Author + information
- Received August 9, 2016
- Accepted August 25, 2016
- Published online November 28, 2016.
- aDivision of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
- bDepartment of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- cDepartment of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- dDivision of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
- ↵∗Reprint requests and correspondence:
Dr. Arka Chatterjee, Division of Cardiovascular Disease, University of Alabama at Birmingham, 1520 3rd Avenue S FOT 907, Birmingham, Alabama 35294.
A 67-year-old man with a history of hypertension and coronary artery disease (requiring aortocoronary bypass 18 years ago and multiple percutaneous coronary interventions) presented to a referring hospital with chief symptoms of fever, chills, and diaphoresis after a recent gastrointestinal illness. Blood cultures obtained revealed Salmonella bacteremia. Transesophageal echocardiography revealed no evidence of endocarditis and he was treated with intravenous ciprofloxacin.
One month after discharge, he returned with recurrent fevers with blood cultures revealing recurrent Salmonella growth. He was started on an outpatient course of intravenous ceftriaxone before developing increased shortness of breath prompting his return. His physical examination showed increased jugular venous pressure and marked crackles in both lungs with a chest radiograph showing pulmonary edema and enlargement of the left atrium (Figure 1A). Troponin I was elevated at 63 ng/ml. A transthoracic echocardiogram revealed a reduced ejection fraction of 30% to 35%. Coronary angiography showed severe native 3-vessel disease with a patent left internal mammary graft to the left anterior descending artery, saphenous vein graft (SVG) to the right coronary artery, as well as an occluded vein graft to the diagonal. More notably, angiography of the SVG to the first obtuse marginal branch showed a large aneurysm (Figure 1B) around a previously stented segment in the body which had ruptured into the left atrium/left atrial appendage (Online Video 1).
He was transferred subsequently to our institution for further evaluation and surgical treatment. Transesophageal echocardiography (Figure 1C) revealed a 6.5 × 5-cm mass invading the left atrial appendage. A computed tomography angiogram of his chest (Figures 1D to 1F) was obtained showing a large thick-walled contrast collection along the left margin of the main pulmonary artery, which seemed to communicate with the left atrial appendage. Direct observation during surgery revealed a ruptured SVG aneurysm communicating with the pulmonary artery and left atrial appendage. The SVG aneurysm was resected successfully with repair of the left atrial appendage and the main pulmonary artery. Culture of his saphenous venous aneurysm identified Salmonella enteritidis. He underwent an uncomplicated post-operative course and was discharged 7 days after surgery on intravenous ceftriaxone for 6 weeks followed by chronic suppressive therapy with oral amoxicillin-clavulanic acid. Repeat computed tomography angiogram was performed 2 months after surgery, which showed no new signs of fluid collection or infection.
Coronary stent infection is a rare complication with only 17 documented cases from 1990 to 2012 (1). Nontyphoidal salmonella is a rare cause of bacteremia and an even rarer cause of mycotic aneurysms in atherosclerotic vessels (2). A stented vessel may be an additional risk factor for developing such a complication and a high index of suspicion should be maintained for patients not clearing salmonella bacteremia despite optimal antimicrobial therapy. Multiple imaging modalities may be needed to confirm a diagnosis of coronary stent infection. Transesophageal echocardiography may be able to reveal an aneurysm but coronary angiography/computed tomography angiogram is almost always required to confirm the diagnosis and detect complications such as vessel aneurysm or pseudoaneurysm. Positron emission tomography computed tomography is an active area of interest in diagnosis, because it may be used to reveal occult inflammation surrounding the stent. Surgical excision is almost always needed, especially in stent related infections happening remotely after implantation (3).
For a supplemental video and its legend, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 9, 2016.
- Accepted August 25, 2016.
- American College of Cardiology Foundation
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