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Author + information
- Received December 28, 2016
- Accepted January 12, 2017
- Published online March 15, 2017.
- Joost Daemen, MD, PhD∗ ( and )
- Nicolas M. Van Mieghem, MD, PhD
- ↵∗Address for correspondence:
Dr. J. Daemen, Department of Cardiology, Room Ad-342, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands.
A 69-year-old woman presented to the outpatient clinic with fatigue, weakness, weight loss, and fever. Physical examination revealed dysarthria, left-sided facial palsy, and a cardiac murmur. Imaging assessment revealed a circumscribed right occipital brain lesion by cranial computed tomography and a 10-mm aortic vegetation with mild aortic regurgitation by echocardiography (Figure 1). Serial blood cultures were positive for Streptococcus anginosus. Invasive coronary angiography was deemed necessary in the work-up for aortic valve replacement. Given the large mobile vegetation, filter-based embolic protection (Figure 2) was deployed in the brachiocephalic trunk and left common carotid artery during invasive coronary angiography. Coronary artery disease was excluded. Filters were retrieved and sent for pathology analysis. Macroscopic evaluation of the filters revealed 3 white tissue fragments (1.9 × 1.0 × 0.3 cm; 1.9 × 1.1 × 0.4 cm; and 2.7 × 1.2 × 0.3 cm) with brown spots (Figure 3). Microscopically, the tissue appeared typical for aortic valve tissue with focal calcification (Online Figure 1A) and a large central area of necrosis and acute inflammation, consistent with infective endocarditis (Online Figure 1B). Filter-based protection devices may prevent embolization of dislodged infective material to the brain in patients with aortic valve endocarditis who need to undergo invasive coronary angiography. Furthermore, this case illustrates the evident risk of invasive coronary angiography in the presence of large aortic valve vegetations and supports the use of other diagnostic coronary imaging modalities.
For supplemental figures, please see the online version of this article.
Dr. Van Mieghem has received research grants from Claret Medical Inc. Dr. Daemen has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received December 28, 2016.
- Accepted January 12, 2017.
- 2017 American College of Cardiology Foundation