Abstract
BackgroundInfective 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 presentationAn 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.ConclusionsPatients 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.
Highlights
Infective endocarditis (IE) is still a condition with high mortality and morbidity, especially in the elderly, and in patients with prosthetic valves
We report a case of primary percutaneous coronary intervention performed during ST segment elevation myocardial infarction (STEMI) in the setting of a bioprosthetic aortic root abscess compressing the left main coronary artery
We describe a rare complication of prosthetic valve endocarditis: an aortic root abscess causing external coronary artery compression and acute myocardial infarction
Summary
Considering the paucity of data available, the management of each patient presenting with ST elevation and valve/prosthetic endocarditis should be individualized and a multidisciplinary discussion should be advocated. (Trans-esophageal short axis view of the aorta): the clip shows a normal opening of the aortic bioprosthesis and a pronounced aortic root thickening. (Wires advancement in the left coronary system): the clip shows the wires that have been introduced in the LAD and LCx. (Post stent implantation in the LAD): videos showing the stent deployment in the LAD and the result of the procedure. (Final result): videos showing the stent deployment in the LCx and the final procedural result. (Parasternal long axis view): evidence of severe left ventricle dysfunction. (Parasternal long axis view with color): the clip shows a significant tissue damage in the aortic prosthetic region, where a cavity is identified, suggesting an abscess. (Parasternal short axis of the aortic valve without and with color mode representation): different view of the significant tissue damage in the aortic prosthetic region.
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