Recurrent Calcium Emboli in a Patient with Aortic Stenosis
Little information regarding the natural history of calcium emboli from diseased heart valves is available and it is not known whether this complication should be considered an indication for surgical valve replacement. We report a unique case in which a patient had two calcium emboli to the same location in a period of ten months. Spontaneous calcific emboli have been considered rare; however, necroscopy examination of patients with aortic stenosis reveals an incidence of 19 percent. The majority of these emboli were to the coronary arteries. Clinically obvious cases seem to be much less common. In a series of735 embolectomies for major arterial emboli, the heart was the source of the embolus in 90 percent of the cases. Seven percent of the patients gave a history of rheumatic heart disease. The case we report is the only instance in which calcium embolic material was an operative and pathologic finding. The incidence of recurrence following a calcium embolus is not known and thus, whether to recommend valve replacement in such patients is problematic, especially if their aortic stenosis is not severe. patanol eye drop
A 38-year-old man was admitted to Good Samaritan Hospital on May 6,1987, with the tentative diagnosis of arterial embolus to the left lower extremity. After mowing his lawn the day previously, he had become dizzy and had dull retrosternal pain that lasted only seconds. He then noticed pain in his left calf when he walked. On standing still, the pain immediately went away. He gave a history of five separate hospital admissions for rheumatic fever as a child. Since that time he had been asymptomatic and had received no regular medical care. He reported no other significant medical history.
Physical examination showed that the patients left limb had normal color and was slightly cool to palpation. The femoral and popliteal pulses were easily palpable, but the posterior tibial and dorsalis pedis pulses were absent on the left side. On the right side, all pulses were of normal amplitude. Auscultation of the heart revealed a grade 3/6 systolic ejection murmur audible at both upper sternal borders, with radiation to the neck. No diastolic murmur was heard. The electrocardiogram was normal. An echocardiogram showed thickened aortic leaflets (Fig 1) but was otherwise normal. The Doppler examination revealed a peak systolic velocity of 4 m/s, indicating a 64-mm gradient across the aortic valve. The estimated valve area using the continuity equation was 1.0 cm. A duplex scan was obtained which showed a normally beating left popliteal artery; however, the artery could not be visualized at its termination. Because the aortic stenosis appeared to be moderate and the patient was asymptomatic, valve replacement was not recommended.
The operative findings were as follows: The popliteal artery was exposed with the standard medial incision at the knee level. The proximal artery was pulsating but the distal artery was pulseless and obviously contained a thrombus. This thrombus extended into the anterior tibial artery. The artery was opened and found to contain fresh clot, which was removed. Following this, a firm mass, whitish in hue and friable in nature was removed from the anterior tibial artery and tibial-peroneal trunk (Fig 2). There was no evidence that this material was attached to the intima. A firm, trailing, well-defined thrombus extended from this gray friable material into the origin of the anterior tibial artery for a distance of approximately 4 mm. A long fresh thrombus was removed from both the anterior tibial and posterior tibial arteries by passing a No. 3 and 4 Fogarty embolectomy catheter through them. After removal of the cast and thrombus, there was excellent retrograde bleeding. Fostoperatively, pulses were restored in the foot.
Figure 1. Echocardiogram in the short axis view demonstrating a densely calcified tricuspid aortic valve.
Figure 2. Calcium embolus and associated thrombus was removed from the popliteal artery at the time of the first operation.