Correspondence

Acute Myocardial Infarction Due to Septic Coronary Embolism

N Engl J Med 2000; 342:977-978March 30, 2000

Article

To the Editor:

Lanza et al. (Sept. 30 issue)1 described a case of acute myocardial infarction due to a coronary embolus arising from a left ventricular thrombus. We report a case of myocardial infarction that was fatal, despite fibrinolytic therapy, and that arose from the embolism of bacterial vegetation in a woman with no known coronary risk factors and incompletely treated infective endocarditis. Postmortem examination revealed a bacteria-laden embolus in a major epicardial artery and an intraparenchymal cerebellar hemorrhage.

A 54-year-old woman, who was an intravenous drug abuser, was admitted with a four-week history of fever and interrupted treatment for bronchial pneumonia. She had no known cardiac risk factors and had no history of cardiovascular disease. A few hours after admission, she reported chest pain and shortness of breath. On physical examination, the patient was febrile and hypotensive and was in respiratory distress. Cardiac auscultation revealed a high-pitched early diastolic murmur heard best at the fourth intercostal space at the left sternal border, with moderate bibasilar crackles. An electrocardiogram showed acute ST-segment elevation in the inferolateral leads. Fibrinolytic therapy was started with “front-loaded” alteplase. Since the patient remained in cardiogenic shock, a transesophageal echocardiogram was obtained on an urgent basis; it revealed severe, diffuse left ventricular hypokinesis, severe aortic and moderate mitral-valve regurgitation, and a mobile mass on the aortic valve (Figure 1Figure 1Transesophageal Echocardiogram Showing the Left Ventricular Outflow Tract with an Adherent Mobile Vegetation (Arrow) on the Aortic-Valve Leaflet.). No left ventricular thrombus was seen. The patient became progressively less responsive and died despite attempted cardiopulmonary resuscitation. After her death, several blood cultures that had been performed on admission showed colonies of Staphylococcus aureus and Enterococcus faecalis.

An autopsy revealed minimal vegetation on the edge of the left aortic-valve leaflet, at a distance of 3 cm from the left main ostium; the vegetation was much smaller than expected on the basis of the echocardiographic findings. The mitral and tricuspid valves appeared normal. There was a thromboembolic occlusion of the left circumflex coronary artery, which showed clusters of gram-positive cocci (Figure 2Figure 2Septic Thromboembolism of the Left Circumflex Coronary Artery (Coincident with the Disappearance of the Aortic-Valve Vegetation Seen on Echocardiography).). In the parenchyma of the right cerebellum, there was a 0.9-cm² area of hemorrhagic infarction.

Septic coronary embolism was a relatively common finding in earlier autopsy studies of infective endocarditis.2 When diagnosed during life, myocardial infarction from septic embolism has usually had a poor outcome.3 There have been isolated reports of successful treatment with heparin and fibrinolytic drugs,4 although in patients such as ours, severe sepsis probably indicates a poor prognosis.

Rohan Perera, M.R.C.P.
Sigrid Noack, M.D.
Weifeng Dong, M.D.
St. Luke's–Roosevelt Hospital Center, New York, NY 10025

4 References

1. 1

   Lanza GM, Berman BJ, Taniuchi M. Multifocal coronary thromboembolism from a left ventricular thrombus. N Engl J Med 1999;341:1083-1084
   Full Text | Web of Science | Medline

2. 2

   Brunson JG. Coronary embolism in bacterial endocarditis. Am J Pathol 1953;29:689-701
   Web of Science | Medline

3. 3

   Wenger NK, Bauer S. Coronary embolism: review of the literature and presentation of fifteen cases. Am J Med 1958;25:549-557
   CrossRef | Web of Science | Medline

4. 4

   Blum A, Sclarovsky S, Rechavia E. “Infective“ myocardial infarction. Chest 1993;103:1084-1086
   CrossRef | Web of Science | Medline

Citing Articles (6)

Citing Articles

1. 1

   Czarina J. Roxas, Anthony J. Weekes. (2011) Acute Myocardial Infarction Caused by Coronary Embolism from Infective Endocarditis. The Journal of Emergency Medicine 40:5, 509-514
   CrossRef

2. 2

   Arash Yavari, Gideon Paul, Gordon Jackson. (2008) Aborted sudden cardiac death – a rare presentation of septic coronary embolism. European Journal of Internal Medicine 19:7, 559
   CrossRef

3. 3

   María Carmen Manzano, Isidre Vilacosta, José A. San Román, Paloma Aragoncillo, Cristina Sarriá, Daniel López, Javier López, Ana Revilla, Rocío Manchado, Rosana Hernández, Enrique Rodríguez. (2007) Síndrome coronario agudo en la endocarditis infecciosa. Revista Española de Cardiología 60:1, 24-31
   CrossRef

4. 4

   Holger K. Eltzschig, Robert W. Lekowski, Stanton K. Shernan, Srdjan S. Nedeljkovic, John G. Byrne, Raila Ehlers, Sary F. Aranki. (2002) Intraoperative Transesophageal Echocardiography To Assess Septic Coronary Embolism. Anesthesiology 97:6, 1627-1629
   CrossRef

5. 5

   JAMES J. GLAZIER. (2002) Interventional Treatment of Septic Coronary Embolism: Sailing into Uncharted and Dangerous Waters.. Journal of Interventional Cardiology 15:4, 305-307
   CrossRef

6. 6

   Fred A. Severyn, Nils Albert. (2001) Clinical Pearls Altered Mental Status in an Intravenous Drug—Abusing Patient. Academic Emergency Medicine 8:10, 996-1004
   CrossRef