Footprints Under the Aorta

Abstract

INTRODUCTION: Thromboembolic complications are common in patients with infective endocarditis (IE).We report a case of recurrent myocardial infarction caused by Aspergillus endocarditis. CASE PRESENTATION: A 64-year-old man with history of leukemia, coronary heart disease (CHD), and bronchiolitis (steroid dependant) was admitted for worsening shortness of breath and one episode of severe chest pain. His initial vital signs and physical examination were consistent with congestive heart failure and laboratory work-up showed elevated ultrasensitive cardiac troponin-I (c-TnI) at 5 ng/ml. Admitting electrocardiogram (ECG) demonstrated ST-segment depression in the anterolateral leads. The patient underwent a cardiac catheterization which revealed disease of left main (LM) coronary for which a percutaneous coronary intervention (PCI) was planned in 48-72 hours. Six hours later, the patient developed a severe episode of crushing chest pain and telemetry revealed atrial flutter, ST-segment depressions and complete heart block. The patient was rushed for a repeat coronary angiogram.PCI of the LM and left anterior descending(LAD)arteries was undertaken alongwith insertion of a transvenous pacemaker and intra-aortic balloon pump. However, the patient developed several repeated episodes of chest pain, each necessitating a repeat angiogram and PCIs due to occlusions of the left circumflex, LAD territory (previously placed stents were patent). A transthoracic echocardiogram (TTE) performed on day 3 alluded to the possibility of a vegetation or abscess in the vicinity of the aortic root which was confirmed by a transesophageal echocardiogram (TEE) and a CT angiogram of the chest. Subsequently the patient underwent open heart surgery. Gross examination of the aorta revealed a large vegetation at the commissure of the right and left coronary cusps extending deep within the left ventricle (LV), with extensive tissue destruction of the aortic annulus and pseudoaneurysm formation.An attempt was made to sew a patch into the LV and place the aortic valve above the patch. However, when stitches tore through the ventricular wall, surgical reconstruction was deemed futile. Subsequently, cardiopulmonary support was withdrawn and the patient expired in the operating room. Pathology of the vegetation, aortic valve and left ventricle showed extensively necrotic and fibropurulent material containing numerous fungal hyphae consistent with A.fumigatus. DISCUSSION: Cardiac aspergillosis or Aspergillus endocarditis (AE) is very uncommon and rarely reported in native valves1;. AE and other fungal endocarditides usually occur in the setting of valvular replacement surgery, indwelling central venous catheters, neoplastic disease,prolonged broad-spectrum antibiotic and steroid use, and immunosuppressive therapy.2 The clinical diagnosis of AE is difficult because of the relative paucity of signs and symptoms of endocarditis and universally negative blood cultures. Delayed diagnosis and friable vegetations explain the frequent initial presentation with embolic complications. Also, although unclear, a predilection for left-sided valve endocarditis especially the aortic over the mitral valve has been documented3 regardless of the precipitating factor. The occurrence of embolic phenomenon in a culture-negative environment should raise the suspicion of AE. Radical debridement of necrotic tissue with valve replacement with or without aortic root replacement is the recommended procedure.Immunocompromised status from chronic steroid use and relatively recent chemotherapy (cladrabine) put our patient at risk for AE. CONCLUSIONS: Aspergilllus endocarditis related embolic occlusion of the coronary arteries resulting in myocardial necrosis is a rare event in the absence of prosthetic valves or open heart surgery.