A 45 year old woman with a 17 year history of Crohn's disease and small joint seronegative arthritis, presented with a two year history of exertional chest pain radiating to the jaw and arms, worse on exposure to the cold, which started after an exacerbation of her joint pain. She was a non‐smoker with no hypertension, diabetes or hyperlipidaemia. She had clinical aortic incompetence, blood pressure 130/40 mm Hg, a loud early diastolic murmur and an ejection systolic murmur. Echocardiography showed a dilated left ventricle and severe aortic incompetence. Echocardiography two years previously had shown only minimal aortic incompetence.
Coronary angiography before planned aortic valve replacement showed critical osteal left main stem stenosis with a diameter less than the diameter of a Judgkin's 5 French catheter but otherwise normal coronary arteries. At aortic valve replacement and bypass grafting she was found to have a pinhole osteum of her left main stem.
Aortic root disease now accounts for over 50% of patients presenting with aortic regurgitation requiring aortic valve replacement. In view of this patient's symptoms developing over a period of two years and occurring after an exacerbation of her arthritis and Crohn's disease, it is most likely that this lady had aortitis with inflammation extending into the left main coronary artery with resultant development of left main coronary stenosis.
