Background: Central retinal artery occlusion (CRAO) is an ophthalmic emergency most commonly related to carotid atherosclerosis or cardiac embolism in younger patients. Calcific aortic valve disease is an uncommon source of retinal emboli and rarely presents first as CRAO. Case Presentation: A 30-year-old man with a 7.5 pack-year smoking history presented with sudden, painless, complete left monocular vision loss. Ophthalmic assessment including fundus exam and fluorescein angiography confirmed left central retinal artery occlusion with preserved cilioretinal artery perfusion. Two weeks earlier he had transient chest pain. Cardiac examination revealed a harsh grade III/IV systolic ejection murmur radiating to the carotids. ECG showed sinus rhythm with LV hypertrophy and anterior ST elevation. Transthoracic echocardiography demonstrated moderate-severe aortic stenosis (mean gradient ~40 mmHg), markedly calcified valve with poorly visualized cusps, concentric LV hypertrophy and preserved LVEF (60%). CT chest showed ascending aortic dilation (4.3 cm). Coronary angiography revealed ostial right coronary artery stenosis; cerebral CT and brain MRI/MRA showed no intracranial arterial occlusion. The patient underwent urgent surgical aortic valve replacement; intraoperative inspection revealed a severely stenotic bicuspid aortic valve with large friable calcific vegetations at the fused raphe. A mechanical prosthesis was implanted without complication. Postoperative recovery was uneventful; no further systemic embolic events occurred. Visual prognosis remained limited. Discussion: This case highlights an unusual presentation of calcific bicuspid aortic valve disease in a young adult, manifesting as CRAO. Retinal calcium microemboli may be clinically apparent due to the retina's end-arterial circulation. Identification of a cardiac source - particularly heavily calcified aortic valve - is critical because embolic events may recur and can be bilateral. Urgent cardiac evaluation and consideration of valve replacement are warranted even when conventional hemodynamic indications are borderline, given the embolic risk. Conclusion: CRAO can be the initial manifestation of calcific aortic stenosis. In young patients with retinal artery occlusion, prompt cardiac assessment for valvular calcification (including echocardiography and, where indicated, catheterization) should be undertaken. Urgent valve replacement should be considered to prevent recurrent systemic embolization.
BACKGROUND Cardiac surgical capacity in sub-Saharan Africa remains severely limited, and sustainable locally led programs are scarce. This report describes the first 1000 consecutive cardiac operations performed by a fully local cardiac surgical team in Ethiopia, with a focus on implementation experience, service development, and outcomes. METHODS Study investigators conducted a retrospective descriptive cohort review of 1000 consecutive cardiac surgical procedures performed between June 2017 and January 2025 in Addis Ababa, Ethiopia. The same local team undertook all procedures using standardized protocols. Demographic and operative data were extracted from institutional records. Programmatic challenges and mitigation strategies were identified from team documentation and mapped to a structure-process-outcome framework. Primary outcomes were 30-day all-cause mortality and permanent pacemaker implantation. RESULTS Rheumatic valve disease accounted for 424 procedures (42.4%), and congenital heart disease accounted for 407 (40.7%). Overall 30-day mortality was 2.9%, and permanent pacemaker implantation occurred in 0.2% of patients. Annual surgical volume increased from 31 procedures in 2017 to 204 in 2025. Major challenges included limited access to repair-enabling consumables and intraoperative transesophageal echocardiography, constrained intensive care capacity, advanced disease at presentation, and public and professional hesitancy. Mitigation strategies included phased risk-stratified case selection, protocol standardization, public engagement, and establishment of a locally governed charitable platform to support access to rheumatic valve surgery. CONCLUSIONS A locally led cardiac surgery program can be established and scaled in a resource-limited setting with acceptable outcomes. Explicit alignment of structural capacity, clinical processes, and programmatic strategies is essential for sustainable cardiac surgical service development. (Ann Thorac Surg 2026;122:752-8) (c) 2026 The Authors. Published by Elsevier Inc. on behalf of The Society of Thoracic Surgeons. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
