Sekar Baskar, Wheeler Richard, Masani Navroz, Gallagher Sean
Cardiology Department, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK.
Echo Res Pract. 2018 Jun;5(2):K35-K40. doi: 10.1530/ERP-18-0022. Epub 2018 Apr 11.
SummaryThis case describes an unusual presentation of prosthetic valve endocarditis (PVE): an acute coronary syndrome. A 67-year-old male presented with cardiac sounding chest pain on a background of a short history of night sweats, weight loss and general malaise. Four months previously, he had undergone bio-prosthetic aortic valve replacement for severe aortic stenosis and single vessel bypass grafting of the obtuse marginal. Whilst having chest pain, his ECG showed infero-lateral ST depression. Early coronary angiography revealed a new right coronary artery (RCA) lesion that was not present prior to his cardiac surgery. Using multi-modality cardiac imaging, the diagnosis of PVE was made. An aortic root abscess was demonstrated that was causing external compression of the RCA.
PVE accounts for up to 20% of all cases of infective endocarditis.High clinical suspicion and early blood cultures before empirical antibiotics are key as the presentation of PVE can often be atypical.PVE rarely presents as an acute coronary syndrome. Potential mechanisms by which PVE may result in an ACS include coronary embolization, obstruction of coronary ostia by a large mobile vegetation and external coronary artery compression from an infective aneurysms/abscess.Repeat cardiac surgery is often required for high-risk PVE such as those caused by staphylococcal infection or severe prosthetic dysfunction.
总结
本病例描述了人工瓣膜心内膜炎（PVE）的一种不寻常表现：急性冠状动脉综合征。一名67岁男性，在有盗汗、体重减轻和全身不适的短病史背景下，出现心脏听诊性胸痛。四个月前，他因严重主动脉瓣狭窄接受了生物人工主动脉瓣置换术以及钝缘支单支血管搭桥术。胸痛发作时，他的心电图显示下侧壁ST段压低。早期冠状动脉造影显示出一个新的右冠状动脉（RCA）病变，该病变在他心脏手术前并不存在。通过多模态心脏成像，诊断为PVE。发现一个主动脉根部脓肿，它正在对RCA造成外部压迫。
PVE占所有感染性心内膜炎病例的20%。高度的临床怀疑以及在使用经验性抗生素之前尽早进行血培养是关键，因为PVE的表现通常可能不典型。PVE很少表现为急性冠状动脉综合征。PVE可能导致急性冠状动脉综合征的潜在机制包括冠状动脉栓塞、大的活动赘生物阻塞冠状动脉开口以及感染性动脉瘤/脓肿对冠状动脉的外部压迫。对于高危PVE，如由葡萄球菌感染或严重人工瓣膜功能障碍引起的PVE，通常需要再次进行心脏手术。
