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Reviews in Cardiovascular Medicine  2019, Vol. 20 Issue (1): 35-39     DOI: 10.31083/j.rcm.2019.01.4241
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Infective Endocarditis complicated with Coronary Artery Septic Embolization: Is It Worth to Be Mentioned? Case Presentation and Review of the Literature
Miklós Bitay1, *(), Sándor Varga1, Barna Babik2, Kálmán Havasi3, Tamás Szücsborus4
1 Faculty of Medicine, Second Department of Medicine and Cardiology Center, Department of Cardiac Surgery, Albert Szent-Györgyi Clinical Centre, University of Szeged, 8 Semmelweis Str 6725 Szeged, Hungary
2 Faculty of Medicine, Department of Anaesthesiology and Intensive Therapy, Albert Szent-Györgyi Clinical Centre, University of Szeged, 8 Semmelweis Str 6725 Szeged, Hungary
3 Faculty of Medicine, Second Department of Medicine and Cardiology Center, Department of Cardiology, Albert Szent-Györgyi Clinical Centre, University of Szeged, 8 Semmelweis Str 6725 Szeged, Hungary
4 Faculty of Medicine, Second Department of Medicine and Cardiology Center, Department of Interventional Cardiology, Albert Szent-Györgyi Clinical Centre, University of Szeged, 8 Semmelweis Str 6725 Szeged, Hungary
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Abstract:

Coronary artery septic embolization is a rare, but severe complication of infective endocarditis involving the leftside of the valves. The first case mentioned in the literature was a postmortem finding of a left anterior descending coronary artery occlusion by a vegetation fragment. Since this case, there have been several therapeutic strategies published with this clinical setting including medical treatment, percutaneous coronary angioplasty addressing coronary occlusion, surgical intervention for both the infected valve and coronary embolization, and hybrid procedures with transcatheter septic embolus aspiration followed by surgical valvular interventions. Out of the three interventions mentioned, the latter provided the best results and was in concordance with results observed in a case of mitral valve infected endocarditis complicated with acute occlusion of the left anterior descending coronary artery in patient whose comorbidities included hypertrophic obstructive cardiomyopathy. A transcatheter left anterior descending coronary artery embolus aspiration was performed , followed by a surgical mitral valve replacement and septal myectomy with an uneventful postoperative course. Although rare, this severe complication of infective endocarditis has a specific clinical course and therapeutic strategy, and in our opinion, it could be mentioned as a separate entity among embolic complications of infective endocarditis in future guidelines. Previously published cases suggest that the hybrid intervention might be the therapy of choice for this clinical setting; however, larger studies are necessary for confirmation.

Key words:  Coronary artery septic embolization      infective endocarditis      hybrid approach      infective endocarditis guidelines     
Published:  30 March 2019     
*Corresponding Author(s):  Miklós Bitay     E-mail:  mbitay@gmail.com

Cite this article: 

Miklós Bitay, Sándor Varga, Barna Babik, Kálmán Havasi, Tamás Szücsborus. Infective Endocarditis complicated with Coronary Artery Septic Embolization: Is It Worth to Be Mentioned? Case Presentation and Review of the Literature. Reviews in Cardiovascular Medicine, 2019, 20(1): 35-39.

URL: 

https://rcm.imrpress.com/EN/10.31083/j.rcm.2019.01.4241     OR     https://rcm.imrpress.com/EN/Y2019/V20/I1/35

Fig 1.  Preoperative TEE demonstrates mobile vegetations on both the anterior and posterior mitral leaflets (left white arrow: vegetation on the anterior mitral leaflet), along with a vegetation on the subaortic interventricular septum (left black arrow, right white arrow).

Fig 2.  ECG during chest pain: significant ST segment elevation in V1-V4 (STEMI)

Fig 3.  Coronary angiography showing the proximally occluded LAD.

Fig 4.  Coronary angiography after embolus aspiration. The flow in the LAD is reestablished.

Fig 5.  Surgical intervention showing the septal myectomy step.

Fig 6.  Infective endocarditis of the mitral valve (HE, 6x). Bacterial clouds, fibrin activation and valve necrosis.

Fig 7.  Aspirated embolus (HE, 40x), showing neutrophil granulocytes embedded in fibrin.

Fig 8.  Postoperative transthoracic echocardiography which demonstrated a significantly reduced subvalvular peak gradient.

Table 1  Studies on larger patient cohorts show a low incidence of coronary septic embolization in infective endocarditis, even among patients with embolic events.
Author Number of patients Number of CASE Incidence (%) Incidence among systemic embolization (%)
Thuny et al., 2005 384 2 0.52 1.5
Fabri et al., 2006 629 2 0.31 3.5
Manzano et al., 2007 586 3 0.51 No data
Baddour, L. M., Wilson, W. R., Bayer, A. S., FowlerJr, V. G., Tleyjeh, I. M., Rybak, M. J., Barsic, B., Lockhart, P. B., Gewitz, M. H., Levison, M. E., Bolger, A. F., Steckelberg, J. M., Baltimore, R. S., Fink, A. M., O'Gara, P., and Taubert, K. A . and on behalf of the American Heart Association Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and Stroke Council. ( 2015) Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications. a scientific statement for healthcare professionals from the American Heart Association. Circulation 132, 1435-1486.
doi: 10.1161/CIR.0000000000000296
Baek, M. J., Kim, H. K. Yu, C. W., Na, C. Y . ( 2008) Mitral valve surgery with surgical embolectomy for mitral valve endocarditis complicated by septic coronary embolism. European Journal Cardiothoracic Surgery 33, 116-118.
doi: 10.1016/j.ejcts.2007.09.024
Brunson, J. G . ( 1953) Coronary embolism in bacterial endocarditis. American Journal of Pathology 29, 689-701.
doi: 10.1002/path.1700670239 pmid: 13065415
Fabri, J. J., Issa, V. S., Pomerantzeff, P. M. A., Grinberg, M., Barretto, A. C. P., Mansur, A. J . ( 2006) Time-related distribution, risk factors and prognostic influence of embolism in patients with left-sided infective endocarditis. International Journal of Cardiology 110, 334-339.
doi: 10.1016/j.ijcard.2005.07.016
Fiedler, A. G., Schutt, R. C., David, G., James, S., Sundt, T. M., Rahul, S . ( 2017) Hybrid approach to the management of infective endocarditis complicated by coronary artery embolism: a case report. Journal of Surgical Case Report 6, 1-3.
doi: 10.1093/jscr/rjx110 pmid: 5491801
Habib, G., Lancellotti, P., Antunes, M. J., Bongiorni, M. G., Zamorano, J. L . ( 2015) 2015 ESC Guidelines for the management of infective endocarditis: the task force for the management of infective endocarditis of the european society of cardiology (ESC) endorsed by: european association for cardio-thoracic surgery (EACTS), the European Association of Nuclear Medicine (EANM). European Heart Journal 36, 3075-3128.
doi: 10.1093/eurheartj/ehv319
Manzano, M. C., Vilacosta, I., San Román, J. A., Aragoncillo, P., Sarriá, C., López, D., López, J., Revilla, A., Manchado, R., Hernández, R., Rodríguez, E . ( 2007) Acute coronary syndrome in infective endocarditis. Revista Espanola de Cardiologia 60, 24-31. (In Spanish)
doi: 10.1157/13097922
Hunter, A. J., Girard, D. E . ( 2001) Thrombolytics in infectious endocarditis associated myocardial infarction. Journal of Emergency Medicine 21, 401-406.
doi: 10.1016/S0736-4679(01)00416-4
Maqsood, K., Sarwar, N., Eftekhari, H., Lotfi, A . ( 2014) Septic coronary artery embolism treated with aspiration thrombectomy: case report and review of literature. Texas Heart Institute Journal 41, 437-439.
doi: 10.14503/THIJ-13-3386
Menzies, C. J. G . ( 1961) Coronary embolism with infarction in bacterial endocarditis. British Heart Journal 23, 464-468.
doi: 10.1136/hrt.23.4.464
Mohananey, D., Mohadjer, A., Pettersson, G., Navia, J., Gordon, S., Shrestha, N., Grimm, R. A., Rodriguez, L. L., Griffin, B. P., Desai, M. Y . ( 2018) Association of vegetation size with embolic risk in patients with infective endocarditis: a systematic review and meta-analysis. Journal of the American Medical Association, Internal Medicine 178, 502-510.
Perera, R., Noack, S., Dong, W . ( 2000). Acute myocardial infarction due to septic coronary embolism. New England Journal of Medicine 342, 977-978.
doi: 10.1056/NEJM200003303421315 pmid: 10744494
Thuny, F., Di Salvo, G., Belliard, O., Avierinos, J. F., Pergola, V., Rosenberg, V., Casalta, J. P., Gouvernet, J., Derumeaux, G., Iarussi, D., Ambrosi, P., Calabró, R., Riberi, A., Collart, F., Metras, D . ( 2005) Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation 112, 69-75.
doi: 10.1161/CIRCULATIONAHA.104.493155
[1] Grigore Tinica, Andrei Tarus, Mihai Enache, Bogdan Artene, Iulian Rotaru, Alberto Bacusca, Alexandru Burlacu. Infective endocarditis after TAVI: a meta-analysis and systematic review of epidemiology, risk factors and clinical consequences[J]. Reviews in Cardiovascular Medicine, 2020, 21(2): 263-274.
[2] Akanksha Agrawal, Hafeez Ul Hassan Virk, Iqra Riaz, Deepanshu Jain, Byomesh Tripathi, Chayakrit Krittanawong, Benham Bozorgnia, Vincent Figueredo, Peter A. McCullough, Janani Rangaswami. Predictors of 30-day re-admissions in patients with infective endocarditis: a national population based cohort study[J]. Reviews in Cardiovascular Medicine, 2020, 21(1): 123-127.
[3] Bhaskar Bhardwaj, Udit B. Bhatnagar, Darcy G. Conaway. An Unusual Presentation of Native Valve Endocarditis Caused by Staphylococcus warneri[J]. Reviews in Cardiovascular Medicine, 2016, 17(3-4): 140-143.
[4] Todd L. Kiefer, Thomas M. Bashore. Infective Endocarditis: A Comprehensive Overview[J]. Reviews in Cardiovascular Medicine, 2012, 13(2-3): 105-120.
[5] Davinder S. Jassal, Arthur E. Weyman. Infective Endocarditis in the Era of Intracardiac Devices: An Echocardiographic Perspective[J]. Reviews in Cardiovascular Medicine, 2006, 7(3): 119-129.
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