Managing embolic myocardial infarction in infective endocarditis: current options

Infective Endocarditis by Lactobacillus Species-A Narrative Review

Bacteria of the genus Lactobacillus are microaerophilic or aerotolerant anaerobic Gram-positive non-spore-forming rods. They are considered essential members of the human gut microbiome; however, recent studies have revealed that these microorganisms are less predominant in the gut microbiome than initially thought. Lactobacillus spp. is mainly known for its use as a probiotic in foods and supplements to prevent and treat specific issues such as infectious diseases, irritable bowel syndrome, and diabetes mellitus. However, Lactobacillus spp. may occasionally cause infections such as bacteremia or infective endocarditis (IE). The present study aimed to review all cases of IE by Lactobacillus spp. and describe the epidemiology, microbiology, clinical characteristics, treatment, and outcomes of this infection by collecting relevant data from studies existing in Pubmed and Scopus until 28 September 2023. A total of 77 studies containing data for 82 patients were included. The median age was 56 years, and 69.6% were male. A prosthetic valve was present in 16% of patients, and 17.3% had previously been on probiotics. The aortic valve was the most commonly involved intracardiac site, followed by the mitral valve. Fever, embolic phenomena, sepsis, and heart failure were the most common clinical presentations. Aminoglycosides and penicillin were the most commonly used antimicrobials for definitive treatment. Surgery was performed in 53.7% of patients. Overall mortality was 17.1%. IE in prosthetic valves and presentation with shock were independently associated with overall mortality.

When Enterococcus faecalis becomes a murderer

We describe the case of a 64 years old patient, known for an Enterococcus faecalis endocarditis on a 25 mm Edwards-Carpentier biological aortic valve in 2020, who was re-hospitalized one year later in cardiac surgery for a recurrence of Enterococcus faecalisbacteriemia. During hospitalization, the patient presented a cardiac arrest. The coronarography revealed an acute occlusion of the left coronary artery. The autopsy confirmed an Enterococcus faecalis thrombus on aortic valve and left coronary artery. Although systemic embolism is a common complication of infective endocarditis, septic embolism is an unsual cause of acute coronary syndrome and a very rare cause of cardiac arrest. Our case highlights a rare and potentially fatal complication of infective endocarditis: acute coronary syndrome on septic coronary embolism.

Polymicrobial bacteremia due to Lactobacillus jensenii and Veillonella montpellierensis in a pregnant patient; case report and review of literature

Prompt and accurate diagnosis of polymicrobial bacteremia, which causes the difficulty in anti-infective treatments, poor treatment outcome and high mortality, is essential for initiating effective antimicrobial therapy. Here we present a case of bacteremia caused by two types of uncommon bacteria, Lactobacillus jenseniand and Veillonella montpellierensis in a 29-year-old pregnant woman at 33 weeks of gestation with anemia due to iron deficiency. She had no comorbidity or other chronic illnesses and was successfully treated with appropriate antibiotic use.

Predictors of Complications Secondary to Infective Endocarditis and Their Associated Outcomes: A Large Cohort Study from the National Emergency Database (2016-2018)

INTRODUCTION

Literature regarding outcomes and predictors of complications secondary to infective endocarditis (IE) is limited. We aimed to study the outcomes and predictors of complications of IE.

METHODS

Data from a national emergency department sample, which constitutes 20% sample of hospital-owned emergency departments in the USA, were analyzed for hospital visits for IE. Complications of endocarditis were obtained by using ICD codes. Multivariable generalized linear method was used to evaluate predictors of in-hospital mortality and complications.

RESULTS

Out of 255,838 adult IE patients (mean age 60.3 ± 20.1 years, 48.5% females), 97,803 (38.2%) patients developed one or more major complications. The major complications were cardiovascular system complications [57,900 (22.6%)], neurologic [42,851 (16.7%)] complications, and renal [16,236 (6.4%)] complications. These included cardiogenic shock [3873 (1.5%)], septic shock [25,798 (10.1%)], acute heart failure [35,602 (14%)], systemic thromboembolism (STE) [21,390 (8.36%)], heart block [11,430 (4.47%)], in-hospital dialysis [2880 (1.1%)], and disseminated intravascular coagulation (DIC) [2704 (1.1%)]. Patients with complicated IE had risk of mortality (adjusted RR 1.12, 95% CI 1.11-1.13, p < 0.001). The complications strongly associated with mortality were septic shock (RR 1.29, 95% CI 1.27-1.30, p < 0.001), cardiogenic shock (RR 1.24, 95% CI 1.20-1.29, p < 0.001), DIC (RR 1.4, 95% CI 1.35-1.46, p < 0.001), and STE (RR 1.07, 95% CI 1.05-1.08, p < 0.001). Staphylococci were the predominant causative organisms (30.8%) among the complicated IE subgroups with higher associated mortality (42.8%). The main predictors of complications from IE were congenital heart disease, history of congestive heart failure, high Elixhauser comorbidity profile, staphylococcal infection, and fungal infections. The prevalence of cardiogenic shock increased over the study years from 1.13 to 1.98% (p-trend 0.04).

CONCLUSION

Complicated IE is not uncommon and is associated with significant mortality. Staphylococcal infections were associated with high mortality rates. There has been an increasing trend of cardiogenic shock among IE patients across the US. Further research is needed to improve the outcomes of complicated endocarditis.

Mitral Valve Infective Endocarditis Complicated With Coronary Artery Embolization

Infective endocarditis is a multisystem and potentially fatal disease. Systemic embolization is a relatively common complication, the spleen and central nervous system being the most frequent sites for septic emboli formation. Coronary artery septic embolization is extremely uncommon and its management remains controversial.

We present the case of a 50-year-old male diagnosed with mitral valve infective endocarditis complicated with spleen and central nervous system embolization, who developed acute myocardial infarction two weeks after disease onset. The patient was successfully treated with combined mitral valve replacement and coronary artery bypass grafting.

Acute myocardial infarction in a young patient with triple valve replacement

Rheumatic heart disease is an important cause of mortality and morbidity in developing countries, and is the leading cause of triple valve replacement. Myocardial infarction (MI) in such cases can be due to the coronary embolism from the prosthetic valves or due to atherosclerotic vascular disease. Intravascular imaging helps in delineating the cause. We present a case of a 34-year-old premenopausal woman with no conventional cardiovascular risk factors and had triple valve replacement 4 years ago and anterior wall MI with cardiogenic shock and left ventricular failure. She was managed with mechanical ventilation, thrombolysis, diuretics, double antiplatelets and anticoagulation with low molecular weight heparin. Intravascular ultrasound showed a lipid-rich plaque with associated plaque rupture and thrombosis. Intravascular imaging helps in delineating the cause of MI and further management. Atherosclerotic MI in a patient with no conventional risk factors is rare and needs to be considered.

Fatal Embolic ST-Elevation Myocardial Infarction Secondary to Healed-Phase Mitral Valve Infective Endocarditis

Embolic myocardial infarction (MI) caused by infective endocarditis (IE) is rare, but it is increasingly recognized as an important complication. This complication typically occurs in patients with aortic valve endocarditis during the acute phase of the infection. It is also known to have a high mortality rate; however, the best practice for its management is unclear owing to scarce available data. In addition, most cases of embolic acute MI (AMI) caused by IE are indirectly diagnosed with a combination of angiographic examination such as coronary angiography or cardiac computed tomography. Herein, we report a case of fatal embolic ST-elevation MI (STEMI) caused by mitral valve IE during the healed phase, which was clearly proven by the pathology findings.

ST-Segment Elevation Myocardial Infarction from Septic Emboli Secondary to Infective Endocarditis by Abiotrophia Defectiva

This article showcases a young patient who presented with STEMI secondary to septic emboli due to endocarditis with Abiotrophia Defectiva in the setting of a congenital bicuspid aortic valve. We aim to discuss current considerations for STEMI in young individuals including embolism due to IE, especially in patients with known or suspected congenital heart valve disease.

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.

Case of Acute ST Segment Elevation Myocardial Infarction in Infective Endocarditis-Management with Intra Coronary Stenting

Embolic events from infective endocarditis can cause acute coronary syndrome. Mortality rate is high and optimal management might be different from those chosen in setting of classic atherosclerotic coronary artery disease. We present a case of 56-year-old male who had received 5 weeks of antibiotics for aortic valve endocarditis and developed acute ST segment elevation myocardial infarction in hospital settings. Interestingly, patient had recent left heart catheterization that was normal. This was recognized as embolic event from sterile vegetation. Patient was managed with balloon angioplasty and placement of intracoronary stent. Following re-vascularization, patient chest pain and electrocardiogram normalized and he improved in short term. However due to multiple comorbidities he had to be intubated and placed on dialysis.

Gemella Endocarditis Presenting as an ST-Segment-Elevation Myocardial Infarction

Acute myocardial infarction from septic embolization is a rare initial presentation of endocarditis. We report the case of a 67-year-old man who presented with acute chest pain, in whom emergency cardiac catheterization revealed findings that suggested coronary embolism. The patient was found to have Gemella endocarditis, with its initial presentation an embolic acute ST-segment-elevation myocardial infarction. We suggest that endocarditis be considered among the potential causes of acute myocardial infarction.

Long-term clinical outcome of major adverse cardiac events in survivors of infective endocarditis: a nationwide population-based study

BACKGROUND

Substantial infective endocarditis (IE)-related morbidity and mortality may occur even after successful treatment. However, no previous study has explored long-term hard end points (ie, stroke, myocardial infarction, heart failure, cardiovascular death) in addition to all-cause mortality in IE survivors.

METHODS AND RESULTS

A nationwide population-based cohort study was conducted among IE survivors identified with the use of the Taiwan National Health Insurance Research Database during 2000 to 2009. IE survivors were defined as those who survived after discharge from first hospitalization with a diagnosis of IE. A total of 10 116 IE survivors were identified. IE survivors were matched to control subjects without IE at a 1:1 ratio through the use of propensity scores. The primary outcomes were stroke, myocardial infarction, readmission for heart failure, and sudden cardiac death or ventricular arrhythmia. The secondary outcomes were repeat IE and all-cause mortality. Compared with the matched cohort, IE survivors had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.59; 95% confidence interval [CI], 1.40-1.80), hemorrhagic stroke (aHR, 2.37; 95% CI, 1.90-2.96), myocardial infarction (aHR, 1.44; 95% CI, 1.17-1.79), readmission for heart failure (aHR, 2.24; 95% CI, 2.05-2.43), sudden death or ventricular arrhythmia (aHR, 1.69; 95% CI, 1.44-1.98), and all-cause death (aHR, 2.27; 95% CI, 2.14-2.40). Risk factors for repeat IE were older age, male sex, drug abuse, and valvular replacement after an initial episode of IE.

CONCLUSION

Despite treatment, the risk of long-term major adverse cardiac events was substantially increased in IE survivors.

Septic coronary artery embolism treated with aspiration thrombectomy: case report and review of literature

Coronary embolization is a potentially fatal sequela of endocarditis. We report a case of Candida endocarditis with septic embolism to the left anterior descending coronary artery. This embolism was successfully treated with aspiration thrombectomy followed by balloon angioplasty. The treatment of acute coronary syndrome in the presence of septic embolism is controversial. Aspiration thrombectomy has been performed in this situation before, and it appears to be safer and more feasible than is thrombolysis or percutaneous transluminal angioplasty.

Unusual cause of myocardial infarction and congestive heart failure in a patient with prosthetic valve endocarditis

In a patient with staphylococcus lugdunensis prosthetic aortic valve endocarditis and coronary septic embolism accompanied by antero-lateral myocardial infarction, embolic material was successfully aspirated from the bifurcation of the left anterior descending coronary artery and the first diagonal branch. A good angiographic result was documented six months thereafter when the patient presented with a second complication, pulsatile compression of the left main coronary artery by an abscess cavity originating between the aortic and mitral annulus, leading to congestive heart failure. The patient underwent successful surgical replacement of the aortic valve prosthesis with concomitant patch reconstruction of the annulus as well as tricuspid annuloplasty.

Infective endocarditis presenting as ST-elevation myocardial infarction: an angiographic diagnosis

While systemic embolic events occur with relative frequency in infective endocarditis (IE), coronary embolization remains an uncommon cause of ST elevation myocardial infarction. Herein we report a case of ventricular fibrillation and anterior ST elevation myocardial infarction occurring in a patient initially presenting with septic shock. Angiography proved diagnostic for IE of a native bicuspid aortic valve complicated by root abscess and left anterior descending artery occlusion. Histologic examination of the embolectomy specimen from the left anterior descending artery confirmed the presence of thrombus and bacteria. The present case highlights difficulties in identifying and managing patients with coronary embolism of vegetations from IE.

Successful treatment of ST elevation myocardial infarction caused by septic embolus with the use of a thrombectomy catheter in infective endocarditis

A 71-year-old patient suffered a transmural (ST elevation) myocardial infarction (MI) as a result of a septic embolus from an infected tissue aortic valve replacement. Following failed fibrinolysis, his MI was successfully treated with thrombectomy using an export catheter. He suffered bleeding complications following the administration of tenectaplase and required aortic valve and root replacement due to ongoing systemic embolisation.

Left ventricular pseudoaneurysm due to embolic myocardial infarction in infective endocarditis: real time three-dimensional transesophageal echocardiographic evaluation

We report a case of a 63-year-old woman who presented with infective endocarditis and developed a pseudoaneurysm (PA) of the left ventricle presumably as a result of an embolic infarct. The diagnosis was made by typical features of PA on tranesophageal echocardiography and color Doppler studies. In addition, three-dimensional transesophageal echocardiography showed the narrow neck of the PA. Findings were confirmed at surgery and she was discharged after successful repair.

Cardiac Rupture in Embolic Myocardial Infarction after Implantation of a Valved Aortic Conduit

We report a case of an apical myocardial infarction complicated by left ventricular wall rupture due to coronary artery embolism four years after surgery of an acute type A dissection of an aortic aneurysm with implantation of a valved aortic conduit.