Catheterization and Cardiovascular Interventions 83:E168–E170 (2014)
External Coronary Artery Compression Due to Prosthetic Valve Bacterial Endocarditis Matthew E. Harinstein,*
MD,
and Oscar C. Marroquin,
MD
Acute coronary syndromes in the setting of infective endocarditis may be the result of coronary compression secondary to periannular aortic valve complications, coronary embolism, obstruction of the coronary ostium due to a large vegetation, coronary atherosclerosis, and severe aortic insufficiency. External coronary artery compression as a result of infective endocarditis is a rare and lethal finding with few reported cases available in the medical literature. We present a rare occurrence of an acute coronary syndrome occurring in the setting of a bioprosthetic aortic valve abscess in which there was no complete coronary occlusion visualized and given the patient’s recent unremarkable catheterization and findings of diffuse tapering of the proximal left coronary system, the most likely etiology was external compression secondary to the known aortic root abscess, which caused myocardial ischemia, and was confirmed during surgery. Although uncommon, external compression should be considered in the differential diagnosis of acute coronary syndrome in this setting and coronary angiography can be diagnostic of this entity. VC 2012 Wiley Periodicals, Inc. Key words: angiography-coronary; diagnostic cardiac catheterization; acute coronary syndrome; valvular heart disease
INTRODUCTION
Acute coronary syndromes in patients with infective endocarditis are relatively uncommon, occur early in the disease, and are more commonly due to coronary atherosclerosis, aortic insufficiency, or embolization. External coronary artery compression, as a result of infective endocarditis and subsequent abscess formation, which causes myocardial ischemia, is exceedingly rare and life threatening. We report a case of a 66-year-old patient who presented with prosthetic valve endocarditis due to methicillin resistant staphylococcus epidermidis (MRSE) and suffered an acute coronary syndrome and cardiogenic shock.
tion fraction was estimated to be 60% by contrast ventriculography. He now presents with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and increasing lower extremity edema. Initial blood cultures, which were obtained on admission returned positive for MRSE. A transthoracic echocardiogram performed upon admission revealed a preserved ejection fraction, grade 3 diastolic dysfunction, and severe aortic insufficiency. The patient was initiated on an antibiotic regimen of vancomycin, moxifloxacin, and rifampin and transferred to our institution for further management. Upon arrival, his initial examination Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
CASE REPORT
A 66-year-old male with a past medical history significant for bioprosthetic aortic valve replacement for severe aortic stenosis, atrial fibrillation, hypertension, grade 3 diastolic dysfunction, and chronic obstructive pulmonary disease presented with worsening dyspnea. He presented with a similar complaint 6 months earlier, at the time of his aortic valve replacement, which was performed for severe aortic stenosis. At that time, preoperative coronary angiography revealed only mild luminal irregularities in the left anterior descending and left circumflex arteries. The left ventricular ejecC 2012 Wiley Periodicals, Inc. V
Additional Supporting Information may be found in the online version of this article. Conflict of interest: Nothing to report. *Correspondence to: Matthew E. Harinstein, MD, Heart & Vascular Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, Scaife 5-553, Pittsburgh, PA 15213. E-mail: [email protected] Received 6 April 2012; Revision accepted 17 July 2012 DOI 10.1002/ccd.24578 Published online 6 August 2012 in Wiley Online Library (wileyonlinelibrary.com)
External Coronary Compression due to PVE
Fig. 1. A: Two-dimensional mid-esophageal short axis view of the aortic valve with an abscess in between the aortic bioprosthesis and aortic wall along the non-coronary and left coronary cusps; (B) color Doppler image at the aortic valve level revealing flow into the abscess cavity.
was notable for a middle aged gentleman who was comfortable and speaking in full sentences. He had a 2/6 systolic ejection murmur as well as a soft 1/4 diastolic murmur, bibasilar rales, and severe pitting edema of both lower extremities. A transesophageal echocardiogram (TEE) was performed and revealed a mildly reduced ejection fraction, a 3.7 cm 1 cm abscess in between the aortic bioprosthesis and aortic wall along the non-coronary cusp and left coronary cusp (Fig. 1 and Supporting Information Video 1), a small perforation in the strut between the left and right coronary cusps, and a 1.6 cm 1.1 cm echodensity inside the abscess cavity which communicates with the aortic lumen through a breach in the strut. There was also evidence of moderate to severe paraprosthetic aortic regurgitation with holodiastolic reversal of flow in the descending aorta. Later that evening, the patient developed central chest discomfort which radiated to his neck and jaw and he
E169
became more hypotensive. An electrocardiogram revealed evidence of ST segment elevations in the anterior precordial leads. A cardiac catheterization was performed and revealed diffuse proximal narrowings and reduced TIMI 2 flow of the left anterior descending and left circumflex coronary arteries, which given the patient’s unremarkable angiogram from 6 months prior and current presentation (Fig. 2), were felt to be the result of external compression from the bioprosthetic endocarditis and aortic abscess (Supporting Information Video 2). Since there was no single focal stenosis, but rather diffuse vessel narrowings likely due to external compression, percutaneous coronary intervention was not performed and the patient was taken emergently to the operating room for intervention. The intraoperative TEE revealed an ejection fraction of approximately 15% at the beginning of the case. Surgical inspection revealed a large abscess over the dome of the left atrium into the bifurcation of the left main and extending over the left anterior descending and left circumflex coronary arteries. There was gross endocarditis of the bioprosthetic aortic valve and annular dehiscence. The surgical findings confirmed the diagnosis of external compression of the coronary arteries as the etiology of his acute coronary syndrome and resultant severe reduction of systolic function. Pathology and subsequent blood cultures were consistent with MRSE prosthetic valve endocarditis. The aortic root was replaced with a 26 mm homograft and two vessel coronary artery bypass grafting was performed. Unfortunately, the patient remained acidemic postoperatively and suffered a cardiac arrest 4 hr later, from which he did not recover. DISCUSSION
External coronary artery compression as a result of infective endocarditis is a rare and lethal finding with few reported cases available in the medical literature [1–3]. To our knowledge, this is the first case reported which is the result of MRSE. Mechanisms for myocardial ischemia in patients with infective endocarditis include coronary compression secondary to periannular aortic valve complications, coronary embolism, obstruction of the coronary ostium due to a large vegetation, coronary atherosclerosis, and severe aortic insufficiency [4]. Studies using intravascular ultrasound have shown that vessels with even mild disease can progress rapidly to become acute lesions. However, in this case, there was no complete coronary occlusion visualized and given the patient’s recent catheterization and findings of diffuse tapering of the proximal left coronary system, not simply a focal stenosis, the most likely etiology
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
E170
Harinstein and Marroquin
Fig. 2. A: Preoperative selective angiogram of the short left main and left anterior descending coronary artery; (B) preoperative angiogram of the left circumflex coronary artery; (C) angiogram of the left coronary system after ST elevations were noted on telemetry.
was external compression secondary to the known aortic root abscess, which caused an acute coronary syndrome, and was confirmed during surgery.
this setting and coronary angiography can be diagnostic of this entity. REFERENCES
CONCLUSION
This case demonstrates a rare occurrence of a bioprosthetic aortic valve abscess causing external coronary artery compression resulting in an acute coronary syndrome and myocardial ischemia. Although uncommon, external compression should be considered in the differential diagnosis of acute coronary syndrome in
1. Cripps T, Guvendik L. Coronary artery compression caused by abscess formation in infective endocarditis. Int J Cardiol 1987;14:99–102. 2. Dean JW, Kuo J, Wood AJ. Myocardial infarction due to coronary artery compression by aortic root abscess. Int J Cardiol 1993;41:165–167. 3. Cowan SW, Fiser SM, Albrecht M, Fifer M, Vlahakes GJ, Madsen JC. Management of coronary artery compression caused by recurrent aortic root abscess. J Cardiac Surg 2008;23:195–197. 4. Manzano MC, Vilacosta I, San Roman JA, Aragoncillo P, Sarria C, Lopez D, Lopez J, Revilla A, Manchado R, Hernandez R, Rodriguez E. Acute coronary syndrome in infective endocarditis. Rev Esp Cardiol 2007;60:24–31.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
External Coronary Artery Compression Due to Prosthetic Valve Bacterial Endocarditis Matthew E. Harinstein,*
MD,
and Oscar C. Marroquin,
MD
Acute coronary syndromes in the setting of infective endocarditis may be the result of coronary compression secondary to periannular aortic valve complications, coronary embolism, obstruction of the coronary ostium due to a large vegetation, coronary atherosclerosis, and severe aortic insufficiency. External coronary artery compression as a result of infective endocarditis is a rare and lethal finding with few reported cases available in the medical literature. We present a rare occurrence of an acute coronary syndrome occurring in the setting of a bioprosthetic aortic valve abscess in which there was no complete coronary occlusion visualized and given the patient’s recent unremarkable catheterization and findings of diffuse tapering of the proximal left coronary system, the most likely etiology was external compression secondary to the known aortic root abscess, which caused myocardial ischemia, and was confirmed during surgery. Although uncommon, external compression should be considered in the differential diagnosis of acute coronary syndrome in this setting and coronary angiography can be diagnostic of this entity. VC 2012 Wiley Periodicals, Inc. Key words: angiography-coronary; diagnostic cardiac catheterization; acute coronary syndrome; valvular heart disease
INTRODUCTION
Acute coronary syndromes in patients with infective endocarditis are relatively uncommon, occur early in the disease, and are more commonly due to coronary atherosclerosis, aortic insufficiency, or embolization. External coronary artery compression, as a result of infective endocarditis and subsequent abscess formation, which causes myocardial ischemia, is exceedingly rare and life threatening. We report a case of a 66-year-old patient who presented with prosthetic valve endocarditis due to methicillin resistant staphylococcus epidermidis (MRSE) and suffered an acute coronary syndrome and cardiogenic shock.
tion fraction was estimated to be 60% by contrast ventriculography. He now presents with dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and increasing lower extremity edema. Initial blood cultures, which were obtained on admission returned positive for MRSE. A transthoracic echocardiogram performed upon admission revealed a preserved ejection fraction, grade 3 diastolic dysfunction, and severe aortic insufficiency. The patient was initiated on an antibiotic regimen of vancomycin, moxifloxacin, and rifampin and transferred to our institution for further management. Upon arrival, his initial examination Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
CASE REPORT
A 66-year-old male with a past medical history significant for bioprosthetic aortic valve replacement for severe aortic stenosis, atrial fibrillation, hypertension, grade 3 diastolic dysfunction, and chronic obstructive pulmonary disease presented with worsening dyspnea. He presented with a similar complaint 6 months earlier, at the time of his aortic valve replacement, which was performed for severe aortic stenosis. At that time, preoperative coronary angiography revealed only mild luminal irregularities in the left anterior descending and left circumflex arteries. The left ventricular ejecC 2012 Wiley Periodicals, Inc. V
Additional Supporting Information may be found in the online version of this article. Conflict of interest: Nothing to report. *Correspondence to: Matthew E. Harinstein, MD, Heart & Vascular Institute, University of Pittsburgh Medical Center, 200 Lothrop Street, Scaife 5-553, Pittsburgh, PA 15213. E-mail: [email protected] Received 6 April 2012; Revision accepted 17 July 2012 DOI 10.1002/ccd.24578 Published online 6 August 2012 in Wiley Online Library (wileyonlinelibrary.com)
External Coronary Compression due to PVE
Fig. 1. A: Two-dimensional mid-esophageal short axis view of the aortic valve with an abscess in between the aortic bioprosthesis and aortic wall along the non-coronary and left coronary cusps; (B) color Doppler image at the aortic valve level revealing flow into the abscess cavity.
was notable for a middle aged gentleman who was comfortable and speaking in full sentences. He had a 2/6 systolic ejection murmur as well as a soft 1/4 diastolic murmur, bibasilar rales, and severe pitting edema of both lower extremities. A transesophageal echocardiogram (TEE) was performed and revealed a mildly reduced ejection fraction, a 3.7 cm 1 cm abscess in between the aortic bioprosthesis and aortic wall along the non-coronary cusp and left coronary cusp (Fig. 1 and Supporting Information Video 1), a small perforation in the strut between the left and right coronary cusps, and a 1.6 cm 1.1 cm echodensity inside the abscess cavity which communicates with the aortic lumen through a breach in the strut. There was also evidence of moderate to severe paraprosthetic aortic regurgitation with holodiastolic reversal of flow in the descending aorta. Later that evening, the patient developed central chest discomfort which radiated to his neck and jaw and he
E169
became more hypotensive. An electrocardiogram revealed evidence of ST segment elevations in the anterior precordial leads. A cardiac catheterization was performed and revealed diffuse proximal narrowings and reduced TIMI 2 flow of the left anterior descending and left circumflex coronary arteries, which given the patient’s unremarkable angiogram from 6 months prior and current presentation (Fig. 2), were felt to be the result of external compression from the bioprosthetic endocarditis and aortic abscess (Supporting Information Video 2). Since there was no single focal stenosis, but rather diffuse vessel narrowings likely due to external compression, percutaneous coronary intervention was not performed and the patient was taken emergently to the operating room for intervention. The intraoperative TEE revealed an ejection fraction of approximately 15% at the beginning of the case. Surgical inspection revealed a large abscess over the dome of the left atrium into the bifurcation of the left main and extending over the left anterior descending and left circumflex coronary arteries. There was gross endocarditis of the bioprosthetic aortic valve and annular dehiscence. The surgical findings confirmed the diagnosis of external compression of the coronary arteries as the etiology of his acute coronary syndrome and resultant severe reduction of systolic function. Pathology and subsequent blood cultures were consistent with MRSE prosthetic valve endocarditis. The aortic root was replaced with a 26 mm homograft and two vessel coronary artery bypass grafting was performed. Unfortunately, the patient remained acidemic postoperatively and suffered a cardiac arrest 4 hr later, from which he did not recover. DISCUSSION
External coronary artery compression as a result of infective endocarditis is a rare and lethal finding with few reported cases available in the medical literature [1–3]. To our knowledge, this is the first case reported which is the result of MRSE. Mechanisms for myocardial ischemia in patients with infective endocarditis include coronary compression secondary to periannular aortic valve complications, coronary embolism, obstruction of the coronary ostium due to a large vegetation, coronary atherosclerosis, and severe aortic insufficiency [4]. Studies using intravascular ultrasound have shown that vessels with even mild disease can progress rapidly to become acute lesions. However, in this case, there was no complete coronary occlusion visualized and given the patient’s recent catheterization and findings of diffuse tapering of the proximal left coronary system, not simply a focal stenosis, the most likely etiology
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
E170
Harinstein and Marroquin
Fig. 2. A: Preoperative selective angiogram of the short left main and left anterior descending coronary artery; (B) preoperative angiogram of the left circumflex coronary artery; (C) angiogram of the left coronary system after ST elevations were noted on telemetry.
was external compression secondary to the known aortic root abscess, which caused an acute coronary syndrome, and was confirmed during surgery.
this setting and coronary angiography can be diagnostic of this entity. REFERENCES
CONCLUSION
This case demonstrates a rare occurrence of a bioprosthetic aortic valve abscess causing external coronary artery compression resulting in an acute coronary syndrome and myocardial ischemia. Although uncommon, external compression should be considered in the differential diagnosis of acute coronary syndrome in
1. Cripps T, Guvendik L. Coronary artery compression caused by abscess formation in infective endocarditis. Int J Cardiol 1987;14:99–102. 2. Dean JW, Kuo J, Wood AJ. Myocardial infarction due to coronary artery compression by aortic root abscess. Int J Cardiol 1993;41:165–167. 3. Cowan SW, Fiser SM, Albrecht M, Fifer M, Vlahakes GJ, Madsen JC. Management of coronary artery compression caused by recurrent aortic root abscess. J Cardiac Surg 2008;23:195–197. 4. Manzano MC, Vilacosta I, San Roman JA, Aragoncillo P, Sarria C, Lopez D, Lopez J, Revilla A, Manchado R, Hernandez R, Rodriguez E. Acute coronary syndrome in infective endocarditis. Rev Esp Cardiol 2007;60:24–31.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
