Bilateral coronary ostial stenosis and aortic regurgitation due to syphilitic aortitis

Introduction: Syphilitic aortitis classically involves aortic root, resulting in coronary ostial stenosis (COS) and aortic valve insufficiency. Case report: We present a 63-year-old male with aortic valve regurgitation and recurrent COS due to syphilitic aortitis after percutaneous coronary intervention (PCI), the patient accepted Aortic Valve Replacement (AVR) and Coronary Artery Bypass Graft (CABG). Antibiotic therapy (benzathine penicillin G) is a supplement for cardiovascular syphilis. Conclusion: CABG is a possible and effective interventions to treat syphilitic COS and long-term follow-up is mandatory.

branch, and to the posterior descending artery. The surgical approach was performed through a medianthoracotomy. After harvesting of the left ITA, a cardiac arrest burst that the harvesting of the right ITA was force suspension. We established Cardiopulmonary Bypass (CPB) immediately followed by cannulation of the femoral artery, superior and inferior vena cava, clamping of the ascending aorta. Persistent retrograde cardiac perfusion was performed via cannulation of the coronary sinus due to the COS. The patient presented with thickened wall at the aortic root and the ascending aorta, epidermoid hyperplasia around bilateral coronary ostial, and fibrosis at the aortic valve edge. Because of the thickened wall at ascending aorta, we used bovine pericardium to enlarge aorta root, and anastomosed the saphenous vein to the bovine pericardium.  The patient was transmitted to the intensive care unit for postoperative cardiovascular treatment.
Mechanical ventilation was ceased three days later, and IABP was removed ten days later. Pathological biopsy showed multifocal infiltration of lymphocytes and plasma cells in the media, and coagulative necrosis in the local area ( Figure 3C). Laboratory test showed syphilis TRUST descended to 1: 16. Two months after surgery, the patient visited a cardiologist with no complaint. During the follow-up visit, echocardiography revealed reduced LVEDD (46 mm), normal left ventricular function (LVEF 54%), and normal aortic biological valve function, coronary artery computed tomography showed patency of blood flow of graft vessels ( Figure 3D).

Discussion
COS and aortic regurgitation occur in patients with syphilitic aortitis. Antibiotic therapy should be recommended according to the guideline for cardiovascular syphilis [4]. Although syphilitic aortitis has declined due to the efficacy of antibiotic therapy [2], the prevalence of COS with aortic regurgitation has been reported to be 14% in patients with syphilitic aortitis [5]. Matsuyama et al. reported a case with high positive titers 2 months after antibiotic therapy for 2 months [1]. Our case developed recurrent bilateral COS after antibiotic therapy and PCI,that suggested continuous infection of the aortic wall.
The options of different revascularization strategies for COS is disquisitive. Marcelo et al. reported a case with Acute Myocardial Infarction (AMI) due to syphilitic COS treated by PCI, that suggested PCI is a possible and effective intervention to treat syphilitic COS [6]. PCI is recommended within first 12 h from onset of symptoms [7], CABG is preferred if there are stable angina or delayed admission from presentation [2,8]. There are no comparative studies of PCI versus CABG in treating syphilitic COS [9], and potential anastomotic stenosis or restenosis in-stent restenosis caused by continuous infection of the ascending aorta may exist [2]. In the present case, we anastomose SVG to the bovine pericardium to avoid this situation, long-term follow is mandatory as a result of potential anastomotic stenosis.
Bilateral ITA, instead of Saphenous Vein Graft (SVG), should be preferred as a result of potential graft failure caused by syphilitic aortitis. Rūta et al. described a 37-year-old male with AMI due to syphilitic COS, which treated by CABG with the left ITA diverted into the proximal part of the left anterior descending artery, and the right ITA diverted to the proximal part of the right coronary artery [2]. In the present case, we abandoned the right ITA due to the cardiac arrest, which was attributed to coronary hypoperfusion caused by COS and low blood pressure during anesthesia. Hence, low blood pressure should be avoided before CPB especially in patients with COS.
Long-term follow-up is mandatory as a result of syphilitic aortitis, the occurrence of prosthetic valve dehiscence, or graft failure caused by continuous infection of the aortic wall. Further comparative studies are required to compare PCI with CABG in syphilitic COS.

Conclusions
Although syphilitic aortitis has declined due to the efficacy of antibiotic therapy, syphilitic COS with aortic regurgitation are still present. CABG is a possible and effective interventions to treat syphilitic COS, and further comparative studies are required to compare PCI with CABG in syphilitic COS. Long-term follow-up is mandatory as a result of syphilitic aortitis, the occurrence of prosthetic valve dehiscence, or graft failure caused by continuous infection of the aortic wall.