- Email: [email protected]
Multiple myocardial abscesses secondary to late stent infection
Multiple Myocardial Abscesses secondary to Late Stent Infection Ayman Elbadawi, Marwan Saad, Islam Y. Elgendy, Aniqa Zafar, MingYan Chow PII: DOI: Reference:
S1054-8807(16)30198-3 doi: 10.1016/j.carpath.2017.01.007 CVP 6971
To appear in:
Cardiovascular Pathology
Received date: Revised date: Accepted date:
11 November 2016 12 January 2017 17 January 2017
Please cite this article as: Elbadawi Ayman, Saad Marwan, Elgendy Islam Y., Zafar Aniqa, Chow Ming-Yan, Multiple Myocardial Abscesses secondary to Late Stent Infection, Cardiovascular Pathology (2017), doi: 10.1016/j.carpath.2017.01.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Multiple Myocardial Abscesses secondary to Late Stent Infection Ayman Elbadawi, MD,a Marwan Saad, MD PhD,b Islam Y. Elgendy, MD,c Aniqa Zafar,
T
MD,a Ming-Yan Chow, MD.d Department of Internal Medicine, Rochester General Hospital, Rochester, NY.
b
Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences,
SC
RI P
a
Little Rock, AR.
Division of Cardiovascular Medicine, University of Florida, Gainesville, FL.
d
Department of Pulmonary Medicine, Rochester General Hospital, Rochester, NY.
MA
NU
c
Corresponding author:
ED
Ayman Elbadawi, MD
PT
1425 Portland Avenue, Rochester, NY12641 Phone: +1 (585) 943-7821
CE
Fax: +1(585)922-4440
AC
Email: [email protected]
Conflict of interests: none. Funding: none.
1
ACCEPTED MANUSCRIPT Abstract A 53-year-old woman presented to our hospital with dizziness and low grade fever. She
T
underwent percutaneous coronary intervention to the obtuse marginal artery with a
RI P
drug-eluting stent 20-months prior to this presentation. Physical examination was remarkable for bradycardia. Electrocardiogram showed a junctional rhythm with heart
SC
rate of 35 bpm. Blood and urine cultures were negative. Despite successful urgent
NU
pacemaker placement, she had cardiac arrest the following day with unsuccessful cardiopulmonary resuscitation attempt. Cardiac autopsy report revealed multiple
ED
the adjacent myocardial regions.
MA
abscesses involving the obtuse marginal and left anterior descending arteries as well as
AC
CE
PT
Keywords: Stent; infection; abscess; percutaneous coronary intervention
2
ACCEPTED MANUSCRIPT
Case
T
A 53-year-old woman with past history of end-stage renal disease (ESRD), coronary
RI P
artery disease and peripheral vascular disease presented to our hospital with progressive dizziness and low-grade fever of 2-weeks duration. She underwent
SC
coronary angiogram 20-months prior to this presentation, which revealed a 90%
NU
stenosis of the first obtuse marginal (OM1) branch and otherwise no significant obstructive disease. Percutaneous coronary intervention (PCI) with a zotarolimus-
MA
eluting stent was performed with no acute post-procedural complications. Eight months prior to this presentation, she underwent multiple surgeries for an infected left foot
ED
wound ending in a below-knee amputation. After the amputation, she was admitted
PT
multiple times for symptoms of fever and confusion, with a negative diagnostic work up each time.
CE
Physical examination was significant for a temperature of 100.9º F, lethargy and
AC
bradycardia on cardiac auscultation. Electrocardiogram showed junctional rhythm at a heart rate of 35 bpm. Transthoracic echocardiogram revealed a left ventricular ejection fraction of 45% and hypokinesis of the lateral and basal inferior walls. There were no vegetations, significant valvular disease or pericardial effusion observed. The patient underwent immediate pacemaker insertion and was clinically stable during the immediate post-procedure period. However, one-day later the patient suffered a ventricular
fibrillation
cardiac
arrest
and
unsuccessful.
3
cardiopulmonary
resuscitation
was
ACCEPTED MANUSCRIPT Cardiac autopsy revealed multiple
aneurysmal dilatations of the OM1 artery
involving the stent and extending distally, filled with greenish-grey necrotic material
T
consistent with multiple abscesses (Figure 1, panel A and C, white arrows). A larger
RI P
abscess was observed in the mid segment of the left anterior descending artery (Figure 1, panel A, B and C, black arrows). These abscesses extended to the adjacent
SC
myocardial regions. The lateral wall of the left ventricle showed an area of recent infarct.
NU
Microscopic examination illustrated thrombosed lumen of the affected coronary arteries, and surrounding cavitary areas. There were infiltrates of neutrophils and macrophages
MA
into the adventitia of the coronary artery and the adjacent myocardium. (Figure 2, panel A and B, asterisks).
ED
We report an extremely rare case of multiple myocardial abscesses in the setting
PT
of presumed very-late stent infection (i.e., 20 months) after PCI with a drug-eluting stent. Coronary stent infection could occur early or late (1). Typically, patients present
CE
with constitutional symptoms, typical angina or symptoms of pericarditis (1).
AC
Pathologically, stent infections have been reported in the form of abscesses, aneurysms or pseudo-aneurysms after vessel rupture, with Staphylococcus aureus being the most common causative organism. The highest yield diagnostic modality is coronary angiogram, followed by trans-esophageal echocardiography (1, 2). The underlying pathophysiology remains unclear; but one theory is that the metallic struts of the stent act as a nidus for bacterial colonization with subsequent spread to the arterial wall causing inflammation, necrosis and eventually vessel rupture (2). This could explain why stent infection is more observed with drug-eluting stents compared to bare metal stents (2), likely due to delayed stent endothelialization. The
4
ACCEPTED MANUSCRIPT eluted drugs in the previously reported cases of stent infection included rapamycine, sirolimus, paclitaxel and everolimus. (2)
T
To the best of our knowledge, only one case of very-late stent infection was
RI P
reported in the literature.(3) Furthermore, we report the first case of zotarolimus-eluting stent infection. Occult bacteremia from her previous surgeries or hemodialysis likely
SC
initiated the process. The presentation of our patient with heart block in the absence of
NU
typical angina symptoms hindered the clinical suspicion of this rare complication. Our case report highlights the importance of including coronary stent infection in the
AC
CE
PT
ED
bacteremia after stent placement.
MA
differential diagnosis of patients presenting with cardiac symptoms and possible
5
RI P
T
ACCEPTED MANUSCRIPT
SC
References:
AC
CE
PT
ED
MA
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1. Elieson M, Mixon T, Carpenter J. Coronary stent infections: a case report and literature review. Tex Heart Inst J2012;39(6):884. 2. Bosman W, van der Burg BB, Schuttevaer H, Thoma S, Joosten PPH. Infections of intravascular bare metal stents: a case report and review of literature. Eur J Vasc Endovasc Surg2014;47(1):87-99. 3. Del Trigo M, Jimenez-Quevedo P, Fernandez-Golfin C, Vaño E, Delgado-Bolton R, Alfonso F, Gonzalo N, Kallmeyer A, Montes L, Escribano N. Very late mycotic pseudoaneurysm associated with drug-eluting stent fracture. Circulation2012;125(2):390-2.
6
ACCEPTED MANUSCRIPT
T
Figure legends:
RI P
Figure 1 (A, B, and C): Cardiac autopsy, gross images showing myocardial abscesses involving OM (white arrows), and LAD arteries (black arrows).
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SC
OM= obtuse marginal artery; LAD= left anterior descending artery.
Figure 2 (A and B): Cardiac autopsy, microscopic images showing thrombosed lumen of
MA
the affected coronary arteries with infiltrates of neutrophils and macrophages into the
AC
CE
PT
ED
adventitia of the coronary artery and the adjacent myocardium (asterisks).
7
AC
Figure 1
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
8
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
MA
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Figure 2
9
S1054-8807(16)30198-3 doi: 10.1016/j.carpath.2017.01.007 CVP 6971
To appear in:
Cardiovascular Pathology
Received date: Revised date: Accepted date:
11 November 2016 12 January 2017 17 January 2017
Please cite this article as: Elbadawi Ayman, Saad Marwan, Elgendy Islam Y., Zafar Aniqa, Chow Ming-Yan, Multiple Myocardial Abscesses secondary to Late Stent Infection, Cardiovascular Pathology (2017), doi: 10.1016/j.carpath.2017.01.007
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Multiple Myocardial Abscesses secondary to Late Stent Infection Ayman Elbadawi, MD,a Marwan Saad, MD PhD,b Islam Y. Elgendy, MD,c Aniqa Zafar,
T
MD,a Ming-Yan Chow, MD.d Department of Internal Medicine, Rochester General Hospital, Rochester, NY.
b
Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences,
SC
RI P
a
Little Rock, AR.
Division of Cardiovascular Medicine, University of Florida, Gainesville, FL.
d
Department of Pulmonary Medicine, Rochester General Hospital, Rochester, NY.
MA
NU
c
Corresponding author:
ED
Ayman Elbadawi, MD
PT
1425 Portland Avenue, Rochester, NY12641 Phone: +1 (585) 943-7821
CE
Fax: +1(585)922-4440
AC
Email: [email protected]
Conflict of interests: none. Funding: none.
1
ACCEPTED MANUSCRIPT Abstract A 53-year-old woman presented to our hospital with dizziness and low grade fever. She
T
underwent percutaneous coronary intervention to the obtuse marginal artery with a
RI P
drug-eluting stent 20-months prior to this presentation. Physical examination was remarkable for bradycardia. Electrocardiogram showed a junctional rhythm with heart
SC
rate of 35 bpm. Blood and urine cultures were negative. Despite successful urgent
NU
pacemaker placement, she had cardiac arrest the following day with unsuccessful cardiopulmonary resuscitation attempt. Cardiac autopsy report revealed multiple
ED
the adjacent myocardial regions.
MA
abscesses involving the obtuse marginal and left anterior descending arteries as well as
AC
CE
PT
Keywords: Stent; infection; abscess; percutaneous coronary intervention
2
ACCEPTED MANUSCRIPT
Case
T
A 53-year-old woman with past history of end-stage renal disease (ESRD), coronary
RI P
artery disease and peripheral vascular disease presented to our hospital with progressive dizziness and low-grade fever of 2-weeks duration. She underwent
SC
coronary angiogram 20-months prior to this presentation, which revealed a 90%
NU
stenosis of the first obtuse marginal (OM1) branch and otherwise no significant obstructive disease. Percutaneous coronary intervention (PCI) with a zotarolimus-
MA
eluting stent was performed with no acute post-procedural complications. Eight months prior to this presentation, she underwent multiple surgeries for an infected left foot
ED
wound ending in a below-knee amputation. After the amputation, she was admitted
PT
multiple times for symptoms of fever and confusion, with a negative diagnostic work up each time.
CE
Physical examination was significant for a temperature of 100.9º F, lethargy and
AC
bradycardia on cardiac auscultation. Electrocardiogram showed junctional rhythm at a heart rate of 35 bpm. Transthoracic echocardiogram revealed a left ventricular ejection fraction of 45% and hypokinesis of the lateral and basal inferior walls. There were no vegetations, significant valvular disease or pericardial effusion observed. The patient underwent immediate pacemaker insertion and was clinically stable during the immediate post-procedure period. However, one-day later the patient suffered a ventricular
fibrillation
cardiac
arrest
and
unsuccessful.
3
cardiopulmonary
resuscitation
was
ACCEPTED MANUSCRIPT Cardiac autopsy revealed multiple
aneurysmal dilatations of the OM1 artery
involving the stent and extending distally, filled with greenish-grey necrotic material
T
consistent with multiple abscesses (Figure 1, panel A and C, white arrows). A larger
RI P
abscess was observed in the mid segment of the left anterior descending artery (Figure 1, panel A, B and C, black arrows). These abscesses extended to the adjacent
SC
myocardial regions. The lateral wall of the left ventricle showed an area of recent infarct.
NU
Microscopic examination illustrated thrombosed lumen of the affected coronary arteries, and surrounding cavitary areas. There were infiltrates of neutrophils and macrophages
MA
into the adventitia of the coronary artery and the adjacent myocardium. (Figure 2, panel A and B, asterisks).
ED
We report an extremely rare case of multiple myocardial abscesses in the setting
PT
of presumed very-late stent infection (i.e., 20 months) after PCI with a drug-eluting stent. Coronary stent infection could occur early or late (1). Typically, patients present
CE
with constitutional symptoms, typical angina or symptoms of pericarditis (1).
AC
Pathologically, stent infections have been reported in the form of abscesses, aneurysms or pseudo-aneurysms after vessel rupture, with Staphylococcus aureus being the most common causative organism. The highest yield diagnostic modality is coronary angiogram, followed by trans-esophageal echocardiography (1, 2). The underlying pathophysiology remains unclear; but one theory is that the metallic struts of the stent act as a nidus for bacterial colonization with subsequent spread to the arterial wall causing inflammation, necrosis and eventually vessel rupture (2). This could explain why stent infection is more observed with drug-eluting stents compared to bare metal stents (2), likely due to delayed stent endothelialization. The
4
ACCEPTED MANUSCRIPT eluted drugs in the previously reported cases of stent infection included rapamycine, sirolimus, paclitaxel and everolimus. (2)
T
To the best of our knowledge, only one case of very-late stent infection was
RI P
reported in the literature.(3) Furthermore, we report the first case of zotarolimus-eluting stent infection. Occult bacteremia from her previous surgeries or hemodialysis likely
SC
initiated the process. The presentation of our patient with heart block in the absence of
NU
typical angina symptoms hindered the clinical suspicion of this rare complication. Our case report highlights the importance of including coronary stent infection in the
AC
CE
PT
ED
bacteremia after stent placement.
MA
differential diagnosis of patients presenting with cardiac symptoms and possible
5
RI P
T
ACCEPTED MANUSCRIPT
SC
References:
AC
CE
PT
ED
MA
NU
1. Elieson M, Mixon T, Carpenter J. Coronary stent infections: a case report and literature review. Tex Heart Inst J2012;39(6):884. 2. Bosman W, van der Burg BB, Schuttevaer H, Thoma S, Joosten PPH. Infections of intravascular bare metal stents: a case report and review of literature. Eur J Vasc Endovasc Surg2014;47(1):87-99. 3. Del Trigo M, Jimenez-Quevedo P, Fernandez-Golfin C, Vaño E, Delgado-Bolton R, Alfonso F, Gonzalo N, Kallmeyer A, Montes L, Escribano N. Very late mycotic pseudoaneurysm associated with drug-eluting stent fracture. Circulation2012;125(2):390-2.
6
ACCEPTED MANUSCRIPT
T
Figure legends:
RI P
Figure 1 (A, B, and C): Cardiac autopsy, gross images showing myocardial abscesses involving OM (white arrows), and LAD arteries (black arrows).
NU
SC
OM= obtuse marginal artery; LAD= left anterior descending artery.
Figure 2 (A and B): Cardiac autopsy, microscopic images showing thrombosed lumen of
MA
the affected coronary arteries with infiltrates of neutrophils and macrophages into the
AC
CE
PT
ED
adventitia of the coronary artery and the adjacent myocardium (asterisks).
7
AC
Figure 1
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
8
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
MA
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Figure 2
9