Coronary artery thromboembolism as a cause of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Acute myocardial infarction (AMI) usually represents the clinical manifestation of atherothrombotic coronary artery disease (CAD) resulting from atherosclerotic plaque rupture. However, there are cases in which coronary angiography or coronary computed tomography angiography reveals patients with acute coronary syndrome with non-obstructive CAD. This clinical entity is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA) and often considered as a clinical dynamic working diagnosis that needs further investigations for the establishment of a final etiologic diagnosis. The main causes of a MINOCA working diagnosis include atherosclerotic, non-atherosclerotic (vessel-related and non-vessel-related), and thromboembolic causes This literature review aimed to investigate the major thromboembolic causes in patients presenting with MINOCA regarding their etiology and pathophysiologic mechanisms, as well as diagnostic and treatment methods.

Coronary artery embolism and acute coronary syndrome: A critical appraisal of existing data

The occurrence of coronary artery embolism (CE) has been associated with various clinical conditions, including aortic and mitral prosthetic heart valve implantation, atrial fibrillation (AF), dilated cardiomyopathy, neoplasia, infective endocarditis, atrial septal defect, cardiac tumors, and hypercoagulable states. CE is also a rare cause of myocardial infarction (MI), with a prevalence of about 5%, a figure probably underestimated. The purpose of this article was to determine the current state of knowledge on acute coronary syndrome (ACS) related to CE. We thus performed a comprehensive structured literature search of the MEDLINE database for articles published between 1 January 1990 and 31 December 2021. The diagnosis of CE remains difficult despite the currently used Shibata classification, which is based on major criteria, including angiographic characteristics: globular filling defects, saddle thrombi or multiple filling defects and absence of atherosclerosis in the coronary arteries. Suspected or confirmed CE requires the identification of an etiology. There are only two published series on CE, including about 50 cases each. The three main causes in these series were: 1) atrial fibrillation (73% vs 28.3%), 2) cardiomyopathy (9.4% vs 25%) and 3) malignancy (9.6% vs 15.1%). Finally, 26.3% of the MI patients with CE had no identifiable cause of CE. When anatomically possible, analyzing the thrombus after thrombectomy may help. MI due to CE requires systematic assessment of other locations, i.e. multiple coronary and extracardiac locations. Simultaneous systemic embolization to the brain (67%), limbs (25%), kidneys (25%) or spleen (4%) is frequent, occurring in approximately 25% of CE-related MI. In the setting of acute MI, CE is associated with significant morbidity and mortality. Coronary artery thromboembolism is a rare, non-atherosclerotic, cause of ACS, and prospective studies are needed to evaluate a systematic diagnostic approach and personalized therapeutic strategies.

Perioperative Complications in Infective Endocarditis

Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.

Myocardial infarction due to septic thromboembolism in chronic rheumatic heart disease

Chronic rheumatic heart disease (RHD) is the most troublesome complication of rheumatic fever. Extensive valvular scarring and ventricular remodeling due to pressure and volume overload occur in chronic RHD. Deformed valves are at potential risk for developing infective endocarditis (IE) with further systemic embolism. We hereby describe a case of a patient diagnosed with chronic rheumatic heart disease and severe ventricular dysfunction, planned for aortic valve replacement. The patient developed septic shock during a hospital stay. The autopsy revealed infective endocarditis in the aortic valve with septic thromboembolism in the peripheral branches of the coronary artery and early multifocal myocardial infarction changes.

Outcomes of Cardiac Arrest with Valve Surgery Among Infective Endocarditis Patients: A United States National Cohort Study

OBJECTIVE

Cardiac arrest can complicate infective endocarditis (IE) and is associated with significant in-hospital complications and mortality rates. We report the characteristics, outcomes, and readmission rates for IE patients with cardiac arrest in the United States.

METHODS

We surveyed the Nationwide Readmission Database (NRD), a database designed to support national level readmission analyses, for patients admitted with IE and who had cardiac arrest during index admission between 2016 and 2019. Baseline demographics, comorbidities, surgical procedures, and outcomes were identified using their respective International Classification of Diseases (ICD) codes.

RESULTS

There were 663 index admissions (mean age 55.87 ± 17.21 years;34.2 % females) for IE with cardiac arrest in the study period, with an overall mortality rate of 55.3 %. Of these, 270 (40.7 %) had surgical procedures performed during the hospitalization encounter. In patients who had a surgical procedure, 72 (26.8 %) patients had in-hospital mortality while 293 (74.9 %) patients without surgical procedures had in-hospital mortality (p < 0.001). After coarsened matching for baseline characteristics, surgical valve procedures were less likely to be associated with mortality (OR = 0.09, 95%CI 0.04-0.24; p < 0.001). Among the 295 alive discharges associated with cardiac arrest, 76 (38.57 %) were readmitted within 30-days, with a mortality rate of 22 % noted for readmissions.

CONCLUSION

Among IE patients who had cardiac arrest, surgical procedures subgroup had low mortality despite having higher complication rates. However, due to chances of bias more randomized trials are needed evaluate the hypothesis.

Dialysis catheter-related sepsis resulted in infective endocarditis, septic pulmonary embolism and acute inferolateral STEMI: a case report

Background

Embolic myocardial infarction is an uncommon but increasingly recognized complication of infective endocarditis (IE). Although the incidence is low and ranges from 1% to 10%, the mortality rate is high (64%). The characteristics of septic embolism on presentation are nonspecific and usually are unrecognized by clinicians. This case report aims to build a high index of suspicion among clinicians for IE presenting with the complication of embolic myocardial infarction especially in patients with indwelling venous catheters.

Case Summary

A 62-year-old woman with end-stage renal disease on haemodialysis presented with shortness of breath and desaturation. Her history was significant for end-stage renal disease managed with regular haemodialysis by a right-sided double-lumen tunnelled catheter. An initial diagnosis was made of pulmonary embolism, and management with intravenous heparin was initiated. She subsequently developed inferolateral ST-elevation myocardial infarction, and treatment with percutaneous coronary intervention to the posterior descending artery failed. Then, the patient developed complete heart block, aortic valve vegetation, acute severe aortic regurgitation, and shock.

Discussion

Acute coronary syndrome is usually an early and uncommon complication of IE and the risk of embolism decreases after antibiotic therapy is initiated. Due to the low incidence of coronary events in IE, only case reports have been published. Most patients with septic pulmonary embolism have a presentation similar to that for pneumonia. The diagnosis is therefore often delayed, which consequently influences prognosis. Our case report presents an example of IE-related multiple systemic embolization with poor patient outcome due to delayed diagnosis.

Acute coronary syndrome complicating infective endocarditis: A case report with an etiological review

Introduction

Acute coronary syndrome (ACS) is an uncommon complication associated with high mortality in patients with endocarditis. It requires prompt and appropriate management to cure the patient.

Cases presentation

We report the case of a 52-year-old patient, initially admitted for an acute non-ST-segment elevation coronary syndrome at very high ischemic risk, in whom coronary exploration was negative, and whose echocardiography showed a mobile image on the aortic valve, suggesting infective endocarditis. The patient benefited from an aortic valve replacement because of the size and the embolic complications he presented, with a favorable evolution.

Discussion

Acute coronary syndrome during infective endocarditis is a rare complication with a high mortality rate. Several mechanisms are possible: the embolic mechanism, coronary extraluminal compression due to coronary mycotic aneurysm and obstruction of the coronary ostium by a large vegetation. The management remains multidisciplinary and personalized according to the phenotype of the patient, with the need to have the endocarditis team to be able to take the best therapeutic choice.

Conclusion

Infective endocarditis must be evoked in any patient without usual cardiovascular risk factors who presents with an ACS that is accompanied by fever and elevated inflammatory markers, and a thorough clinical examination as well as the performance of additional tests.

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Acute coronary syndrome (ACS) is an uncommon complication associated with high mortality in patients with endocarditis.

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Our case presents a diagnostic challenge in the face of an initial misleading clinical presentation evoking ACS in a patient finally diagnosed with infective endocarditis.

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The management of endocarditis remains multidisciplinary, between cardiologist, infectiologist, radiologist, resuscitator and heart surgeons.

Percutaneous management of septic left anterior descending coronary occlusion following minimally invasive surgery for mitral valve infective endocarditis

Coronary artery embolization is an unusual complication following infective endocarditis (IE) surgery. A 43 year-old woman developed an anterior STEMI with acute left anterior descending artery occlusion during due to septic emboli during the immediate postoperative period following minimally invasive mitral valve repair for IE. It was successfully treated with thromboaspiration and balloon angioplasty. Coronary septic emboli should be part of the differential diagnosis in patients presenting with STEMI during the early post-operative period for IE.

Human bite wounds as a portal of entry for infective endocarditis and purulent pericarditis: a very rare association

Human bites are an infrequent cause of emergency department visits and hospital admissions. There are rarely published cases of complicated infection, such as infective endocarditis. We present a rare case of a patient with acute infective endocarditis in a healthy native valve and purulent pericarditis from a human bite. A 40-year-old man with obesity suffered deep human bites by an adult woman, with two deep lesions in the anterior thorax and one superficial lesion in the upper abdomen and admitted in intensive care unit with septic shock and a persistent aortic murmur. Echocardiography described evidence of vegetation, perforation and severe regurgitation of aortic valve. Scanner described moderate pericardial effusion. Cardiac surgery was performed, with evidence of purulent pericardial effusion after pericardiotomy, and subsequently aortic valve replacement with a 25 mm bioprosthesis. The patient showed positive progress.

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 caused by ostial right coronary artery obstruction in infective endocarditis: a case report

Background

Acute coronary syndrome (ACS) is a rare, but serious complication of infective endocarditis, and diagnosis can be challenging given clinical overlap with other syndromes. A rare cause of ACS in infective endocarditis is mechanical obstruction of the coronary artery. We present the case of a patient with infective endocarditis who developed ST segment myocardial infarction due to occlusion of the right coronary artery ostium by a vegetation.

Case presentation

A 53-year-old female with no prior history of coronary artery disease was transferred to our tertiary care facility for evaluation and treatment of suspected myopericarditis. After transfer she developed inferior ST segment elevations on ECG along with fever and positive blood cultures for methicillin susceptible Staphylococcus aureus (MSSA). A transesophageal echocardiogram revealed a vegetation on the aortic valve that intermittently prolapsed into the right coronary ostium. She decompensated from a hemorrhagic brain infarct and subsequently transferred to the intensive care unit. She underwent surgical aortic valve debridement without prior cardiac catheterization given the danger of septic coronary embolization. After a prolonged hospital course with multiple complications, she was able to discharge home, with no neurologic deficits on follow-up.

Conclusions

ACS presents a diagnostic and therapeutic challenge in the setting of infective endocarditis. Careful attention to the history, physical exam and testing can help differentiate infective endocarditis from other conditions sharing similar symptoms. Traditional atherosclerotic ACS management may cause great harm when treating patients with infective endocarditis. The presence of a multidisciplinary endocarditis team is ideal to provide the best clinical outcomes for this population.

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.

Imaging of the aortic root on high-pitch non-gated and ECG-gated CT: awareness is the key!

The aortic pathologies are well recognized on imaging. However, conventionally cardiac and proximal aortic abnormalities were only seen on dedicated cardiac or aortic studies due to need for ECG gating. Advances in CT technology have allowed motionless imaging of the chest and abdomen, leading to an increased visualization of cardiac and aortic root diseases on non-ECG-gated imaging. The advances are mostly driven by high pitch due to faster gantry rotation and table speed. The high-pitch scans are being increasingly used for variety of clinical indications because the images are free of motion artifact (both breathing and pulsation) as well as decreased radiation dose. Recognition of aortic root pathologies may be challenging due to lack of familiarity of radiologists with disease spectrum and their imaging appearance. It is important to recognize some of these conditions as early diagnosis and intervention is key to improving prognosis. We present a comprehensive review of proximal aortic anatomy, pathologies commonly seen at the aortic root, and their imaging appearances to familiarize radiologists with the diseases of this location.

Myocardial infarction associated with infective endocarditis: a case series

Introduction

Embolic myocardial infarction is an uncommon but increasingly recognized complication of infective endocarditis (IE). Its incidence ranges between 1% and 10%, but it has a high mortality rate. A high index of suspicion is required to diagnose it. Only case reports and small studies on this condition have been published; thus, it is unknown what the ideal treatment is. We review the challenges to diagnosing this disease and the most effective treatments for it.

Case presentation

We report a case series of three patients with acute coronary syndrome (ACS) in IE. The first patient presented with non-ST-elevation ACS. He underwent a stent placement for late-diagnosed embolic myocardial infarction, after which he was treated conservatively without valve replacement, with good results. The second patient with ST-elevation presented with ACS, for which conventional balloon angioplasty and successful double valve replacement were performed. ST-elevation ACS was also observed in the last patient, who experienced periannular complications, which necessitated surgery.

Discussion

Acute coronary syndrome is a rare complication of IE but is associated with an increased risk of heart failure and high mortality rate. Its management is complicated and cannot be standardized. Because each situation is unique, a multidisciplinary discussion is required to choose the best treatment.

ST-Elevation Myocardial Infarction Associated With Infective Endocarditis

ST-elevation myocardial infarction (STEMI) as a complication of infective endocarditis (IE) is a rarely reported entity. No clear guidelines exist with regards to the management of this medical emergency. We sought to systematically review the clinical presentation and management of this condition. We searched relevant articles on STEMI associated with IE and extracted data on demographic variables, key clinical characteristics upon presentation, treatment strategies, and clinical outcomes. We identified 100 patients from 95 articles. The mean age at presentation was 53 ± 17 years with male preponderance (n = 63, 63%, p = 0.01). Most patients (63 of 100, 63%) presented with STEMI as their first manifestation of IE, with others occurring at 15 ± 17 days after diagnosis of IE. Findings that suggested possible septic emboli were not consistently present, including history of prosthetic valve placement (15%), presence of other embolic disease (27%), fever (42%) increased leukocyte count (80%), and presence of murmur (88%). Atherosclerotic disease was absent in 95% on cardiac catheterization. Eleven patients receiving tissue plasminogen activator fared poorly, with 9 major bleeds; balloon angioplasty was successful in 56% (9 of 16 cases), aspiration thombectomy in 68% (21 of 31 cases), and coronary stenting in 81% (14 of 16 cases). The 30-day mortality was 43%. In conclusion, patients with STEMI in the face of recent IE, new precordial murmur, fever, increased leukocyte count or other embolic events, septic emboli should be considered as a cause for STEMI. Best practices for management are not known, but thrombolytics appear to carry significant bleeding and embolic risks.

Native Aortic and Tricuspid Valve Endocarditis Complicated by Embolic ST Elevation Myocardial Infarction

Acute myocardial infarction due to a coronary embolic event can occur as a complication of infective endocarditis in up to 2.9% of cases and can frequently be the presenting symptom. A 35-year-old female presented with 4 hours of typical chest pain and was found to have ST elevations in inferior leads as well as an elevated serum Troponin I of 8.29 ng/ml (normal: <0.06 ng/ml). Urgent cardiac catheterization revealed total occlusion of the right coronary artery without other coronary disease or collaterals. Following a failed attempt at thrombus extraction, a 3.0 × 38 mm bioabsorbable drug-eluting stent was placed. Echocardiography then revealed large mobile aortic valve vegetations with the largest measuring 1.4 × 1.7 cm, severe tricuspid regurgitation with a 1.1 × 0.5 cm mobile vegetation on the anterior leaflet along with a patent foramen ovale with right-to-left shunting. Blood cultures identified Enterococcus faecalis in 4 of 4 vials. The patient underwent urgent replacement of tricuspid and aortic valves as well as 6 weeks of IV antibiotics followed by chronic antibiotic suppression.

Histoplasma Endocarditis Diagnosed by Thrombus Aspiration

Negative cultures in endocarditis often lead to delays in targeted life-saving therapies. We present the case of a 68-year-old man who presented with culture-negative endocarditis, which was complicated by coronary embolization resulting in anterior ST-elevation myocardial infarction (STEMI). Aspiration thrombectomy led to the diagnosis of fungal endocarditis, one of the most serious causes of culture-negative presentation.

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.

Hybrid approach to the management of infective endocarditis complicated by coronary artery embolism: a case report

Septic coronary embolization in a patient with endocarditis is a rare and can be a devastating complication. The management of this clinical problem in the current era may be best served with a multi-modality approach. We present an interesting case of a patient with septic coronary embolization managed with the combined use of aspiration thrombectomy followed by surgical management of the infected valve.

Position-Dependent Ventricular Tachycardia Related to Peripherally Inserted Central Venous Catheter

We report a case of a 51-year-old male who developed frequent nonsustained episodes of monomorphic ventricular tachycardia after being diagnosed with bioprosthetic aortic valve endocarditis and treated with intravenous antibiotics. A peripherally inserted central venous catheter (PICC) had been placed without complication less than 24 hours prior to the episodes. Ventricular tachycardia (VT) occurred during the night, while sleeping, when he assumed a right lateral decubitus position with abduction of the right arm and placement of the forearm under his head. VT occurred repeatedly when such position was assumed again upon request, and it would terminate immediately when sitting upright. The PICC was repositioned in the superior vena cava without further VT. He was discharged home the same day and underwent successful aortic valve replacement 2 months later. Position-dependent VT related to PICC requires careful history taking and PICC repositioning to make the diagnosis. X-ray in different patient positions during PICC placement can be considered to evaluate for ventricular migration.

Right Coronary Artery Septic Embolization Secondary to Aerococcus urinae Native Mitral Valve Endocarditis

Septic embolization to the coronary arteries from infective endocarditis is a rare occurrence. Appropriate treatment is not yet fully determined. We report a case of mitral valve endocarditis due to Aerococcus urinae presenting as acute inferior myocardial infarction.

Left main occlusion secondary to infective endocarditis vegetation: "The unusual suspect"

Treatment of acute coronary syndrome secondary to septic coronary embolism during valvular endocarditis is controversial. Urgent coronary angiography and stent implantation or surgical intervention have been proposed. We present the case of a patient presented at the emergency department with chest pain and cardiogenic shock. The coronary angiography showed a large filling defect in the left main due to a septic coronary embolism.

[Which patients with infective endocarditis require emergency surgery?]

Half of patients with infectious endocarditis have surgery during the active phase of infective endocarditis (before the end of antibiotic therapy). The American Heart Association and the European Society of Cardiology, independently from each other, have published guidelines in September 2015. As regards surgical indications, these guidelines are similar. The surgical indication must be a common decision of a multidisciplinary team of experts in cardiology, cardiac surgery, imaging and infectious diseases. The main indications are heart failure, non-infectious process control and prevention of embolisms.

Infective endocarditis

Infective endocarditis (IE) is a rare, life-threatening disease that has long-lasting effects even among patients who survive and are cured. IE disproportionately affects those with underlying structural heart disease and is increasingly associated with health care contact, particularly in patients who have intravascular prosthetic material. In the setting of bacteraemia with a pathogenic organism, an infected vegetation may form as the end result of complex interactions between invading microorganisms and the host immune system. Once established, IE can involve almost any organ system in the body. The diagnosis of IE may be difficult to establish and a strategy that combines clinical, microbiological and echocardiography results has been codified in the modified Duke criteria. In cases of blood culture-negative IE, the diagnosis may be especially challenging, and novel microbiological and imaging techniques have been developed to establish its presence. Once diagnosed, IE is best managed by a multidisciplinary team with expertise in infectious diseases, cardiology and cardiac surgery. Antibiotic prophylaxis for the prevention of IE remains controversial. Efforts to develop a vaccine that targets common bacterial causes of IE are ongoing, but have not yet yielded a commercially available product.

Multiple systemic embolism in infective endocarditis underlying in Barlow's disease

Background

Systemic embolism, especially septic embolism, is a severe complication of infective endocarditis (IE). However, concurrent embolism to the brain, coronary arteries, and spleen is very rare. Because of the risk of hemorrhage or visceral rupture, anticoagulants are recommended only if an indication is present, e.g. prosthetic valve. Antiplatelet therapy in IE is controversial, but theoretically, this therapy has the potential to prevent and treat thrombosis and embolism in IE. Unfortunately, clinical trial results have been inconclusive.

Case presentation

We describe a previously healthy 50-year-old man who presented with dysarthria secondary to bacterial endocarditis with multiple cerebral, coronary, splenic, and peripheral emboli; antibiotic therapy contributed to the multiple emboli. Emergency splenectomy was performed, with subsequent mitral valve repair. Pathological examination confirmed mucoid degeneration and mitral valve prolapse (Barlow’s disease) as the underlying etiology of the endocardial lesion. Continuous antibiotics were prescribed, postoperatively. Transthoracic echocardiography at 1.5, 3, and 6 months after the onset of his illness showed no severe regurgitation, and there was no respiratory distress, fever, or lethargy during follow-up.

Conclusions

Although antibiotic use in IE carries a risk of septic embolism, these drugs have bactericidal and antithrombotic benefits. It is important to consider that negative blood culture and symptom resolution do not confirm complete elimination of bacteria. However, vegetation size and Staphylococcus aureus infection accurately predict embolization. It is also important to consider that bacteria can be segregated from the microbicide when embedded in platelets and fibrin. Therefore, antimicrobial therapy with concurrent antiplatelet therapy should be considered carefully.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-016-1726-5) contains supplementary material, which is available to authorized users.

Transesophageal imaging of a left main coronary artery ostium occlusion in infective endocarditis: a case report

A 43-year-old woman was admitted due to fever, chills, and headache for several days and was diagnosed as infective endocarditis. Intraoperative transesophageal echocardiography (TEE) examination confirmed severe aortic stenosis and showed relatively fresh 1.5 cm vegetation on the left coronary cusp of the aortic valve (AV) with frequent diastolic prolapse into the aortic root. This mobile vegetation partially occluded left coronary ostium, but it did not cause cardiac failure. TEE showed the vegetation to be in good position across the AV. The AV replacement with removal of vegetation and mitral valvuloplasty were performed. The patient was weaned from cardiopulmonary bypass without any hemodynamic instability or changes in ST segment on electrocardiography. She was discharged on the 28th postoperative day without any complication.

Infective endocarditis epidemiology over five decades: a systematic review

AIMS

To Assess changes in infective endocarditis (IE) epidemiology over the last 5 decades.

METHODS AND RESULTS

We searched the published literature using PubMed, MEDLINE, and EMBASE from inception until December 2011.

DATA FROM

Einstein Medical Center, Philadelphia, PA were also included. Criteria for inclusion in this systematic review included studies with reported IE microbiology, IE definition, description of population studied, and time frame. Two authors independently extracted data and assessed manuscript quality. One hundred sixty studies (27,083 patients) met inclusion criteria. Among hospital-based studies (n=142; 23,606 patients) staphylococcal IE percentage increased over time, with coagulase-negative staphylococcus (CNS) increasing over each of the last 5 decades (p<0.001) and Staphylococcus aureus (SA) in the last decade (21% to 30%; p<0.05). Streptococcus viridans (SV) and culture negative (CN) IE frequency decreased over time (p<0.001), while enterococcal IE increased in the last decade (p<0.01). Patient age and male predominance increased over time as well. In subgroup analysis, SA frequency increased in North America, but not the rest of the world. This was due, in part, to an increase in intravenous drug abuse IE in North America (p<0.001). Among population-based studies (n=18; 3,477 patients) no significant changes were found.

CONCLUSION

Important changes occurred in IE epidemiology over the last half-century, especially in the last decade. Staphylococcal and enterococcal IE percentage increased while SV and CN IE decreased. Moreover, mean age at diagnosis increased together with male:female ratio. These changes should be considered at the time of decision-making in treatment of and prophylaxis for IE.