Sudden death in infective endocarditis

Abstract

The case fatality rate of infective endocarditis (IE) is high and is associated with varying causes. Among them, acute myocardial infarction due to an embolism in a coronary artery is rare; the incidence of this complication in the setting of IE is reported to be up to 1.5%. We report a case of sudden death in a 22-year-old woman diagnosed with systemic lupus erythematosus who was referred to the Cardiology Center for the treatment of mitral valve incompetence due to IE. She was hemodynamically stable with antibiotic therapy and vasoactive drugs, despite severe mitral valve regurgitation. Unexpectedly, she presented cardiac arrest and died. The autopsy showed total occlusion of the left main coronary artery by septic embolus, which originated from the mitral vegetation, as the cause of death. Thus, although a rare complication, it should always be kept in mind that a coronary embolism can be a lethal complication of IE, and the possibility of surgical treatment combined with the underlying antibiotic therapy should be raised.

Fatal outcome in a case of infective endocarditis due to delay in diagnosis and the autopsy findings

“…Infective endocarditis is associated with a broad array of a complications; cardiac, neurologic, renal, musculoskeletal, and systemic complications related to the infection (embolization, metastatic infection, and aneurysm) [5,6]. Some autopsy case reports regarding causes of death, which are due to fatal complications, have previously been published [7,10,11,14]. In this case, although the patient did not have fatal complications which have been reported in past such cases, he subsequently died as a result of this uncontrollable infection.…”

“…Some autopsy case reports regarding causes of death have previously been published. These cases reported that the condition of patients with infective endocarditis worsened drastically, and they suddenly died from fatal complications, such as acute severe heart failure, cerebrovascular major embolism, and hemorrhage or acute coronary embolism [6][7][8][9][10][11][12][13]. In these cases, early diagnosis did not necessarily have an important role because of the unpredictable and relatively rare situation.…”

The Advancement of Postmortem Investigations in Sudden Cardiac Death

“…Histologically, the classic findings of vegetation in infective endocarditis are tissue infiltration of neutrophils and fibrin deposition along with the implicated bacteria can be identified using gram stain. In rare cases, a vegetative embolus may lodge in a coronary artery which can be the cause of SCD, in these circumstances the embolus has the same characteristic microscopic picture of the original vegetation [5]. The hearts of patients who suffered from arrhythmogenic right ventricular dysplasia exhibit microscopic features of fat infiltrating the myocardium, fibrofatty replacement along with patchy areas of myocarditis [18].…”

“…Infective endocarditis is another infectious cardiac disease which can induce SCD due to many causes. On gross examination of the heart, one can detect the presence of a vegetation on the infected valve, erosion of the underlying tissue, the chordae tendineae may be disrupted resulting in their rupture [5]. Congenital heart diseases occupy a high rank in the causes of SCD in children, with coarctation of the aorta (CoA) and transposition of the great vessels in the forefront [22].…”

“…Identifying patients at risk of SCD is the most challenging task clinicians often face, because the great majority of SCD victims who suffer from cardiac diseases are only discovered through postmortem microscopic and macroscopic examinations when the incident of sudden death has already occurred without the presence of any previous clinical manifestations [3]. The underlying cardiac causes of SCD include coronary artery diseases (CAD), valvular heart diseases, cardiomyopathy syndromes, infiltrative diseases of the myocardium, myocarditis, infective endocarditis, inherited ion channels defects and congenital heart diseases [4,5]. Epidemiologically, CAD is responsible for 80% of the cases of SCD, cardiomyopathies account for 10-15% of the cases, while 5-10% of SCD are caused by inherited cardiac disorders, such as coronary artery anomalies or cardiac channelopathies [6].…”