Stone Heart Syndrome After Aortic Valve Replacement for Severe Aortic Stenosis: A Case Report

Stone heart syndrome (SHS) is a rare but catastrophic complication of cardiac surgery, characterized by irreversible ischemic myocardial contracture following prolonged global myocardial ischemia, and is almost uniformly fatal once established. We report the case of a 55-year-old woman with severe symptomatic aortic stenosis who underwent elective mechanical aortic valve replacement. Preoperative echocardiography showed preserved ventricular dimensions with low-normal systolic function. Due to technical difficulties during mini-sternotomy, a prolonged aortic cross-clamp time was required with repeated cardioplegia. Failure to wean from cardiopulmonary bypass was followed by complete left ventricular akinesia, immobile left-sided valves, and minimal right ventricular activity despite maximal support. Full sternotomy revealed a rigid, non-compliant myocardium consistent with SHS. Central veno-arterial extracorporeal membrane oxygenation was instituted without myocardial recovery. The patient died from multiorgan failure on postoperative day three. SHS results from profound myocardial ischemia, causing adenosine triphosphate depletion, calcium overload, and irreversible actin-myosin binding. Prevention, achieved through meticulous myocardial protection and strict minimization of ischemic time, remains the only effective strategy against this devastating and irreversible complication of cardiac surgery.