A 58 year old woman was referred to our centre for aortic valve replacement because of a severe symptomatic aortic stenosis. She had no coronary risk factors. Rest ECG showed complete left bundle branch block. Coronary angiography showed normal coronary anatomy (fig 1) . The gradient over the aortic valve could not be measured because of repetitive iatrogenic induction of ventricular tachycardia on inserting the catheter into the left ventricle. Non-invasive evaluation showed an echo Doppler

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... dient of 70 mm Hg and an aortic valve area of 1.2 cm 2 with normal left ventricular function. The patient was scheduled for aortic valve replacement. One litre of cold cardioplegia solution was given through antegrade cannulation of both coronary ostia. A St Jude Medical HP 23 mm valve was placed; the valve was attached with single stitches Ethibond 3.0 (Ethicon, Sommerville, New Jersey, USA). A few days after the procedure she developed atrial fibrillation with rapid ventricular response, which was successfully cardioverted. The rest of her stay was uneventful and she was discharged on an oral blocker, oral anticoagulation, and propafenone 150 mg tid, which was stopped four weeks later. She remained well until five months later, when on various occasions she presented with Figure 1 Coronary angiography showing (A) normal main stem (left anterior oblique view); (B) main stem stenosis (left anterior oblique view); (C) normal main stem (right anterior oblique view); (D) main stem stenosis (right anterior oblique view).