External coronary artery compression due to prosthetic valve bacterial endocarditis

The pathogenicity and virulence of the opportunistic pathogen Staphylococcus epidermidis

The pervasive presence of Staphylococcus epidermidis and other coagulase-negative staphylococci on the skin and mucous membranes has long underpinned a casual disregard for the infection risk that these organisms pose to vulnerable patients in healthcare settings. Prior to the recognition of biofilm as an important virulence determinant in S. epidermidis, isolation of this microorganism in diagnostic specimens was often overlooked as clinically insignificant with potential delays in diagnosis and onset of appropriate treatment, contributing to the establishment of chronic infection and increased morbidity or mortality. While impressive progress has been made in our understanding of biofilm mechanisms in this important opportunistic pathogen, research into other virulence determinants has lagged S. aureus. In this review, the broader virulence potential of S. epidermidis including biofilm, toxins, proteases, immune evasion strategies and antibiotic resistance mechanisms is surveyed, together with current and future approaches for improved therapeutic interventions.

Unusual Case of Acute Coronary Syndrome Due to Compression of the Left Main Coronary Artery From a Contained Aortic Root Perforation

We present an intriguing and rare case of a 71-year-old male who presented with a non-ST elevation myocardial infarction (NSTEMI). Initial coronary angiography revealed severe and unusual systolic extrinsic compression of the left main coronary artery (LM), warranting further advanced imaging investigations. Computed tomography angiography (CTA) and transesophageal echocardiography (TEE) were employed to determine the underlying cause, which was identified as a contained aortic rupture leading to the formation of a pseudoaneurysm in the left coronary sinus of Valsalva and aortic root. This condition was found to be a sequela of previously undiagnosed endocarditis, likely secondary to lower extremity osteomyelitis and bacteremia, for which the patient received prolonged intravenous (IV) antibiotic therapy. This case highlights the critical role advanced imaging techniques play in accurately diagnosing and characterizing complex cardiovascular abnormalities, enabling early intervention and optimizing patient outcomes. Healthcare providers should remain vigilant for such atypical presentations to ensure timely and appropriate management.

Acute Coronary Syndrome with Non-ruptured Plaques (NONRUPLA): Novel Ideas and Perspectives

PURPOSE OF REVIEW

In this review article, we focus on the mechanisms and features of acute coronary syndromes (ACS) with no ruptured plaque (NONRUPLA) highlighting the uncertainties over diagnostic evaluation and treatment.

RECENT FINDINGS

The most common cause of ACS is obstruction due to atherosclerotic plaque ruptured or erosion. In 14% of patients who present in the Emergency Department as myocardial infarction, the final diagnosis is ACS with NONRUPLA. Although the clinical presentation of NONRUPLA may mimic myocardial infarction, the underlying pathogenesis is different, and it may guide therapeutic approaches and overall prognosis that vary according to etiology. The possible mechanisms of ACS with NONRUPLA are coronary embolism, acute dissection of the aorta or coronary artery, vasospasm, microvascular dysfunction, the imbalance between oxygen demand and supply, coronary trauma and stent complications, direct cellular toxicity and damage, Takotsubo syndrome, and myocardial infarction with non-obstructive coronary arteries (MINOCA).

Coronary Embolism: A Systematic Review

BACKGROUND

Coronary embolism is a rare and potentially fatal phenomenon that occurs primarily in patients with valvular heart disease and atrial fibrillation. There is a lack of consensus regarding the diagnosis, treatment, and management of coronary embolism, leaving management at the discretion of the treating physician. Through this review, we aim to establish a better understanding of coronary embolism, and to identify treatment options - invasive and non-invasive - that may be used to manage coronary embolism.

METHODS AND RESULTS

Our systematic review included 147 documented cases of coronary embolism from case reports and case series. The average age of our population was 54.2 ± 17.6 years. The most common causes of coronary embolism included infective endocarditis (22.4%), atrial fibrillation (17.0%), and prosthetic heart valve thrombosis (16.3%). Initial presentation was indistinguishable from an acute coronary syndrome (ACS) due to coronary atherosclerosis, and the diagnosis required a high level of suspicion and evaluation with angiography. Treatment strategies included, but were not limited to, thrombectomy, thrombolysis, balloon angioplasty and stent placement. Myocardial dysfunction on echocardiography was observed in over 80% of patients following coronary embolism. "Good outcomes" were reported in 68.7% of case reports and case series, with a mortality rate of 12.9%.

CONCLUSION

Coronary embolism is an under-recognized etiology of myocardial infarction with the potential for significant morbidity and mortality. To improve outcomes, physicians should strive for early diagnosis and intervention based on the underlying etiology. Thrombectomy may be considered with the goal of rapid restoration of coronary flow.

Myocardial ischaemia as a result of external coronary compression from infective aortic root aneurysm: atypical presentation of prosthetic valve endocarditis

This case describes an unusual presentation of prosthetic valve endocarditis (PVE): an acute coronary syndrome. A 67-year-old male presented with cardiac sounding chest pain on a background of a short history of night sweats, weight loss and general malaise. Four months previously, he had undergone bio-prosthetic aortic valve replacement for severe aortic stenosis and single vessel bypass grafting of the obtuse marginal. Whilst having chest pain, his ECG showed infero-lateral ST depression. Early coronary angiography revealed a new right coronary artery (RCA) lesion that was not present prior to his cardiac surgery. Using multi-modality cardiac imaging, the diagnosis of PVE was made. An aortic root abscess was demonstrated that was causing external compression of the RCA.

Primary percutaneous coronary intervention during ST elevation myocardial infarction in prosthetic valve endocarditis: a case report

Background

Infective endocarditis (IE) is still a condition with high mortality and morbidity, especially in the elderly, and in patients with prosthetic valves. The concept of “time-to-therapy” plays a key role for the prompt management of IE and related complications, and the currently available multimodality imaging may play a key role in this setting. Myocardial ischemia due to extrinsic coronary compression from an aortic abscess is an extremely rare condition where the optimal therapeutic strategy has not been defined yet. We present herein the first case of a patient with ST elevation myocardial infarction caused by an aortic root abscess treated with percutaneous stent implantation.

Case presentation

An 82-year-old woman with a history of atrial fibrillation, chronic renal failure, anemia and a bioprosthetic aortic valve replacement performed in 2014, was admitted to hospital with profound asthenia and a pyrexia of unknown origin. Because of high clinical suspicion of endocarditis, a trans-esophageal echocardiogram was performed. Empirical broad-spectrum antimicrobial therapy was initiated, followed by targeted treatment based on the results of blood cultures (Staphylococcus aureus). The echocardiogram did not show vegetations and the patient was managed conservatively. She suddenly deteriorated, due to an acute coronary syndrome (ACS) with anterior ST segment elevation. An urgent angiogram was performed, and extrinsic compression of the left coronary system, due to an aortic root abscess, was suspected. After discussion with the surgical team, percutaneous revascularization was attempted, aiming to restore satisfactory hemodynamics, in order to plan surgery. Unfortunately, the patient rapidly developed cardiogenic shock, with multi organ failure, and died in less than 24 h.

Conclusions

Patients with fever, and significant risk factors for endocarditis, who develop ACS, need a prompt diagnostic work up, including trans-esophageal echocardiography. At present, the specific timing of echocardiographic follow-up and surgical intervention is still a matter of debate, and our case aims to highlight the importance of this aspect in the management of endocarditis, in order to avoid severe complications that adversely affect patient prognosis.

Electronic supplementary material

The online version of this article (10.1186/s12872-018-0750-3) contains supplementary material, which is available to authorized users.

Unusual mechanism of myocardial infarction in prosthetic valve endocarditis

A 46-year-old man with bicuspid aortic valve and severe calcific aortic stenosis was submitted to aortic valve replacement with a stented bioprosthesis. He developed Staphylococcus epidermidis prosthetic valve endocarditis a month later, presenting in the emergency room with acute myocardial infarction. The mechanism of myocardial ischemia was a large aortic root abscess causing left main extrinsic compression. He was urgently taken to the operating room, and an aortic root replacement with cryopreserved homograft was performed, associated with autologous pericardium patch closure of aortic to right atrium fistula and coronary artery bypass grafting of the left anterior descending. After a difficult postoperative period with multiple problems, he was eventually discharged home. At 36-month follow-up, he is asymptomatic with no recurrent infection, and the left main coronary artery is widely patent on control chest computed tomography.

Aortic valve endocarditis complicated by ST-elevation myocardial infarction

Infective endocarditis complicated by abscess formation and coronary artery compression is a rare clinical event with a high mortality rate, and diagnosis requires a heightened degree of suspicion. We present the clinical, angiographic, and echocardiographic features of a 73-year-old woman who presented with dyspnea and was found to have right coronary artery compression that was secondary to abscess formation resulting from diffuse infectious endocarditis. We discuss the patient's case and briefly review the relevant medical literature. To our knowledge, this is the first reported case of abscess formation involving a native aortic valve and the right coronary artery.