Abstract 14075: Infective Endocarditis Associated With Irreversible Coronary Spasm and Cardiac Arrest

Abstract

Introduction: Coronary artery spasm (CAS) can elicit ischemia with transient ST-segment deviation that usually responds to nitrates; however, CAS can precipitate arrhythmias leading to sudden cardiac arrest. Infective endocarditis (IE) is associated with the acute coronary syndrome (ACS) usually via coronary embolism and compression secondary to peri-annular complications. CAS in association with IE causing ACS is extremely rare. Case: A 54-year-old man had a recent ST-elevation (STE) myocardial infarction, which required stenting to obtuse marginal artery (OM2) artery. He presented with a fever for one week. A new diastolic murmur at the aortic area on examination. Echocardiography showed a bicuspid aortic valve with perforation and new-onset aortic regurgitation suggestive of vegetation. Diagnosis of infective endocarditis was established, and the patient was started on medical treatment and was being prepared for surgical repair. During the hospital stay, he had recurrent episodes of severe chest pain accompanied by transient STE on ECG but normal troponin level. It was always responding to sublingual nitrates. CT coronary Angiogram showed no significant coronary stenosis and patent stent in OM2. The patient had again an attack of severe chest pain with ECG showed extensive STE then he developed pulseless electrical activity. Result: Resuscitation was started and emergency coronary angiography was performed and showed severe spasms in both LAD and LCX with TIMI-1 flow. A repeated image during resuscitation showed patent arteries with TIMI-III flow. A prolonged CPR in Cath-lab failed and the patient died. Although there was no clear explanation of the mechanism, the simultaneous association between the CAS and IE raises the suspicion of a possible relationship between both pathologies. Conclusions: Severe coronary spasm should be considered as a possible cause of ACS in association with IE.