Managing embolic myocardial infarction in infective endocarditis: current options

Khan, Fida A.; Khakoo, Rashida; Failinger, Conard

doi:10.1016/j.jinf.2004.10.006

Cited by 50 publications

(43 citation statements)

References 15 publications

(14 reference statements)

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“…[4][5][6] It most often occurs with Streptococcus species and usually involves the LAD. 7 Acute MI from suspected septic embolism raises certain management concerns. The concerns with percutaneous coronary intervention (PCI) include stent infection from bacteremia, the generation of mycotic aneurysms at the dilation site, and difficulty performing angioplasty in a nonatherosclerotic artery.…”

Section: Discussionmentioning

confidence: 99%

Gemella Endocarditis Presenting as an ST-Segment-Elevation Myocardial Infarction

Winkler¹,

Chaudhry²,

Stockwell³

2016

Texas Heart Institute Journal

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Presenting as an ST-Segment-Elevation Myocardial InfarctionAcute myocardial infarction from septic embolization is a rare initial presentation of endocarditis. We report the case of a 67-year-old S eptic embolization causing an ST-segment-elevation myocardial infarction (STEMI) is a rare initial presentation of infective endocarditis (IE). We present a case of coronary embolization in a patient with undiagnosed IE. We review therapeutic options in this situation and highlight the importance of including endocarditis as a potential cause of acute myocardial infarction (MI). Case ReportIn October 2014, a 67-year-old man whose medical history included hypertension, hyperlipidemia, and diabetes mellitus presented at our emergency department with the chief report of sharp, nonradiating, substernal chest pain in association with nausea and diaphoresis.The patient's vital signs upon admission were a temperature of 37 °C, a heart rate of 110 beats/min, a blood pressure of 194/107 mmHg, and an oxygen saturation of 100% on room air. An electrocardiogram showed a right bundle branch block with anterolateral ST-segment elevations and reciprocal inferior ST-segment depressions. Laboratory results were notable for a white blood cell count of 13.3 ×10 9 /L, a creatinine level of 1.44 mg/dL, and a troponin level of 0.26 ng/mL. The patient was treated with aspirin, clopidogrel, and heparin. Emergency cardiac catheterization revealed a culprit 95% lesion at the bifurcation of the left anterior descending coronary artery (LAD) and first diagonal artery (Fig. 1). The catheterization was complicated by distal emboli to both vessels. The absence of substantial atherosclerotic plaque on angiography raised the possibility of coronary embolism.The next day, a transthoracic echocardiogram revealed a left ventricular ejection fraction of 0.30 to 0.35 and a 6 × 3.7-mm mobile, echodense structure attached to the mitral valve, consistent with vegetation (Fig. 2). The patient's hospital course was significant for persistent fevers, the initiation of antibiotic therapy, and blood cultures positive for Gemella. He was also given milrinone and diuretic agents as post-MI and heart-failure therapy. Before his discharge from the hospital after 21 days, a transesophageal echocardiogram showed a 3.3 × 2.2-mm vegetation on scallop A2 of the mitral valve with associated leaflet perforation and mild mitral regurgitation (Fig. 3). It was decided to treat the condition medically for 6 weeks. However, the patient returned to the hospital 15 days later and died within 2 days of severe heart failure and septic shock secondary to a central-line infection. DiscussionThis report describes what we think is the first instance of Gemella endocarditis initially presenting as acute anterior STEMI from coronary artery embolization.Septic coronary embolism was first established through autopsy studies in patients with IE.

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Section: Discussionmentioning

confidence: 99%

Gemella Endocarditis Presenting as an ST-Segment-Elevation Myocardial Infarction

Winkler¹,

Chaudhry²,

Stockwell³

2016

Texas Heart Institute Journal

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“…In a study by Manzano et al (3) incidence of ACS from coronary embolism in patient with infective endocarditis was 0.6%. The LAD is the most common location for coronary artery embolism from endocarditis (3)(4)(5). The vegetation of the mitral valve, particularly at the anterior mitral valve leaflet, has a higher chance of embolization to the coronary artery (4).…”

Section: Discussionmentioning

confidence: 99%

“…The use of thrombolytic is largely unfavorable given an increased risk of intracranial hemorrhage from coexisting cerebral septic embolism or mycotic aneurysms (7)(8)(9). Despite lack of direct comparison, PCI in this setting appears to be a preferred approach and considered to be safer than thrombolytic therapy (3)(4)(5)9). Catheter thrombectomy appears to be useful in this clinical setting (10).…”

Section: Discussionmentioning

confidence: 99%

Cardiac arrest and ventricular tachycardia from coronary embolism: an unusual presentation of infective endocarditis

Kitkungvan¹,

Denktaş²

2014

Anadolu Kardiyol Derg

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“…The prognosis is difficult to quantify, but there is CASE REPORT a clear trend towards excess mortality when compared to those without septic coronary embolism [4]. Virtually any described microorganism causing endocarditis may be involved but Streptococci are thought to be the most commonly isolated pathogen [5].…”

Section: Discussionmentioning

confidence: 99%

"The plug and the bug"- a case of coronary embolism in bacterial endocarditis

2014

Cardiovasc Med

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SummarySystemic embolism is a classic complication of infective endocarditis. Coronary involvement and acute myocardial infarction (MI) are rare and increase mortality significantly. Recognising this unusual entity is crucial to provide adequate care. Percutaneous coronary intervention and thrombus aspiration is preferred to thrombolysis, which classically increases intracerebral haemorrhage risk. The present article describes the case of an acute inferior ST-elevated MI due to a Streptococcus salivarius endocarditis in a patient with known bicuspid aortic valve.Key words: bacterial endocarditis; septic embolism; coronary embolism; myocardial infarct Case reportA 79 year-old female with prior history of hypertension and moderate aortic insufficiency due to bicuspid aortic valve presented to the emergency department with STelevation myocardial infarction (MI). She complained of acute retro-sternal chest pain and left arm radiation of 2 hours duration. T he presentation followed a one-month period of fatigue, weight-loss and progressive dyspnea. Physical examination revealed an acutely ill lady. Non invasive blood pressure was 150/60 mm Hg on both sides; pulse regular at 100 beats per minute; respiratory rate at 20/minute; saturation 97% under 2L/min oxygen and temperature was 37.9 °C. Significant signs were a rapid upstroke followed by quick collapse of peripheral pulses, an enlarged hyperdynamic cardiac apical impulse, a blowing pandiastolic decrescendo murmur in the left upper sternal border, a midsystolic ejection murmur with carotid radiation and no extra heart sounds. Pulmonary auscultation was consistent with bilateral basal crackles. Chest radiograph revealed a marked cardiomegaly and dilation of the aortic knob and root but no signs of widened mediastinum or pulmonary congestion. Troponin Ic was 0.35 ug/L, white blood cell count of 13.5 G/L with normal differential and a C-reactive protein of 60 mg/L, and the rest of the laboratory work-up was unremarkable.On arrival, the 12-lead electrocardiogram (ECG) showed normal sinus rhythm, first-degree atrioventricular block and a 2 mm ST-elevation in leads II, III avF, V5 and V6 ( fig. 1A). Therapy was initiated with aspirin 500 mg, heparin 5000 U and clopidogrel 600 mg. An urgent coronary angiography revealed the distal occlusion of a marginal branch of the circumflex artery but otherwise normal coronary arteries ( fig. 1B). The aortogram showed significant ascending aorta dilatation ( fig. 1C) as well as severe aortic valve regurgitation. The left ventricular ejection fraction was deemed normal with inferolateral hypokinesia. Considering the history and presentation, a septic embolus was thought to be the cause of the occlusion and, due to vessel tortuosity, distal lesion and spontaneous symptom alleviation no intravascular treatment was attempted. Peak troponin Ic was 12.3 ug/L and total CK 545 U/L. Four different peripheral blood cultures grew penicillin sensitive Streptococcus salivarius (minimum inhibitory concentration <0.125 mg/L). A trans-oesophageal ech...

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Managing embolic myocardial infarction in infective endocarditis: current options

Cited by 50 publications

References 15 publications

Gemella Endocarditis Presenting as an ST-Segment-Elevation Myocardial Infarction

Gemella Endocarditis Presenting as an ST-Segment-Elevation Myocardial Infarction

Cardiac arrest and ventricular tachycardia from coronary embolism: an unusual presentation of infective endocarditis

"The plug and the bug"- a case of coronary embolism in bacterial endocarditis

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