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Background: Syphilitic ostial coronary stenosis is an uncommon manifestation of cardiovascular syphilis, characterized by concomitant aortic regurgitation and isolated or bilateral ostial involvement. Although much has been written about syphilis in the pre-antibiotic era, the key imaging and operative findings were rarely reported in the modern literature. Through multimodality imaging and operative videos, we demonstrate the unique diagnostic and therapeutic hurdles associated with the condition. Case Description: A 47-year-old woman presented with acute decompensated heart failure due to bilateral ostial coronary stenosis and severe aortic insufficiency, which raises suspicion for underlying syphilis. She underwent successful aortic valve replacement, right coronary ostioplasty and bypass grafting of the left coronary system. The syphilitic process was confirmed by histopathological examination of the aortic valve and aortic wall as well as serological tests. She recovered from the operation uneventfully. Conclusions: The manifestations of cardiovascular syphilis are protean and can pose significant diagnostic challenges even in the modern era. The presence of isolated coronary ostial stenosis should raise suspicion for syphilis. Timely surgery and antibiotics can lead to successful outcomes. Furthermore, the evolution and nuances of surgical techniques addressing ostial coronary stenosis was reviewed. Surgical strategy should be individualized based on preoperative multimodality imaging.

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OBJECTIVES: Anomalous aortic origin of a coronary artery (AAOCA) is the second leading cause of sudden death in children and young adults. The most threatening anatomy is an interarterial and an intramural course, both probably involved in ischaemic phenomena and sudden death. The treatment of interarterial AAOCA remains controversial. Most of the published studies describe the results of the unroofing technique. Our study aims to evaluate the results of a different surgical approach. METHODS: From 2005 to 2019, 61 patients were operated on for an interarterial AAOCA (median age 14.7 years). Forty patients had a right AAOCA, and 21 patients had a left AAOCA including 5 patients with intraseptal course. Seventy percent of patients were symptomatic. Five patients had an aborted sudden cardiac death. Two surgical techniques were used: an 'anatomical' repair for 35 patients (15 left and 22 right AAOCA) or a coronary translocation with creation of a neo-ostia in 19 patients (1 left and 18 right AAOCA). The 5 left AAOCA patients with an intra-septal course required a complete release of the coronary artery from the septum. RESULTS: There was no early or late postoperative death. Three patients had an acute postoperative ischaemic event. Two patients required immediate angioplasty and stenting: 1 patient (7 years) with a hypoplastic right AAOCA and 1 patient (66 years) for inadequate tailoring after septal release. The third patient required an immediate surgical revision (H-2) for left AAOCA thrombosis at the level of the pericardial patch with full myocardial recovery at discharge. During follow-up, 1 patient with right AAOCA translocation and chronic chest pain required subsequent stenting and finally a coronary artery bypass grafting 2 years after initial surgery. One patient who had an asymptomatic mild right coronary stenosis 1 year after anatomical repair was successfully treated by angioplasty alone. All patients but 1 who underwent coronary translocation are totally asymptomatic. All patients with anatomical repair or septal release are free from ischaemic symptoms. CONCLUSIONS: Anatomical repair might provide a better protective option for these patients. Unlike unroofing, it treats the entire intramural segment, relocates the ostium at the appropriate sinus level and corrects any acute take-off angle.

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Coronary artery involvement in Takayasu's arteritis is a relatively rare, and potentially lethal but surgically correctable disease. A 28-year-old female was admitted for the evaluation of headache associated with dizziness, palpitation and claudication of left arm. Her aortogram and coronary angiogram showed Takayasu's arteritis with bilateral coronary ostial stenosis. We performed bilateral coronary ostioplasty with saphenous vein patch graft. The patient was discharged in good condition. We report this case with literature review.

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The isolated coronary ostial stenosis is a lesion of the aortic wall that encroaches on the orifice of the left main coronary artery, atherosclerosis is belived to be a common cause and premenopausal female patients are most commonly affected. Stenosis of the left coronary ostium is a critical lesion which requires urgent myocardial revascularization including a surgical intervention because this lesion jeopardizes such a large volume of left ventricular myocardium. We report the case of a patient in whom percutaneous transluminal coronary angioplasty (PTCA) was performed successfully for the stenotic lesion of distal anastomotic site after surgical ostioplasty with autologous pericardium.

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