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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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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:

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.

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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
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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.
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