Bacterial endocarditis presenting as acute myocardial infarction: A cautionary note for the era of reperfusion

Herzog, Charles A.; Henry, Timothy D.; Zimmer, Stevan D.

doi:10.1016/0002-9343(91)90583-j

Cited by 52 publications

(25 citation statements)

References 21 publications

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“…The benefit of catheter thrombus aspiration prior to percutaneous coronary intervention in the setting of ST elevation MI has been established16 and is likely to have an important role in MI secondary to septic embolisation. Mycotic aneurysm has been reported following angioplasty in this setting,17–19 and some authors advocate follow-up angiography to screen for this complication if angioplasty is performed 7. It has been suggested that the deployment of intracoronary stents in this setting may increase the probability of developing a mycotic aneurysm 13.…”

Section: Discussionmentioning

confidence: 99%

Successful treatment of ST elevation myocardial infarction caused by septic embolus with the use of a thrombectomy catheter in infective endocarditis

Whitaker

Saha²,

Fulmali³

et al. 2011

Case Reports

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SummaryA 71-year-old patient suffered a transmural (ST elevation) myocardial infarction (MI) as a result of a septic embolus from an infected tissue aortic valve replacement. Following failed fi brinolysis, his MI was successfully treated with thrombectomy using an export catheter. He suffered bleeding complications following the administration of tenectaplase and required aortic valve and root replacement due to ongoing systemic embolisation. cerebellum, left thalamus and both cerebral hemispheres. The central nervous system infarcts were in several arterial territories suggesting a likely cardiac source for the emboli. The MRI scan demonstrated that these infarcts had undergone haemorrhagic transformation, most likely the result of the administration of thrombolytic therapy. MRI of the spine and ultrasound imaging of the renal tract did not reveal any evidence of emboli or abscesses. Apart from haemorrhagic transformation of the intracerebral infarcts and gastrointestinal bleed, the patient experienced frank haematuria in the days following thrombolysis. BMJ Case ReportsThe material from the LAD ( fi gure 2A ) was sent for microscopy and culture. Although neither pus cells nor organisms were seen on initial examination, when incubated it grew Enterococcus . Histological analysis of the embolus revealed fi brin, acute infl ammatory cells and bacterial colonies ( fi gure 2B ). Gram stain of the embolus demonstrated Gram-positive cocci within fi brin ( fi gure 2C ). TOE demonstrated a well-seated biological valve replacement with no vegetations. An echo-free space was identifi ed between the left atrium and aorta which was thought most likely to represent a postsurgical pouch or an abscess cavity. TREATMENTOur patient's antibiotic treatment was changed to amoxicillin and gentamicin. He continued to improve clinically and his CRP and white cell count improved. His dizziness and co-ordination responded well to neurophysiotherapy. Seven weeks following his initial presentation, the patient again developed vertigo and clinical signs of cerebellar dysfunction. Repeat MRI brain demonstrated a punctate focus of restricted diffusion in the right postcentral gyrus that was suggestive of an acute infarct. The patient was reviewed by the cardiothoracic surgical team who agreed that in the context of ongoing septic embolisation despite appropriate antibiotic therapy surgical intervention was indicated. He was taken to theatre for an aortic valve replacement. At operation, a partly healed abscess cavity was visualised and there was residual vegetation on the tissue aortic valve. The aortic valve was completely excised and the aortic root was replaced with a Medtronic freestyle prosthetic root. OUTCOME AND FOLLOW-UPAlthough the patient recovered well following surgery, he did require a permanent pacemaker for second degree heart block. He completed a further week of antibiotics following surgery and underwent further neurorehabilitation before being discharged with cognition and function back to his admission baseline. DISCUSS...

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Section: Discussionmentioning

confidence: 99%

Successful treatment of ST elevation myocardial infarction caused by septic embolus with the use of a thrombectomy catheter in infective endocarditis

Whitaker

Saha²,

Fulmali³

et al. 2011

Case Reports

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“…4 Myocardial infarction is rarely caused by a coronary embolism reported in the setting of a variety of clinical situations such as endocarditis, postcardiac or coronary interventional procedures, or calcified aortic stenosis. [5][6][7][8] Coronary embolism with a tumorous origin is very rare (one of 61 cases in a series 6 ) and it usually appears in the medical literature as case reports. 9 10 Most often the embolism comes from left sided tumours such as myxomas or fibroelastomas.…”

Section: Discussionmentioning

confidence: 99%

Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma

Castro

Bueno²,

Nebreda³

2004

Heart

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A 71 year old patient presented with a non-ST segment elevation acute myocardial infarction. The echocardiogram showed several masses attached to the interatrial septum. Several days after admission the patient died. A postmortem examination found a large hepatocarcinoma with intravascular and intracardiac metastases and several myocardial infarctions of different ages. The infarctions had been caused by coronary paradoxical embolisms through a patent foramen ovale and contained neoplastic cells from the liver carcinoma, which had not been diagnosed. The cause of death was a massive pulmonary embolism.A 71 year old man was admitted to the emergency department with typical oppressive chest pain accompanied by profuse sweating and mild dyspnoea lasting for three hours at the time of admission. The patient had a previous diagnosis of chronic C type hepatitis, porphyria, and mild chronic obstructive lung disease. The ECG showed block of the anterior division of the left bundle branch and 0.5 mV ST segment elevation in the right precordial leads. The patient was admitted to the coronary care unit and treated with nitrates, aspirin, diltiazem, and enoxaparin, becoming asymptomatic. The laboratory tests showed a rise and fall of the cardiac markers with a peak creatine kinase MB concentration of 40 ng/ml.On the third day a transthoracic echocardiogram showed a large mass in the right atrium arising from the inferior vena cava that was partially occupied. No abnormalities in global or segmental contractility in the left or the right ventricles were found. Transoesophageal echocardiography showed a large 6 6 3 cm mass placed against the interatrial septum ( fig 1A). The Doppler study showed a patent foramen ovale. Laboratory analyses showed a major increase of biochemical tumour markers, particularly a fetoprotein (more than 2500 ng/ml).The day after the transoesophageal echocardiogram was recorded, the patient presented with a sudden pleuritic chest pain, with severe dyspnoea and refractory hypoxaemia and cyanosis. Pulmonary arteriography was urgently performed, showing obstruction of the main right and left pulmonary arteries. Intra-arterial thrombolysis with urokinase was administered with no clinical or haemodynamic improvement. The patient died four hours later. The pathological findings showed several yellowish 2 cm diameter nodules in the liver. One of the masses had invaded the suprahepatic veins and the inferior vena cava ( fig 1C). Several masses were attached to the inferior vena cava and right atrial wall (fig 1B), as well as to a dilated right ventricle, main pulmonary arteries, and their distal branches. A 7-8 mm diameter patent foramen ovale was also found. Histological analysis of the hepatic masses showed neoplastic cells with an eosinophilic cytoplasm and areas of focal necrosis. The same type of neoplastic cells were found in intravascular and intracardiac masses. The epicardial coronary arteries had no signs of atherosclerotic obstructions but had several microscopic embolisms in the distal branches o...

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“…Intramyocardial abscesses were noted in 18 of the 80 patients. 5 Embolic occlusion of large coronary arteries or their major branches is an unusual complication of left-sided infective endocarditis [27][28][29][30] that is likely to occur earlier rather than later in the course of the disease. Some patients with endocarditis have undergone thrombolysis and coronary angioplasty for infarction associated with acute ST-segment elevation.…”

Section: Differential Diagnosismentioning

confidence: 99%

“…Some patients with endocarditis have undergone thrombolysis and coronary angioplasty for infarction associated with acute ST-segment elevation. 29,31 Compromise of a coronary ostium by a large vegetation or by an expanding mycotic aneurysm has also been reported. 32,33 In this case, the persistently subtherapeutic prothrombin time provides another possible explanation for a postoperative myocardial infarction: thromboembolism from the tissue valve.…”

Section: Differential Diagnosismentioning

confidence: 99%

Case 25-1998

O’Gara¹,

Narula²,

Mark³

1998

N Engl J Med

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A 34-year-old man was admitted to the hospital because of worsening dyspnea and increasing mitral regurgitation after replacement of the aortic valve for acute bacterial endocarditis.The patient had a history of intravenous drug abuse. Four months before admission he had been transferred to this hospital because of acute bacterial endocarditis caused by Staphylococcus aureus, with aortic regurgitation. A test for antibodies to the human immunodeficiency virus was negative. A transesophageal ultrasonographic examination of the heart (Fig. 1) revealed a large prolapsing vegetation on the right coronary cusp of the aortic valve, with severe aortic regurgitation; there was a small mobile vegetation on the septal leaflet, associated with moderate tricuspid regurgitation. Oxacillin, gentamicin, ceftriaxone, and metronidazole were administered.A computed tomographic (CT) scan of the brain showed three enhancing foci, each less than 1 cm in diameter, in the subcortical white matter, a finding consistent with septic embolism. An abdominal CT scan showed multiple splenic infarcts and probable focal infarction or necrosis of an ileal loop, with perforation. The infarcted, perforated segment of terminal ileum and the infarcted spleen were resected, and a pelvic abscess was drained. Subsequently, the aortic valve and a large vegetation were excised (Fig. 2), and a Carpentier-Edwards prosthetic pericardial valve was inserted; an adjacent abscess and a vegetation on the septum near the tricuspid valve were débrided. The patient was discharged, free of symptoms, on the 46th hospital day, after having received oxacillin intravenously for 42 days; warfarin therapy was continued.Five weeks after discharge, a low-grade fever developed, with occasional chest pain, cough, chilliness, sweats, and increasing dyspnea. Clarithromycin was ineffective in treating these symptoms, and after one week the patient returned to the hospital.Examination revealed that the temperature was 37.7°C. The jugular venous pressure was 10 cm, and crackles were heard at both lung bases. A grade 2 systolic murmur was transmitted from the apex to the axilla. The results of a urinalysis were normal. The urea nitrogen and creatinine levels were also normal. The results of other laboratory tests are shown in Tables 1 and 2.

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Bacterial endocarditis presenting as acute myocardial infarction: A cautionary note for the era of reperfusion

Cited by 52 publications

References 21 publications

Successful treatment of ST elevation myocardial infarction caused by septic embolus with the use of a thrombectomy catheter in infective endocarditis

Successful treatment of ST elevation myocardial infarction caused by septic embolus with the use of a thrombectomy catheter in infective endocarditis

Acute myocardial infarction caused by paradoxical tumorous embolism as a manifestation of hepatocarcinoma

Case 25-1998

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