Abstract

A 53-year-old male presented with acute coronary syndrome (ACS). Outside hospital coronary angiography a week ago had been normal. One year ago, patient had undergone aortic valve replacement with a bioprosthetic valve. Bedside echocardiography showed a rocking AV prosthesis. Patient underwent immediate valve surgery disclosing bioprosthetic ring endocarditis with partial ring detachment. ACS in prosthetic valve carriers should prompt early bedside TTE.

Keywords: Acute Coronary Syndrome; Prosthetic Valve Endocarditis; MINOCA

Introduction

The clinical definition of acute myocardial infarction denotes the presence of acute myocardial injury detected by abnormal cardiac biomarkers, preferably hs-cTn, and clinical signs of myocardial ischemia, such as symptoms of myocardial ischemia, new ischemic ECG changes including the appearance of new pathological Q-waves, imaging evidence of loss of viable myocardium or identification of new coronary thrombus by angiography or autopsy. Apart from coronary causes, there are numerous conditions underlying myocardial injury such as heart failure, myocarditis, trauma, cardiac procedures, sepsis, infection, kidney dysfunction, acute pulmonary embolism, chemotherapy, radiation, hypertrophic cardiomyopathy and other structural heart disease. We are describing a patient presenting with chest pain, ECG changes, elevation of cardiac troponin and a new wall motion abnormality, finally classified as type 2 myocardial infarction [1] associated with prosthetic valve endocarditis. We highlight the role of echocardiography in non-invasive imaging of ACS [2].

History of presentation: how the patient was admitted, physical examination

A 53-year-old male was admitted because of recurrent chest pain irradiating to the left hand and left shoulder, and hs-cTn elevation. Electrocardiogram (ECG) in the asymptomatic patient showed elevated ST segments in V1-V3 and a loss of R-wave progression in V1-3 (Figure 1), compared with a previous ECG. On clinical examination, the patient was a pleasant man in excellent condition, bronzed from a recent holiday in Italy, without fever, chills or malaise. Except for a systolic murmur at the right sternal border physical examination was normal. On current admission hemoglobin was 10.7 g/dL (normal value 13,5-18,0 g/dl), white blood cell count was 20,29 G/L (normal value 4,0-10,0 G/L), CRP was 2.0 mg/dl (normal value <0,5 mg/dl), myoglobin was 1742 ng/ml (normal value 23-72 ng/ml), hs-cTn was 169 pg/mL (normal value 0-14 ng/L), and CK was 763 U/L (normal value < 190 U/L).

Past Medical History

Patient had a history of systemic lupus, and had undergone aortic valve replacement with a biological prosthesis (25 mm Carpentier Edwards Inspiris) two years ago for aortic regurgitation. On the night when he had arrived at the Italian seaside four weeks ago, he had first noted abrupt precordial chest pain. He had been seen in a local hospital late that night, but was dismissed with a normal ECG and a hs-cTn around 300pg/mL, with the recommendation to consult with a cardiologist upon return home. The patient had followed the advice, and undergone cardiac catheterization two weeks ago, which was normal (Figure 2). Laboratory values at the time of the catheterization showed a white blood cell count of 12,8 G/L (normal value 4,0-10,0 G/L), NT proBNP of 344 ng/L (normal value <125 ng/L), and Troponin I of 151 ng/L (normal value < 45,2 ng/L). TTE was reported as showing minimal mitral valve regurgitation and a prosthetic aortic valve, but no other abnormalities. Patient had been discharged same day because he was clinically well.

Figure 1: Electrocardiogram on current admission.

  

Figures 2A and 2B: Coronary angiography prior to current admission.

Differential diagnosis

Differential diagnoses of the patient‘s condition are psychosocial derangements, metabolic disturbances including insulin-resistance, and inflammatory diseases [2].

Investigations

Bedside TTE in the emergency room showed a rocking motion of the AV prosthesis (Video 1), compared with a TTE 10 months before (Video 2). Furthermore, new apical dyskinesia was noted. Acute TEE confirmed combined aortic valve prosthesis stenosis and regurgitation resulting from partial ring detachment.

Management (medical/interventions)

No cardiac catheterization was done. Instead, patient underwent immediate valve surgery. Vegetations on the ventricular and aortic aspect of the non-coronary cusp of the AV prosthesis were found (supplemental Figure 1) with a perforating connection to the left ventricle. The non-coronary aspect of the valve ring was completely detached by a circumferential aortic ring abscess. The dysfunctional aortic valve prosthesis was replaced with an Edwards Inspiris Resilia-23 mm, including a patch reconstruction of the aortic annulus after cleaning the abscess cavity.