Embolized Infective Vegetation-Induced ST-Elevation Myocardial Infarction After Transcatheter Aortic Valve Implantation

An 87-year-old male was admitted to hospital due to fever lasting for 2 weeks after undergoing gastric cancer surgery 1 month earlier. He had also undergone a transcatheter aortic valve implantation (TAVI) procedure for aortic valve stenosis 2 months prior to admission.

On admission, he had no symptom except for fever, but 5 days later, he experienced sudden chest pain accompanied by ST-segment elevation in V_2–6 leads on ECG. Cardiac ultrasound revealed regional left ventricular wall akinesia in the anteroseptal segment and a 7-mm mobile mass attached to the transcatheter heart valve (THV) (Figure A, Supplementary Movie). He was diagnosed with ST-elevation acute myocardial infarction (STEMI). Emergency coronary angiography was performed, revealing a total occlusive lesion of the proximal left anterior descending artery (LAD) (Figure B). Successful recanalization was achieved following repeated thrombus aspiration and ballooning (Figure C).

Figure.

(A) Cardiac ultrasound showing regional left ventricular wall akinesia in the anteroseptal segment (Left) and a 7-mm mobile mass attached to the transcatheter heart valve (Right). Coronary angiography before (B) and after (C) percutaneous coronary intervention. (D) Gross appearance of material aspirated from the coronary artery. (E) Hematoxylin and eosin staining. (F) Gram staining.

However, the shock state persisted, despite catecholamine administration and intra-aortic balloon pump support, and the patient died the following day. Pathological examination of the aspirated material from the LAD (Figure D) revealed several colonies of gram-positive cocci in the thrombi (Figure E,F), resulting in a diagnosis of STEMI caused by embolization of infective endocarditis (IE) vegetation attached to the THV.

The reported incidence of IE after TAVI (1.4%) is comparable to that recorded after surgical aortic valve replacement,¹ although induction of STEMI by embolized vegetation is extremely rare. Therefore, in cases of STEMI after TAVI, clinicians should consider the potential involvement of IE.

Disclosures

Y.I. is a member of Circulation Journal’s Editorial Team.

IRB Information

This case report was approved by Tokai University School of Medicine. Reference number: 23J004.

Supplementary Files

Supplementary Movie. Cardiac ultrasound.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-23-0494

Reference

• 1.   Bjursten H, Rasmussen M, Nozohoor S, Götberg M, Olaison L, Rück A, et al. Infective endocarditis after transcatheter aortic valve implantation: A nationwide study. Eur Heart J 2019; 40: 3263–3269.