Acute coronary embolism complicating bacterial endocarditis: operative treatment

Coronary Embolism and Myocardial Infarction: A Scoping Study

Coronary embolism is a cause of acute myocardial infarction (AMI)in which obstructive foci enter the coronary circulation, block normal blood flow and precipitate ischemia. Precise studies focusing on patient population affected, pathophysiological mechanisms, and treatment strategies are scanty, in spite of a reported prevalence estimated at 2.9%. As the understanding of myocardial infarction without evidence of coronary artery disease continues to grow, an in-depth review of this previously seldomly reported subtype of coronary ischemia was in order. Patients suffering coronary embolism are 15 to 20 years younger than traditional AMI patients with a slight predominance towards male sex, which resembles the gender data of the populations affected by non-traditional myocardial infarction in published reports. While the expected prevalence rate of cardiovascular disease risk factors such as hypertension and hyperlipidemia are present, this population also has a relatively high prevalence of atrial fibrillation and valve pathology, especially endocarditis. Initial presentation is indistinguishable from other causes of myocardial infarction however fever is commonly present, when endocarditis with valvular involvement is the primary cause of the coronary embolism. Mechanical thrombectomy is the mainstay of treatment, followed by percutaneous coronary intervention. Mortality is the highest in patients who do not receive targeted treatment for the coronary embolism, particularly if only antimicrobial agents or anticoagulation without thrombolytic agents are employed. The unique features of coronary embolism highlighted in this historical study justify further examination in contemporary patient populations.

Sudden death in infective endocarditis

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.

A Coronary Septic Embolism in Double Prosthetic Valve Endocarditis Presenting as Acute Anteroseptal ST-Segment-Elevation Myocardial Infarction

Acute myocardial infarction caused by septic embolism is usually fatal. A 40-year-old male patient who presented within 30 minutes of severe chest pain was admitted to the emergency department. An electrocardiogram showed a maximum 6 mm of acute ST elevations at V1-V4 derivations. His body temperature was as high as 38.5ºC. Blood cultures were taken three times before parenteral ampicillin/ sulbactam treatment was administered. Later, coagulase negative staphylococci (Methicillin Sensitive Staphylococcus epidermidis) were identified from his blood cultures. Coronary angiographic examination was performed. Lobulated contours of a septic embolus was shown in the mid region of left anterior descending artery as an outcome. Trans-esophageal echocardiography showed; mobile multiple vegetations on the prosthetic mitral and aorta valves. After six weeks of antibiotherapy, he was completely healed and discharged from hospital.Six months later, he was rehospitalized and died because of complications of recurrent infective endocarditis.

Coronary embolism complicating aortic valve endocarditis: Treatment with successful coronary angioplasty

A 59-year-old female was hospitalised with the diagnosis of infective endocarditis. On the fifth day of her antibiotic treatment, she experienced an anterior ST segment elevation myocardial infarction. Emergency transthoracic echocardiography showed that the vegetation on the aortic valve did not exist anymore. It was thought to be an embolic myocardial infarction. Primary percutaneous coronary intervention with conventional balloon angioplasty was performed. TIMI-3 flow was obtained after intervention. Antibiotic treatment was continued for 6 weeks. She was uneventful at the end of the 3-month follow-up.

Managing embolic myocardial infarction in infective endocarditis: current options

Systemic embolization is common in infective endocarditis and is known to occur in 45-65% of cases. Coronary artery embolism has been seen in as many as 60% of cases at necropsy. However, it only rarely has been described as resulting in transmural myocardial infarction. In most cases, coronary embolism is inferred from circumstantial evidence. We present two patients with myocardial infarction in the setting of acute infective endocarditis. Current issues regarding the management of myocardial infarction in infective endocarditis are described in this article. We also describe the first documented case of Lactobacillus jensenii endocarditis leading to myocardial infarction. Possible factors, which may be instrumental in producing endocarditis with this organism, are also discussed.

Acute myocardial infarction caused by coronary embolism complicated by left ventricular free wall rupture

Acute myocardial infarction with normal coronary arteries is a relatively infrequent finding. This report describes a rare combination of an embolic event to a normal coronary artery, presumably originating from a left atrial thrombus. An anomalous origin of the infarct-related coronary artery presumably enabled preferential penetration of the clot into the artery. The infarction was further complicated by rupture of the left ventricular free wall.

Coronary embolism complicating aortic valve endocarditis: treatment with placement of an intracoronary stent

A 37-year-old man, who had received 3 weeks of antimicrobial therapy for aortic value endocarditis, presented with an acute anteroseptal wall myocardial infarction. Coronary angiography demonstrated occlusion of the mid left anterior descending artery, thought to have been caused by embolization of a sterile vegetation. Following failure of balloon dilation to achieve vessel patency, this was achieved by placement of an intracoronary stent.

Fatal intracerebral hemorrhage following thrombolytic therapy of embolic myocardial infarction in unsuspected infective endocarditis

Cerebral hemorrhage occurs in 0.2% of patients under the age of 60 years treated with thrombolytic therapy for acute myocardial infarction. A case of fatal cerebral hemorrhage following TPA therapy for myocardial infarction due to probable coronary artery embolism during unsuspected native valve infective endocarditis is reported.

Coronary embolism by metastatic choriocarcinoma of the uterus: an unusual cause of ischemic heart disease

Although gestational choriocarcinoma is a rapidly invasive malignancy, metastatic invasion of this tumor to the heart is rare. We report an unusual case of coronary embolism, which was caused by malignant trophoblasts from choriocarcinoma in a 26-year-old woman. The woman presented with classic symptoms of ischemic heart disease after having successfully undergone chemotherapeutic treatment for choriocarcinoma several months earlier. Thus, she was thought to have coronary heart disease or to have developed cardiotoxicity from antineoplastic drugs. This is the first report of this type of metastatic localization and tumor involvement in the heart and underscores the need for suspecting isolated metastases in uncommon sites in patients with choriocarcinoma.

Coronary embolism causing myocardial infarction

Two cases of myocardial infarction due to coronary embolism arising from bacterial endocarditis are reported. The importance of this condition in the differential diagnosis of myocardial infarction from non-atheromatous coronary artery disease is highlighted and the literature on the subject is reviewed.

Electrocardiographic findings in infective endocarditis

Management of infective endocarditis includes early recognition of complications and prompt intervention when necessary to avert an untoward result. Among the most serious potential complications of this disorder are those that involve the heart itself. Although the ECG is often normal or nearly so in patients with endocarditis, at other times apparently minor abnormalities may be harbingers of potentially fatal complications. The ECG therefore plays an important role in the initial and ongoing evaluation of patients in whom endocarditis is suspected.