Ann Thorac Surg 1998;65:841-842
© 1998 The Society of Thoracic Surgeons
Case Reports
Mycotic Aneurysm of the Left Coronary Artery
Masahiko Matsumoto, MD,
Yutaka Konishi, MD,
Senri Miwa, MD,
Kenji Minakata, MD
Department of Cardiovascular Surgery, Wakayama Red Cross Hospital, Wakayama, Japan
Accepted for publication October 20, 1997.
Dr Matsumoto, Department of Cardiovascular Surgery, Wakayama Red Cross Hospital, 4-20 Komatsubara dori, Wakayama 640, Japan.
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Abstract
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We report a 24-year-old man with mitral valve endocarditis complicated by acute myocardial infarction due to coronary embolism. Percutaneous transluminal coronary angioplasty and subsequent mitral valve replacement were performed. Postoperative coronary angiography revealed formation of a mycotic aneurysm of the left anterior descending coronary artery at the site of balloon inflation. The patient then underwent successful resection of the aneurysm with coronary artery bypass grafting.
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Introduction
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We describe a patient with mitral valve endocarditis complicated by acute myocardial infarction due to coronary embolism. The patient underwent percutaneous transluminal coronary angioplasty (PTCA) and had development of a mycotic aneurysm of the coronary artery at the site of PTCA.
A 24-year-old man was admitted to another hospital on January 30, 1996, with a 3-month history of fever. Blood cultures were positive for 
-Streptococcus. Echocardiography revealed a large vegetation on the mitral valve with mild mitral regurgitation. Administration of benzylpenicillin potassium was started. On February 23, the patient experienced severe retrosternal chest pain while lying in bed. An electrocardiogram showed ST segment elevation in leads I, aVL, and V1 to V6. Emergency coronary angiography revealed total occlusion of the proximal left anterior descending artery (LAD) and no significant stenosis of the circumflex or right coronary arteries. An intraaortic counterpulsation balloon was inserted. Percutaneous transluminal coronary angioplasty was performed, and partial recanalization of the LAD was demonstrated 2.8 hours after the onset of chest pain. However, there was residual severe stenosis of the LAD with emboli. Serial cardiac enzyme measurements showed a peak creatine kinase level of 4,049 IU/L with an MB fraction of 299 IU/L.
On February 24 the patient was transferred to our hospital for surgical treatment 11 hours after the onset of chest pain. His blood pressure was 100/72 mm Hg, pulmonary arterial pressure 37/22 mm Hg, pulmonary capillary wedge pressure 22 mm Hg, and cardiac index 2.98 L · min-1 · m-2. At operation, 14 hours after the onset of chest pain, a large vegetation on the anterior mitral leaflet was found. The mitral valve was replaced with a 29-mm St. Jude Medical (St. Paul, MN) prosthesis. Concomitant coronary artery bypass grafting was not performed because the optimal time period (within 6 hours of onset) had passed and delayed operation might have induced the development of hemorrhagic infarction. The postoperative course was uneventful.
Cardiac catheterization and angiography were repeated on the 38th postoperative day. A saccular aneurysm of the proximal LAD was observed at the PTCA site with delayed filling of the distal LAD (Fig 1). Thallium-201 single-photon emission computed tomographic imaging revealed a significant stress defect in the anterolateral wall. On April 17, an aneurysm of the LAD, measuring 2 x 2 cm, was resected, and simultaneous bypass with a left internal thoracic artery graft to the distal LAD was performed. Pathologic examination of the aneurysmal wall revealed inflammatory cell reaction in the media (Fig 2). Thus, a diagnosis of mycotic aneurysm was made. Postoperative coronary angiography revealed a patent internal thoracic artery graft and no evidence of residual aneurysm of the LAD. The patient remains well and free of angina pectoris 18 months after the operation.
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Photomicrograph of the aneurysmal wall showing inflammatory cell reaction in the media. (Hematoxylin and eosin; x50 before 53% reduction.)
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Comment
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Coronary embolism is not an uncommon complication of infective endocarditis. However, formation of a coronary artery mycotic aneurysm is seldom seen as a complication of endocarditis. Several mechanisms may be involved in the pathogenesis of formation of mycotic aneurysms: (1) embolic occlusion and sterile infarction of the vasa vasorum, (2) direct bacterial invasion of the arterial wall, particularly in acute endocarditis, and (3) injury due to immune complex deposition [1]. In our patient, PTCA was performed because of embolic occlusion of the LAD, and a mycotic aneurysm subsequently developed at the PTCA site. A mycotic aneurysm might result from some of these mechanisms, but PTCA of an embolic occlusion from a vegetation could certainly be expected to produce intimal disruption and seeding of the bacteria, and to facilitate aneurysm formation [2]. To avoid formation of mycotic coronary aneurysms, a less injurious approach should be the choice of a treatment of such a lesion. Bal and associates [3] reported that the long-term prognosis of PTCA-induced coronary aneurysms was excellent. However, mycotic aneurysms have a great tendency to rupture [4][5], and this may result in cardiac tamponade and sudden death [6], making early recognition and surgical treatment mandatory.
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References
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- Weinstein L, Schlesinger JJ Pathoanatomic, pathophysiologic and clinical correlations in endocarditis (second of two parts). N Engl J Med 1974;291:1122-1125.
- Herzog CA, Henry TD, Zimmer SD Bacterial endocarditis presenting as acute myocardial infarction: a cautionary note for the era of reperfusion. Am J Med 1991;90:392-397.[Medline]
- Bal ET, Plokker T, van den Berg EMJ, et al. Predictability and prognosis of PTCA-induced coronary artery aneurysms. Cathet Cardiovasc Diagn 1991;22:85-88.[Medline]
- Cliff MM, Soulen RL, Finestone AJ Mycotic aneurysms—a challenge and a clue. Review of ten-year experience. Arch Intern Med 1970;126:977-982.[Abstract/Free Full Text]
- Yellin AE Ruptured mycotic aneurysm. A complication of parenteral drug abuse. Arch Surg 1977;112:981-986.[Abstract/Free Full Text]
- McGee MB, Khan MY Ruptured mycotic aneurysm of a coronary artery. A fatal complication of Salmonella infection. Arch Intern Med 1980;140:1097-1098.[Abstract/Free Full Text]
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Abstract
Introduction
