Campanile Alfonso, Tavazzi Guido, Caprioglio Francesco, Rigo Fausto
Department of Cardiology, Hospital "S. M. della Misericordia", Perugia, Italy.
Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione Policlinico San Matteo IRCCS, University of Pavia, Pavia, Italy.
BMC Cardiovasc Disord. 2018 Feb 9;18(1):28. doi: 10.1186/s12872-018-0750-3.
Infective endocarditis (IE) is still a condition with high mortality and morbidity, especially in the elderly, and in patients with prosthetic valves. The concept of "time-to-therapy" plays a key role for the prompt management of IE and related complications, and the currently available multimodality imaging may play a key role in this setting. Myocardial ischemia due to extrinsic coronary compression from an aortic abscess is an extremely rare condition where the optimal therapeutic strategy has not been defined yet. We present herein the first case of a patient with ST elevation myocardial infarction caused by an aortic root abscess treated with percutaneous stent implantation.
An 82-year-old woman with a history of atrial fibrillation, chronic renal failure, anemia and a bioprosthetic aortic valve replacement performed in 2014, was admitted to hospital with profound asthenia and a pyrexia of unknown origin. Because of high clinical suspicion of endocarditis, a trans-esophageal echocardiogram was performed. Empirical broad-spectrum antimicrobial therapy was initiated, followed by targeted treatment based on the results of blood cultures (Staphylococcus aureus). The echocardiogram did not show vegetations and the patient was managed conservatively. She suddenly deteriorated, due to an acute coronary syndrome (ACS) with anterior ST segment elevation. An urgent angiogram was performed, and extrinsic compression of the left coronary system, due to an aortic root abscess, was suspected. After discussion with the surgical team, percutaneous revascularization was attempted, aiming to restore satisfactory hemodynamics, in order to plan surgery. Unfortunately, the patient rapidly developed cardiogenic shock, with multi organ failure, and died in less than 24 h.
Patients with fever, and significant risk factors for endocarditis, who develop ACS, need a prompt diagnostic work up, including trans-esophageal echocardiography. At present, the specific timing of echocardiographic follow-up and surgical intervention is still a matter of debate, and our case aims to highlight the importance of this aspect in the management of endocarditis, in order to avoid severe complications that adversely affect patient prognosis.
感染性心内膜炎（IE）仍然是一种死亡率和发病率较高的疾病，尤其是在老年人以及人工瓣膜置换患者中。“治疗时机”的概念对于IE及相关并发症的及时处理起着关键作用，而目前可用的多模态成像在这种情况下可能发挥关键作用。主动脉脓肿导致的外在冠状动脉压迫引起的心肌缺血是一种极为罕见的情况，目前尚未确定最佳治疗策略。我们在此报告首例因主动脉根部脓肿导致ST段抬高型心肌梗死并接受经皮支架植入治疗的患者。
一名82岁女性，有房颤、慢性肾衰竭、贫血病史，2014年接受生物瓣主动脉瓣置换术，因极度乏力和不明原因发热入院。由于临床高度怀疑心内膜炎，遂行经食管超声心动图检查。开始经验性广谱抗菌治疗，随后根据血培养结果（金黄色葡萄球菌）进行针对性治疗。超声心动图未显示赘生物，患者接受保守治疗。她突然病情恶化，因急性冠状动脉综合征（ACS）出现前壁ST段抬高。紧急进行血管造影，怀疑左冠状动脉系统因主动脉根部脓肿受到外在压迫。与手术团队讨论后，尝试进行经皮血管重建，旨在恢复满意的血流动力学，以便安排手术。不幸的是，患者迅速发展为心源性休克，伴有多器官功能衰竭，在不到24小时内死亡。
发热且有显著心内膜炎危险因素并发生ACS的患者，需要进行包括经食管超声心动图在内的快速诊断检查。目前，超声心动图随访和手术干预的具体时机仍存在争议，我们的病例旨在强调这一方面在感染性心内膜炎管理中的重要性，以避免严重并发症对患者预后产生不利影响。
