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Coronary Artery Complications in Infective Endocarditis
IMAGES IN CARDIOTHORACIC SURGERY
Coronary Artery Complications in Infective Endocarditis Rebecca Allan, MD, FRCPC, Mark Hynes, MD, FRCPC, Ian G. Burwash, MD, FRCPC, John P. Veinot, MD, FRCPC, and Kwan L. Chan, MD, FRCPC University of Ottawa Heart Institute and The Ottawa Hospital, Ottawa, Ontario, Canada
Fig 1.
52-year-old man with a prior bioprosthetic aortic valve replacement (Carpentier-Edwards valve; Edwards Lifesciences, Irvine, CA) for Staphylococcus aureus endocarditis 2 years earlier was admitted with sudden onset of fever, headache, vomiting, and confusion. Blood cultures were positive for S aureus. He was transferred to University of Ottawa Heart Institute 9 days later because of a persistent fever despite antibiotic therapy and new-onset chest pain associated with diffuse ST segment depression on the day of transfer. On presentation, he was in respiratory distress, his heart rate was 130 beats/min, and his blood pressure was 95/38 mm Hg. Mechanical ventilation and inotropic support were initiated. An urgent transesophageal echocardiogram (TEE) demonstrated multiple vegetations on the aortic bioprosthesis causing severe stenosis but no insufficiency. A periaortic abscess (Fig 1A, arrowheads) extended laterally and compressed the left main coronary artery (arrow). Pulsed wave Doppler (Fig 1B) showed high velocity coronary flow consistent with significant stenosis. The right coronary artery was aneurysmally dilated. There was severe left ventricular systolic dysfunction with akinesis of the anterior wall. The patient was assessed for emergency aortic valve surgery, but his condition deteriorated rapidly and he died within 12 hours of onset of chest pain. Autopsy confirmed the TEE findings. There were multiple vegetations on the aortic bioprosthesis, extensive abscess formation of the periaortic area, and an aneurysmally dilated right coronary artery (Fig 2A) with saccular mycotic aneurysms demonstrated in multiple transverse sections (Fig 2B). Coronary artery involvement with infective endocarditis can occur by several mechanisms. Aortic root abscess can lead to extrinsic compression and distortion. Coronary Address correspondence to Dr Chan, University of Ottawa Heart Institute, 40 Ruskin St, Rm H3411, Ottawa, Ontario, K1Y 4W7, Canada; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
FEATURE ARTICLES
A
Fig 2.
artery occlusion may also result from embolization of the vegetation or, less commonly, mycotic aneurysm formation. Our case illustrates two uncommon coronary artery complications of infective endocarditis. Ann Thorac Surg 2008;86:1381 • 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.11.012
Coronary Artery Complications in Infective Endocarditis Rebecca Allan, MD, FRCPC, Mark Hynes, MD, FRCPC, Ian G. Burwash, MD, FRCPC, John P. Veinot, MD, FRCPC, and Kwan L. Chan, MD, FRCPC University of Ottawa Heart Institute and The Ottawa Hospital, Ottawa, Ontario, Canada
Fig 1.
52-year-old man with a prior bioprosthetic aortic valve replacement (Carpentier-Edwards valve; Edwards Lifesciences, Irvine, CA) for Staphylococcus aureus endocarditis 2 years earlier was admitted with sudden onset of fever, headache, vomiting, and confusion. Blood cultures were positive for S aureus. He was transferred to University of Ottawa Heart Institute 9 days later because of a persistent fever despite antibiotic therapy and new-onset chest pain associated with diffuse ST segment depression on the day of transfer. On presentation, he was in respiratory distress, his heart rate was 130 beats/min, and his blood pressure was 95/38 mm Hg. Mechanical ventilation and inotropic support were initiated. An urgent transesophageal echocardiogram (TEE) demonstrated multiple vegetations on the aortic bioprosthesis causing severe stenosis but no insufficiency. A periaortic abscess (Fig 1A, arrowheads) extended laterally and compressed the left main coronary artery (arrow). Pulsed wave Doppler (Fig 1B) showed high velocity coronary flow consistent with significant stenosis. The right coronary artery was aneurysmally dilated. There was severe left ventricular systolic dysfunction with akinesis of the anterior wall. The patient was assessed for emergency aortic valve surgery, but his condition deteriorated rapidly and he died within 12 hours of onset of chest pain. Autopsy confirmed the TEE findings. There were multiple vegetations on the aortic bioprosthesis, extensive abscess formation of the periaortic area, and an aneurysmally dilated right coronary artery (Fig 2A) with saccular mycotic aneurysms demonstrated in multiple transverse sections (Fig 2B). Coronary artery involvement with infective endocarditis can occur by several mechanisms. Aortic root abscess can lead to extrinsic compression and distortion. Coronary Address correspondence to Dr Chan, University of Ottawa Heart Institute, 40 Ruskin St, Rm H3411, Ottawa, Ontario, K1Y 4W7, Canada; e-mail: [email protected].
© 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
FEATURE ARTICLES
A
Fig 2.
artery occlusion may also result from embolization of the vegetation or, less commonly, mycotic aneurysm formation. Our case illustrates two uncommon coronary artery complications of infective endocarditis. Ann Thorac Surg 2008;86:1381 • 0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2007.11.012