Aortic prosthetic valve endocarditis as a cause of acute myocardial infarction

Abstract

To the Editor, Compared to other causes, the most common cause of acute myocardial infarction (AMI) by far is atherosclerotic plaque rupture with its corresponding thrombosis and occlusion of the blood vessel. This is called type-1 AMI according to the latest guidelines by the European Society of Cardiology (ESC) published back in 2018 regarding the fourth universal definition of AMI. However, other cases reveal different and less common pathophysiological conditions as the cause of AMI. This is a very rare case of a patient with AMI associated with embolization of vegetation due to endocarditis that would correspond to a type-2 AMI according to the guidelines mentioned before. This is the case of a 69-year-old male patient treated of aortic valve disease in 1994 implanted with a 25 mm Medtronic-Hall mechanical valve (Medtronic, United States). He was admitted to our hospital ER with clinical signs of high fever, poor general health status, and confusional syndrome of 48-hour duration. The cranial CT scan performed showed multiple images compatible with cortical and subcortical ischemic infarctions of possible embolic origin. The transthoracic echocardiography performed was inconclusive when it revealed vegetation at valve level, which is why a transesophageal echocardiography was performed that did show an image consistent with vegetation at valve ventricular level (figure 1A). Empirical antibiotic therapy was started with meropenem, daptomycin, rifampicin, and cloxacillin. A wait-and-see approach was established to see the patient’s clinical progression and make a decision on the next therapeutic approach. Forty-eight hours after admission, the patient showed intense precordial pain and sweating, which is why an electrocardiogram was performed. It revealed the presence of overt ST-segment elevation in leads V2-V5 (figure 1B). Infarction code was activated, and the patient was referred to our unit to perform an emergency coronary angiography.