Abstract
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.
Highlights
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Acute coronary syndrome secondary to septic coronary embolism in valvular endocarditis is rare and treatment is controversial.
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Urgent coronary angiography and stent implantation or surgical intervention have been proposed.
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We present a patient who underwent coronary angiography and following surgical intervention for left main septic embolism from aortic valve.
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Case report
A 66-year-old man was admitted to our emergency department one hour after the onset of acute chest pain, diaphoresis, weakness, and confusion.
His past medical history was significant for hypertension, dyslipidemia, impaired glucose tolerance and hypothyroidism. Physical examination revealed normal heart sounds without murmurs, peripheral edema and severe hypotension, immediately treated with intravenous fluid and dopamine administration. Of note, the patient reported an episode of fever during the prior month treated with empirical antibiotic therapy; however, at admission the patient was afebrile.
On arrival, biochemical analysis showed white blood cell count of 9.96 (10 9 /L), RBC 3.55 (10 12 /L), Hb 9.6 (mg/dl), troponin T 0.105 (μ/dl), creatinine 0.97 (mg/dl), and C-reactive protein 84.6 (mg/L). A chest X-ray examination revealed signs of moderate pulmonary edema. ECG on admission showed sinus tachycardia and signs of anterolateral nonST-elevation myocardial infarction. Thus, the patient underwent an emergency coronary angiography that showed a large filling defect involving the left main, the proximal left anterior descending (LAD) artery and the ostium of the circumflex artery ( Fig. 1 ).
Urgent intra-procedural trans-thoracic echocardiography demonstrated a normal left ventricular ejection fraction (LVEF) and the presence of an abnormal echogenic and irregular mobile formation of 2 cm length attached to the LV side of the aortic valve with independent motion during the cardiac cycle, highly suspicious for endocarditis ( Fig. 2 a ). Moderate aortic regurgitation at color Doppler was also associated ( Fig. 2 b). After Heart Team evaluation, the patient was not deemed suitable for percutaneous coronary interventions due to high risk of septic systemic and coronary embolization and he underwent immediate open-heart surgery.
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