Coronary Artery Embolism from Large Aortic Valve Vegetation due to Staphylococcus aureus Endocarditis

Journal of General Internal Medicine, Dec 2016

Aman M. Shah MD, Ricardo A. Bello MD, PhD, Benjamin T. Galen MD

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Coronary Artery Embolism from Large Aortic Valve Vegetation due to Staphylococcus aureus Endocarditis

Coronary Artery Embolism from Large Aortic Valve Vegetation due to Staphylococcus aureus Endocarditis Aman M. Shah 1 3 Ricardo A. Bello 1 2 Benjamin T. Galen ) 0 1 0 Department of Internal 1 Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Division of Hospital Medicine , Bronx, NY , USA 2 Heart and Vascular Center, University of Massachusetts Memorial Medical Center , Worcester, MA , USA 3 Department of Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Division of Cardiovascular Medicine , Bronx Compliance with Ethical Standards: - 46-year-old man with a history of intravenous drug use presented with 5 days of fever as high as 102°F. He was ill-appearing, tachycardic, and without a heart murmur. Labs revealed marked leukocytosis and elevated troponin-T to 1.31 ng/ml (0.00–0.10 ng/ml), and blood cultures grew methicillinsusceptible Staphylococcus aureus 12 h after collection. Transthoracic echocardiogram showed a 4-cm mobile vegetation on the aortic valve. Troponin-T peaked the next day at 4.83 ng/ml, and while he remained free of chest pain, EKG revealed new ST-segment elevations in the anterolateral leads concerning for an acute coronary syndrome. Coronary angiogram identified 100% occlusion of both the distal left anterior descending artery (LAD) and the second diagonal branch of the LAD, consistent with coronary artery emboli (Fig. 1). The Figure 1 Coronary angiography with distal LAD (red arrow) and second diagonal branch total occlusions (black arrow). Figure 2 Aortic valve vegetations (red arrows) and perforation (black arrow). patient underwent aortic valve replacement and a one-vessel LAD bypass. A perforated aortic valve leaflet and multiple vegetations were seen on gross examination (Fig. 2). He was treated with intravenous cefazolin for 4 weeks. The complications of left-sided endocarditis can be fatal. Surgery may be required in cases of persistent bacteremia or septic embolization.1 Embolism of a vegetation to the coronary arteries is rare. Treatment options include thrombectomy, angioplasty with stenting, and bypass surgery.2,3 Conflict of Interest: The authors declare that they have no conflict of interest and have no financial disclosures to report. 1. Baddour LM , Wilson WR , Bayer AS , et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association . Circulation. 2015 ; 132 : 1435 - 86 . 2. Glazier JJ , McGinnity JG , Spears JR . Coronary embolism complicating aortic valve endocarditis: treatment with placement of an intracoronary stent . Clin Cardiol . 1997 ; 20 ( 10 ): 885 - 8 . 3. Maqsood K , Sarwar N , Efekhari H , Lotfi A. Septic coronary artery embolism treated with aspiration thrombectomy: case report and review of literature . Tex Heart Inst J . 2014 ; 41 ( 4 ): 437 - 9 .


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Aman M. Shah MD, Ricardo A. Bello MD, PhD, Benjamin T. Galen MD. Coronary Artery Embolism from Large Aortic Valve Vegetation due to Staphylococcus aureus Endocarditis, Journal of General Internal Medicine, 2017, 582, DOI: 10.1007/s11606-016-3935-4