Concurrent ST-elevation myocardial infarction and severe valvular regurgitation causing cardiogenic shock in a patient with infective endocarditis: how to manage?

Abstract

A 47-year-old-man without a significant medical history was presented with fever, shock and ST-elevation acute coronary syndrome (ACS, Fig. 1A). Transthoracic echocardiography revealed anteroseptal-apical wall motion abnormalities and severe aortic valve (AV, Fig. 1B, C) regurgitation. Suspecting infective endocarditis (IE) with secondary coronary embolization from AV-vegetations, the patient was scheduled for emergent surgery without pre-operative coronary angiography. Alternatively, a pre-operative CT-thorax was made which excluded para-aortal fistulae and abscesses and revealed an eccentric calcification, causing less than 25% obstruction, in the proximal left anterior descending coronary artery (Fig. 1D, E). Perioperative transoesophagal echocardiography showed a verrucous vegetation on the aortic left and right coronary cusps with severe regurgitation and a second threadlike vegetation (Fig. 1F–H, Movie 1–3 in ESM) prolabating into the left main coronary artery ostium (LMCAO). Peri-operatively, a threadlike vegetation, which was shown not to be connected to any other structure, was removed from the LMCAO (Fig. 1I) and an AV-prosthesis was placed. Microbiological analyses revealed Staphylococcus aureus. ACS is a common (incidence rate 2–11%) complication of IE, with high morbidity and mortality rates (the latter upto 43%) notably observed in case of an infected AV and severe regurgitation [1, 2]. ACS related to IE has been observed in the setting of (1) severe valvular regurgitation/fistula, (2) external CA compression, (3) a vegetation covering/within the coronary ostium, (4) septic embolization and (5) obstructive atherosclerotic CA disease. Management of ACS in the setting of IE lacks evidence from randomized trials. Observational data, however, suggest that conservative management is associated with poor clinical outcomes and should not be preferred. Comparably, fibrinolysis is contra-indicated and the use and even continuation of aspirin is controversial and its initiation is recommended against despite some positive outcomes, e.g., in low compared to high-dosage regimes and in patients with S. aureus as a causative agent [3]. Invasive procedures carry the risk of further embolic phenomena. Mixed results have been described after balloon angioplasty, while percutaneous interventions with stenting carry the risk of re-occlusion, stent infection and mycotic aneurysms behind the stent. Emergency surgical treatment is associated with ongoing bacteraemia and infected subannular tissue, which carry a high risk of both re-infection and dehiscence of the prosthesis. Hence early surgery has a relatively poor prognosis. Conversely, favourable results have been reported after thrombus aspiration [4, 5] and this could be an attractive alternative to emergency surgery in the setting of septic embolism causing hemodynamic instability in a patient with IE.