Corti, Roberto

Falk, Volkmar

Klingenberg, Roland

Lüscher, Thomas

Schmied, Christian

Zbinden, Andrea

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LETTER TO THE EDITORSMolecular evidence of Enterococcus faecalis in an occludingcoronary thrombus from a patient with late prosthetic valveendocarditisRoland Klingenberg • Christian Schmied •Volkmar Falk • Thomas F. Lu¨scher •Andrea Zbinden • Roberto CortiReceived: 13 March 2012 / Accepted: 30 May 2012 / Published online: 12 June 2012 Springer-Verlag 2012Sirs:ST elevation myocardial infarction (STEMI) is commonlycaused by a thrombotic occlusion of an epicardial coronaryartery. The most frequent cause is plaque rupture or erosionof an atherosclerotic plaque with subsequent thrombusformation [1]. Thromboembolism constitutes an infrequentscenario attributable to dislodgement of a thrombus from adistinct site such as in venous thrombosis combined with apatent foramen ovale. Septic thromboembolism from anendocarditic valve is a very rare, but potentially fatal eti-ology and direct evidence of the associated microorganismin the occluding coronary thrombus has not been reported.A 77-year-old male patient with subacute anterior ST-segment elevations on 12-lead ECG was referred to ourinstitution for coronary angiography. His past medical his-tory revealed a left hip joint replacement 10 years ago andaortic valve replacement with a biological prosthetic valvefor symptomatic calcific aortic stenosis 5 years ago. At thattime he had a severely compromised systolic LV functionand non-stenotic epicardial coronary arteries (Fig. 1a). Dueto persistent pain in the left hip, analysis of the joint fluidwas performed 3 weeks prior to admission yieldingEnterococcus faecalis. Surgical hip prosthesis removal wascomplicated by postoperative septicemia (E. faecalis),requiring vasopressor therapy and intravenous antibiotics(amoxicillin and tobramycin iv). During the course of thiscomplication, the patient also experienced chest painassociated with the ECG changes mentioned above. Coro-nary angiography showed complete thromboembolicocclusion of the mid-portion of the left anterior descendingcoronary artery (LAD; Fig. 1b) and a non-stenotic lesion inthe circumflex and right coronary artery. Repetitivethrombus aspiration using an aspiration catheter and stent-ing due to residual thrombus material was performed withsubsequent restoration of normal coronary blood flow. Aselective aortogram showed accumulation of contrast-dyein a perivalvular cavity protruding from the ascending aortain proximity to the biological valve suspicious of an abscess(Fig. 1c). To assess urgency of surgery, serial transo-esophagial echocardiograms over the next 2 days revealedrapidly growing vegetations on the aortic valve, relevantaortic regurgitation and an enlarged perfused perivascularcavity measuring 2.5 9 1.3 cm (Fig. 1d–f). Urgent cardiacsurgery was performed (standard/logistic euro-SCORE = 22/93.65 %) confirming a large abscess cavitywith disentanglement of the aortic valve annulus from themitral valve and substantial valvular vegetations. Followingexplantation of the prosthetic valve and debridement, theaortic root was replaced by a Freestyle-prosthesis with re-implantation of the left and right coronary ostium. Theantibiotic regimen was escalated due to an intercurrentventilator-associated pneumonia and the patient was refer-red 5 weeks later to a regional hospital.Microbiological evaluation yielded E. faecalis for thevegetations on the prosthetic aortic valve using conven-tional culture techniques. The coronary thrombus aspiratedfrom the LAD was positive for bacterial DNA of E. fae-calis by PCR method.R. Klingenberg (&)  C. Schmied  T. F. Lu¨scher  R. CortiDepartment of Cardiology/Cardiovascular Research, UniversityHospital Zurich, Ra¨mistrasse 100, 8091 Zurich, Switzerlande-mail: roland.klingenberg@usz.chV. FalkDepartment of Cardiothoracic Surgery,University Hospital Zurich, Zurich, SwitzerlandA. ZbindenInstitute of Medical Microbiology, University of Zurich,Zurich, Switzerland123Clin Res Cardiol (2012) 101:1021–1023DOI 10.1007/s00392-012-0483-8Fig. 1 Imaging of the coronary vasculature, aortic valve and aorta. a,b Coronary angiogram. Arrow shows thrombotic occlusion. c Selec-tive aortogram showing the bioprosthetic valve (open arrows) and theadjacent abscess (closed arrows). d–f Transoesophageal echocardio-gram ± color doppler. Arrows show paravalvular abscess cavity1022 Clin Res Cardiol (2012) 101:1021–1023123We here report a case of STEMI due to septic emboli-sation as a result of infective endocarditis with E. faecalisleading to a rapid destruction of the prosthetic valve. Wedemonstrate a clear link between colonization of theprosthetic aortic valve with E. faecalis and PCR-baseddetection of the bacterium [2] in the occluding coronarythrombus. In line with our interpretation of a thromboem-bolic source of the thrombus, the LAD showed no detect-able atherosclerotic lesion 5 years prior to the incident andalso was remarkably smooth after thrombus aspiration andstenting at the time of the STEMI. The spectrum of caus-ative organisms for prosthetic valve endocarditis rangesfrom frequently found bacterial species (Staphylococcusaureus, Coagulase-negative Staphylococci, Enterococci,Viridans Streptococci) [3] to rare cases caused by Lacto-coccus garvieae [4] or Granulicatella adiacens [5]. Despitea rising number of patients with prosthetic valves, therelative incidence of prosthetic endocarditis has declinedsubstantially to less than 0.5 % per year for late prostheticendocarditis [6]. This case demonstrates the dramaticcourse of late prosthetic valve endocarditis despite promptinitiation and maintenance of an antibiotic regimen withdocumented sensitivity of E. faecalis to the combination ofa b-lactam and an aminoglycoside which had been imple-mented according to current ESC guidelines [7].Acknowledgments The authors received support from the SwissNational Research Foundation Sonderprogramm Universita¨re Medi-zin SPUM 33CM30-124112; the Swiss Heart Foundation; the Fon-dation Leducq, a strategic alliance with Pfizer Inc. and the ZurichHeart House—Foundation for Cardiovascular Research, Zurich.Conflict of interest No conflict of interest to be declared.References1. Virmani R, Burke AP, Farb A, Kolodgie FD (2006) Pathology ofthe vulnerable plaque. J Am Coll Cardiol 47:C13–C182. Bosshard PP, Kronenberg A, Zbinden R, Ruef C, Bottger EC,Altwegg M (2003) Etiologic diagnosis of infective endocarditis bybroad-range polymerase chain reaction: a 3-year experience. ClinInfect Dis 37:167–1723. Wang A, Athan E, Pappas PA, Fowler VG Jr, Olaison L, Pare C,Almirante B, Munoz P, Rizzi M, Naber C, Logar M, Tattevin P,Iarussi DL, Selton-Suty C, Jones SB, Casabe J, Morris A, CoreyGR, Cabell CH (2007) Contemporary clinical profile and outcomeof prosthetic valve endocarditis. JAMA 297:1354–13614. Wilbring M, Alexiou K, Reichenspurner H, Matschke K, TugtekinSM (2011) Lactococcus garvieae causing zoonotic prostheticvalve endocarditis. Clin Res Cardiol 100:545–5465. Poss J, Schafers HJ, Herrmann M, von Muller L, Bohm M, KilterH (2010) Leukocytoclastic vasculitis and myocardial infarction aspresenting manifestations of infective endocarditis: a case report.Clin Res Cardiol 99:59–616. Piper C, Korfer R, Horstkotte D (2001) Prosthetic valve endocar-ditis. Heart 85:590–5937. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I,Moreillon P, de Jesus Antunes M, Thilen U, Lekakis J, Lengyel M,Muller L, Naber CK, Nihoyannopoulos P, Moritz A, Zamorano JL(2009) Guidelines on the prevention, diagnosis, and treatment ofinfective endocarditis (new version 2009): the task force on theprevention, diagnosis, and treatment of infective endocarditis ofthe european society of cardiology (esc). Endorsed by the europeansociety of clinical microbiology and infectious diseases (escmid)and the international society of chemotherapy (isc) for infectionand cancer. Eur Heart J 30:2369–2413Clin Res Cardiol (2012) 101:1021–1023 1023123

Molecular evidence of Enterococcus faecalis in an occluding coronary thrombus from a patient with late prosthetic valve endocarditis

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Molecular evidence of Enterococcus faecalis in an occluding coronary thrombus from a patient with late prosthetic valve endocarditis

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