Septic coronary embolization in a patient with congenitally corrected transposition of the great arteries

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A 31-year-old man with congenitally corrected transposition of the great arteries (L-type), congenital complete heart block, bicuspid aortic valve, chronic intravenous heroin abuse, multiple episodes of bacteremia, and a remote history of enterococcal endocarditis treated with intravenous antibiotics was admitted with severe sepsis and methicillin-sensitive Staphylococcus aureus bacterial endocarditis. Brain MRI showed multiple septic emboli. Cardiac MRI showed ventricular inversion (Fig. 1) and an 1.2 cm vegetation arising off the right anterior leaflet of the bicuspid aortic valve with fusion of the right anterior and posterior leaflets with a peak gradient of 27 mmHg and a hypertrophied, dilated systemic right ventricle (RV).
After 3 weeks of inpatient intravenous antibiotics, the patient experienced sudden onset of severe chest pain with evidence of pulmonary edema, hypoxemia, and cardiogenic shock. ECG showed anterior ST-segment elevation. Emergency coronary angiography showed complete occlusion of the morphologic left anterior descending artery (Fig. 2a and Supplementary Movie 1, Supplemental digital content 1, http://links.lww.com/MCA/A149). Embolectomy with AngioJet (Boston Scientific; Marlborough, Massachusetts, USA) thrombectomy catheter was unsuccessful. Eventually, perfusion was restored with balloon angioplasty and bare-metal stent (Fig. 2b and Supplementary Movie 2, Supplemental digital content 2, http://links.lww.com/MCA/A150). During the procedure the patient experienced ventricular fibrillation that necessitated defibrillation and antiarrhythmic therapy. Troponin peaked at more than 80 ng/ml.
Eight days following percutaneous intervention (PCI), the patient underwent bioprosthetic aortic valve replacement. Several months after discharge, the patient died following readmission with septic/cardiogenic shock due to methicillin-resistant S. aureus prosthetic valve endocarditis.

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