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Septic Coronary Embolism in Aortic Valvular Endocarditis Anitha Kessavane1, Paul Marticho2, Elie Zogheib1, Emmanuel Lorne1, Hervé Dupont1, Christophe Tribouilloy3, Jean Paul Remadi2 Departments of 1Anesthesiology, 2Cardiovascular Surgery and 3Cardiology, South Hospital, Laennec avenue 80054, Amiens, Salouel, France
Acute myocardial infarction due to septic coronary emboli in active infective endocarditis is rare, but may be fatal. The case is reported of a 58-year-old man who presented with wrist arthritis, which resulted in acute aortic valvular endocarditis. Echocardiography revealed 3 mm vegetations on the posterior and anterior valve cusps, and aortic regurgitation (grade 3-4). As the patient’s clinical status was stable, medical treatment was selected which included antibiotic therapy, but after four weeks the patient reported an acute anterior chest pain. Coronary angiography revealed stenosis of the left
anterior descending (LAD) artery, due to septic embolism. The patient was referred for emergency cardiac surgery, at which a surgical thrombectomy and coronary artery bypass grafting with reconstruction of the LAD artery were performed, along with aortic valve replacement using a bioprosthesis. The postoperative course was uneventful and the patient was discharged on postoperative day 15. An adapted oral antibiotherapy was continued for a further sixweek period.
Despite major advances having been made in cardiology diagnosis, and in both medical and surgical treatments, acute infective endocarditis (IE) remains a continuing challenge due to the high risk of mortality and morbidity; the current in-hospital mortality is about 20% (1). The therapeutic approach for this condition is multidisciplinary, and treatment strategies have been well defined (1). Herein is described a case of acute myocardial infarction (MI) due to a septic embolism resulting from IE that had been surgically treated.
received 40 years earlier had caused multifocal fractures of the left wrist. There were no known cardiac risk factors and no history of cardiovascular disease. On examination, persistent fever, NYHA class II dyspnea, asthenia and weight loss suggested that a multidisciplinary approach be undertaken. During the investigation, transesophageal echocardiography revealed a 3 mm vegetation on the posterior and anterior cusps of the valve, and aortic regurgitation (grade 3-4). The blood cultures proved to be negative, as did the serology. According to the modified Duke criteria, a diagnosis of acute aortic IE was established (2). For reasons of clinical tolerance and the presence of a systemic syndrome, medical treatment was selected that including a triple antibiotic therapy with rifampicin, penicillin M, and netromicin. After a four-week period of treatment the patient reported a sudden, acute anterior chest pain. Coronary angiography revealed an occlusion of the left anterior descending (LAD) artery due to a septic embolism (Fig. 1), which prevented percutaneous balloon angioplasty from being performed. Echocardiography revealed the vegetations to be unchanged, while a decrease in the left ventricular ejection fraction (to 50%) was apparent, due to hypokinesia of the cardiac apex. The patient underwent emergency surgery, during
Case report A 58-year-old man was admitted with a systemic febrile illness and inflammation of his left wrist. A culture-negative septic arthritis was diagnosed, and a seven-day course of antibiotic therapy (amoxicillinclavulanic acid) was initiated. The patient’s medical history included multiple prior fractures, although, of note, a severe injury
Address for correspondence: Dr. Jean Paul Remadi, Cardiovascular Surgery Unit, South Hospital, Laennec avenue 80054, Amiens, Salouel, France e-mail:
[email protected]
The Journal of Heart Valve Disease 2009;18:572-574
© Copyright by ICR Publishers 2009
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Septic coronary embolism in aortic valvular endocarditis A. Kessavane et al.
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Figure 2: An intraoperative view of the heart, showing removal of the intracoronary thrombus.
Figure 1: Coronary angiography. Note the dramatic lowering of coronary flow through the distal left anterior descending (LAD) artery, with several stages of stenosis.
cillin M was continued following surgery. Postoperatively, the patient showed a significant improvement and experienced an uneventful course, with an adapted oral antibiotherapy being continued over a six-week period. At one year after surgery the patient was well, and had shown no recurrent symptoms.
Discussion
Figure 3: Macroscopic views of the intracoronary embolism. T: Coronary thrombus in the left anterior coronary artery; V: Intracoronary aortic septic vegetation. which the anterior and posterior leaflets of the aortic valve were found to be involved with endocarditic lesions. The aortic valve was replaced using a bioprosthesis. A 3 cm arteriotomy was made in the occluded part of the LAD (Fig. 2); this allowed removal of the proximal thrombus and the vegetative emboli that were located distally (Fig. 3). The left internal thoracic artery was used to reconstruct the LAD as a long patch angioplasty. Culture of the vegetations removed from the coronary artery revealed coagulase-negative staphylococci. Intravenous antibiotherapy with rifampicin and peni-
Evidence indicates that endocarditis in the aortic valve occurs more frequently than in the mitral valve (1,3,4), a ratio of 35% versus 29% having been reported by Hoen et al. among 390 patients (1). Whilst cases of mitral IE providing septic coronary embolism are numerous (5,6), aortic valvular vegetations are less likely to embolize to the coronary artery because of the reduced distance from the coronary ostium. During systole, the vegetations are directed towards the systemic circulation, which causes peripheral embolic complications that include splenic abscess (1). Usually, coronary stenosis resulting in acute MI can be treated with percutaneous angioplasty, although in the case of occlusion due to septic embolism coupled with active valvular endocarditis, surgery is warranted. Both, coronary occlusion and the valvular lesion require simultaneous treatment. Endocarditis, if treated only with medical therapy, requires strict patient follow up due to the risk of acute MI caused by septic emboli (7,8), which may be fatal. Moreover, sudden death associated with IE is likely often due to septic embolism (9). Although Staphylococcus aureus may be associated with in-hospital death and peripheral embolism (2,8,10), it has not been documented that staphylococcal vegetations are more prone to septic embolic events.
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574 Septic coronary embolism in aortic valvular endocarditis A. Kessavane et al. References 1. Hoen B, Alla F, Selton S, et al. The changing profile of infective endocarditis: Results of a 1-year survey in France. JAMA 2002;288:53-60 2. Chu HV, Cabell CH, Benjamin DK, Jr., et al. Early predictors of in-hospital death in infective endocarditis. Circulation 2004;110:1364-1371 3. Remadi JP, Habib G, Nadji G, et al, Predictors of death and impact of surgery in Staphylococcus aureus infective endocarditis. Ann Thorac Surg 2007; 83:1295-1302 4. Remadi JP, Najdi G, Brahim A, et al. Superiority of surgical versus medical treatment in patients with Staphylococcus aureus infective endocarditic. Int J Cardiol 2005;99:195-199 5. Baek M-J, Kim HK, Yu CW, et al. Mitral valve surgery with surgical embolectomy for mitral valve
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endocarditis complicated by septic coronary embolism. Eur J Cardiothorac Surg 2008;33:116-118 6. Donal E, Coisne D, Valy Y, et al. Myocardial infarction caused by septic embolism during mitral endocarditis. Arch Mal Coeur Vaiss 1999;92:253-257 7. Perera R, Noack S, Dong W. Acute myocardial infarction due to septic coronary embolism. N Engl J Med 2000;342:977-978 8. Argote C, Colsy M, Collinet P, et al. Widespread septic peripheral emboli from acute Enterococcus faecalis aortic valve endocarditis in 39-year-old drug addict. Ann Fr Anesth Reanim 2007;26:1059-1062 9. Blum A, Sclarovcsky S, Rechavia E. Infective myocardial infarction. Chest 1993;103:1084-1086 10. Li JS, Sexton DJ, Mick N, et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000;30:633-638
