An incidental finding during cardiac catheterization Maria Martin T , In ˜igo Lozano, Ce ´sar Morı ´s, Juan Ronda ´n, Pablo Avanzas, Emma Sua ´rez, Carlos Simarro, Beatriz Dı ´az-Molina Hospital Universitario Central de Asturias, Department of Cardiology, Oviedo, Spain Received 16 October 2004; accepted 31 December 2004 Available online 22 March 2005 Abstract Coronary artery obstruction during cardiac catheterization is rare. It is a serious complication and has been reported to occur in 0.15 to 0.5% of cases. Thromboembolism, air embolism and coronary dissection have been described as the most common causes of intraprocedural coronary occlusion. Aortic valve masses can also cause coronary obstruction. We report the case of a young woman with a complication and an incidental finding during angiographic procedure. A surgical treatment was needed. D 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Cardiac catheterization; Acute coronary syndrome; Left ventriculography 1. Case report A 44-year-old woman, smoker, was transferred to our hospital for cardiac catheterization with diagnosis of acute coronary syndrome treated with IIb/IIIa inhibitors. Cardiac catheterization via right femoral artery was performed, showing a normal left anterior descending coronary artery comprising the anterior, apical and inferior left ventricular wall. An image compatible with thrombus was seen in the first obtuse marginal and the right coronary artery, which was non-dominant, terminated in a small posterolateral branch. Left ventriculography revealed severe hypokinesis of anterobasal, anterolateral, apical and diaphragmatic seg- ment. Ejection fraction was 15%. Immediately after the left ventriculography, profound cardiogenic shock developed. Cardiopulmonary resuscitation was initiated and intraortic balloon counterpulsation and mechanical ventilation installed. Despite these measures and intravenous amines administration systolic blood pressure remained in the level of 50 mm Hg. Coronary angiography and left ventriculog- raphy were reviewed and a 2-cm mobile filling defect just above the sinus of Valsalva was noticed. With the possibility of left main obstruction, guiding catheter was introduced via the left femoral artery, confirming that diagnosis with TIMI 1 flow due to a mass angiographically suggestive of thrombus (Fig. 1A). The mass moved out into the aorta during coronary injection, achieving TIMI 3 flow in the left anterior descending and systolic blood pressure raised to almost normal level (Fig. 1B).An echocardiography was then performed showing severe left ventricle dysfunction with a huge thrombus in the lateral wall of the left ventricle and an ovoid, mobile mass (1.5 Â 1.2 cm) in the aortic surface of the aortic valve (Fig. 2). Diagnosis of thrombotic embolism from the left ventricle to the left sinus of Valsalva was suspected and streptokinase administered. A new echocardiography after thrombolysis showed no thrombus in the left ventricle, but the ovoid mass in aortic valve was still presented. Forty-eight hours after catheterization patient was extubated and counterpulsation balloon removed. Evolution was favorable and new echocardiography revealed that ejection fraction was close to 40%. No thrombi were observed inside of the left ventricle but the mass over the aortic valve was still visible. Because of the lack of response to thrombolysis and the atypical location in the aortic side of the aortic valve, differential diagnosis with a cardiac mass was made. The 0167-5273/$ - see front matter D 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2004.12.061 T Corresponding author. E-mail address: mmartinf7@hotmail.com (M. Martin). International Journal of Cardiology 106 (2006) 137 – 138 www.elsevier.com/locate/ijcard