man with IgG-lamda-type multiple myelomaknown since 1990 and chronic renalfailure on peritoneal dialysis sinceJanuary 1994 was admitted to ouremergency room complaining ofsudden-onset chest pain and shortnessof breath. A 4/6 systolic ejectionmurmur was auscultated along theleft sternal border. An electrocardio-gram suggested the presence of pos-terolateral ischaemia. Transthoracictwo-dimensional echocardiographyshowed an immobile big rounded massattached with a wide base to the aorticand ventricular surfaces of the aorticFigure 1 Transthoracic echocardi-ography revealing the presence of alarge aortic valve mass creatingaortic valve stenosis (arrow).valve, creating an aortic valve stenosiswith a mean gradient of 50 mmHg(Fig. 1).It was supposed that postero-lateral ischaemia was due either tothe partial obstruction of the rightcoronary artery ostium by this mass orto the embolization of a part of it inthe right coronary artery. We optednot to perform coronary arterio-graphy because of the risk of cerebraland/or peripheral embolization dur-ing catheterization of the ostia. Thepatient had not been febrile sincethe multiple myeloma had been di-agnosed. Successive haemoculturesshowed no evidence of bacteria orfungus. At operation, the tumour wasfound to be a grey 2 x 1-cm soft andcrumbly mass with a cauliflower ap-pearance infiltrating the aortic valveleaflets and leaving a valve openingorifice of 6 mm of diameter. The masswas removed and the aortic valve wasreplaced with an aortic cryopreservedhomograft. The patient developedacute hepatic insufficiency on post-operative day 3 and died in hepaticcoma 2 days later. Histopathologicalexamination of the tumour revealed abland fibrinous material with someplasmocytoid cells among the lym-phocytes and histiocytes at the inser-tion site with the valve. No bacteria orfungus were present in serial histologi-cal sections and cultures of the masswere negative. Immunocytochemical.determination of the clonal constitu-tion of the plasmocytoid cells did notconfirm the eventuality of a plasmo-cytoma. In conclusion, based on thesefindings the diagnosis was consistentwith NBTE.Valve dysfunction due toNBTE is rare unless the affected valvehas previous damage such as oldrheumatic valvulitis or degenerativealterations. Our case shows that smallvegetations in NBTE, usually singlealong the closure line of the leaflet, canincrease in size and extensiveness bycontinuous fibrin accumulation andcreate valve dysfunction. Infectiveendocarditis should be considered inthe differential diagnosis of NBTE andparticularly in the setting of immuno-deficiency due either to multiple my-eloma or to its treatment. Clinicalsymptoms, positive blood cultures orpresence of bacteria or fungus in thevalve specimen are required for confir-mation. However, some vegetationsin infective endocarditis can undergoprogressive sterilization, fibrosis andorganization. This "healed' form of in-fective endocarditis manifests as nodu-lar excrescences on the valve leafletsand may mimic vegetations of NBTE.In these instances, pathological fea-tures of the valve specimen can serve todistinguish the 'healed' form of infec-tive endocarditis from NBTE which ischaracterized by the presence of fibrincore and lack of organization and sig-nificant acute inflammatory reaction.In our case, the lack of the consistentsigns of infective endocarditis, prophy-lactic use of antibiotics and potentialcomplications of infective endocarditisin other organs at any time before thediagnosis of the mass during the courseof the multiple myeloma precluded theeventuality of an episode of acute orsubacute endocarditis.This case demonstrates that anaortic valve mass formed in the settingof multiple myeloma with no clinicalevidence of infective endocarditis ordefinitive consensus regarding thepathogenesis of the mass, should besuspected NBTE. Surgical interven-tion is mandatory in states of embo-lism or severe valvular dysfunctionalthough it is impossible to definitelysay what the fate of the patient couldhave been without surgery and topredict the prognosis of the multiplemyeloma in this stage.A. KALANGOS*R. PRETRE*C. GIRARDETtF. RICOUJB. FAIDUTTI**Climc for Cardiovascular Surgery,tDepartment of Pathology,\Cardiology Center,University Cantonal Hospital of Geneva,Geneva, SwitzerlandReferences[1] Rosen P, Armstrong D. Nonbacterialthrombotic endocarditis in patientswith malignant neoplastic diseases. AmJ Med 1973; 54: 23-9.Eur Heart J, Vol. 18, February 1997352 Letters to the Editor[2] Young RS, Zalneraitis EL. Maranticendocarditis in children and youngadults: Clinical and pathological find-ings. Stroke 1981; 12: 635-9.Coronary artery mycotic aneurysmdiscovered by transoesophagealechocardiographyIn February 1991, an 18-year-oldwoman was admitted to hospital witha week-long fever. She was known tohave had asymptomatic aortic regurgi-tation since childhood. At presenta-tion, she had a grade 4 diastolicmurmur and a new mitral regurgi-tation. A Streptococcus mitis grewfrom blood cultures and the diagnosisof acute bacterial endocarditis wasmade. The patient was treated withappropriate antibiotics and becameapyreic after 2 days. The first trans-thoracic echocardiogram revealedworsened aortic insufficiency, mitralregurgitation as a result of anteriorleaflet prolapse and vegetations on theanterior leaflet and below the aorticvalve. Six weeks later, the regularweekly ECG showed an acute antero-lateral myocardial infarction. Therehad been no accompanying thoracicpains. Transoesophageal echocardiog-raphy was performed and revealed thedouble valvular lesion but the vege-tation located below the aortic valvehad disappeared. Transoesophagealechocardiography also revealed aparacardiac mass, round and appar-ently empty measuring 1 cm x 1 cm,located in the anterior interventriculargroove (Fig. 1). No pulsatile flow wasdetected by Doppler examination. Sel-ective coronary angiography revealedan aneurysm of the left anterior de-scending artery at its midportion. Theother coronary arteries were normal.The patient was scheduled for surgi-cal correction. Mitro-aortic replace-ment comprised a St. Jude prosthesisand resection of the coronary arteryaneurysm was completed by a leftinternal thoracic artery graft of theanterior interventricular artery. Histo-logical examination of the aneurysmconfirmed its mycotic origin; theartery wall was fibrosed and invadedby inflammatory cells. There was afresh thrombosis in situ. The 3-yearfollow-up examination revealed ahealthy and asymptomatic patient.Coronary artery aneurysmsare rarely described as a paracardiacmass visualized by transoesophagealechocardiography. Two cases haverecently been reported in adults1'-21.Both patients were asymptomatic andFigure 1 Transoesophageal echo-cardiogram, apical four-chamberview. A = aneurysm of the left cor-onary artery; LA=left atrium;LV=left ventricle; RA=right atrium;RV=right ventricle.the aneurysms were revealed by trans-oesophageal echocardiography. In anautopsy review of 89 cases, Daoudet o/.[3] found that 52% of all casesof coronary artery aneurysm wereatherosclerotic, 17% congenital, 11%mycotic or embolic, 11% dissectingand 4% luetic. The mycotic originof the coronary artery aneurysm de-scribed here may be affirmed by thecontext of fever, the disappearanceof a vegetation and the histologicexamination. The thrombosis of theaneurysm may have explained themyocardial infarction on the ECG andthe absence of flow on Doppler duringthe transoesophageal echocardiogram.Two cases of coronary artery my-cotic aneurysm have reported pre-viously'4'5'. Both were diagnosed bycoronary angiography, late after thebacterial endocarditis was treated andconsidered cured. Both patients diedafter a short course and the diagnosisof coronary artery mycotic aneurysmwas confirmed by autopsy examina-tion, with findings similar to our case.To our knowledge, this is thefirst description of a coronary arterymyocardial aneurysm revealed bytransoesophageal echocardiography.This probably accelerated the thera-peutic course and permitted, in ourcase, a favourable outcome in thislife-threatening complication.V. GEBUHRERJ. L. GENOUDX. ANDRE-FOUETM. PERINETTIR. LOIREG. CHAMPSAURJ. DELAYECardiovascular Department,Hopital Cardiovasculaire el Pneumologique,Lyon, FranceReferences[1] Tunick PA, Slater J, Pasternack P,Kronzon I. Coronary artery aneurysms:a transoesophageal echocardiographystudy. Am Heart J 1989; 118: 176-9.[2] Quinn VJ, Baloch Z, ChandrasekaranK, Ross JJ, Karalis DG. Coronaryartery aneurysm masquerading as aparacardiac mass on transoesophagealechocardiography. Am Heart J 1994;127: 441-3.[3] Daoud AS, Pankin D, Tulgan H,Florentin RA. Aneurysms of the cor-onary artery. Report of ten cases andreview of literature. Am J Cardiol 1963;11: 228-37.[4] Crook BRM, Raftery EB, Oram S. My-cotic aneurysms of coronary arteries. BrHeart J 1973; 35: 107-9.[5] Davidson A, Eshaghpour E, Young N,Mintz GS. Late thrombolysis of a cor-onary artery mycotic aneurysm. AmHeart J 1991; 121: 1549-50.Distinguishing between the warm-upphenomenon and training duringrepeated exercise testingWe read with interest the recent articleentitled 'Mechanisms of the warm upphenomenon'11'. In this study threeexercise tests were performed on 15patients with a 10 min interval be-tween the first and second test and 2 hbetween the second and third. Theyfound an increase in time to 1 mm STdepression and time to angina in boththe second and third tests; however,the rate pressure product at 1.5 mmST depression (ischaemic threshold)was increased only in the second testand was not significantly changed inthe third compared with the baselinetest. They concluded that the reduc-tion in ischaemic threshold seen inthe second test may be due to animprovement of myocardial perfusion(collateral flow) or to ischaemic pre-conditioning, whereas the changes theseen in the third test may be due to thetraining effect.The training effect in repeatedexercise testing has been recognizedfor some time. Burkart et al.l2i found,in 10 healthy subjects who performedtwo exercise tests with a 30 min restperiod, a reduction in pulmonaryartery pressure, aortic pressure, car-diac output and oxygen uptake in thesecond test compared to the first.Smokier et a/.'31 performed a retro-spective analysis to examine the repro-ducibility of exercise testing in 63patients with angina who had per-formed more than one exercise testwith varying time intervals betweenthe tests. The study showed that theEur Heart J, Vol. 18, February 1997

An atypical aortic valve non-bacterial thrombotic endocarditis in the course of multiple myeloma

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