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

Abstract

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...

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

“…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). Percutaneous transluminal balloon angioplasty, though provide satisfactory result, it carries a risk of mycotic aneurysm at the balloon dilation site and reocclusion of the vessel (4-6).…”

Septic Embolism in Endocarditis: Anatomic and Pathophysiologic Considerations

“…First described in the 1910s and 1920s, septic coronary embolism continues to be under-recognized as a cause of acute coronary ischemia [56]. These types of emboli predominantly originate from bacterial valvular vegetations [61]. A high index of clinical suspicion is required because electrocardiographic (ECG) and laboratory changes characteristic of myocardial ischemia can easily be misinterpreted as being due to more typical coronary artery thrombosis [29].…”

Septic Embolism: A Potentially Devastating Complication of Infective Endocarditis

“…Coronary embolization from a septic focus has been relatively well reported in the literature [74,124] and usually originates from valvular vegetations in the setting of IE [125]. Septic coronary embolism has also been reported to occur intraoperatively during mitral valve surgery performed in the setting of IE [126].…”