Embolic ST-elevation Myocardial Infarction from Candida Endocarditis

Abstract

Infective endocarditis in intravenous drug users is uncommon in left-sided native valves. Adding to the rarity, in this case, is endocarditis from Candida species complicated by ST-elevation myocardial infarction. Embolic myocardial infarction has worse outcomes as compared to other etiologies, and the management of septic embolic myocardial infarction is rather challenging. The management of embolic myocardial infarction from Candida endocarditis vegetation includes antifungal therapy. The use of anti-thrombotic therapy and anticoagulation carries a significant risk of fatal neurologic complications and has been controversial, with limited observational data available. Among percutaneous coronary interventions, balloon angioplasty and stenting have been associated with multiple complications while aspiration embolectomy appears to be a safer option. Surgical management is considered if medical and interventional therapies fail or if there is an indication for valve replacement.

Multidisciplinary Perspectives of Challenges in Infective Endocarditis Complicated by Septic Embolic-Induced Acute Myocardial Infarction

“…There are conflicting data in the literature according to which a valve affected by IE is most commonly responsible for the development of septic embolic-induced AMI: there are studies that claim that the aortic valve is most commonly responsible for septic embolization in coronary arteries, with the subsequent development of AMI [ 19 , 21 , 27 ], similar to our findings. There are also previous studies suggesting that vegetations on the mitral valve have the highest embolic risk [ 25 , 35 , 48 , 54 ]. Other studies suggest that the anterior mitral valve has the highest embolic risk, at a rate of 37%, compared to general mitral valve vegetation, at 25%, followed by aortic vegetation, at 10% [ 22 , 25 , 55 ].…”

“…There are also previous studies suggesting that vegetations on the mitral valve have the highest embolic risk [ 25 , 35 , 48 , 54 ]. Other studies suggest that the anterior mitral valve has the highest embolic risk, at a rate of 37%, compared to general mitral valve vegetation, at 25%, followed by aortic vegetation, at 10% [ 22 , 25 , 55 ].…”

“…Studies support that the most frequently affected coronary artery is the LAD (left anterior descending) [ 21 , 25 , 27 , 35 , 48 , 54 ]. A few cases that presented with sudden cardiac death have been described in the literature as being secondary to LMCA occlusion from septic embolisms in IE.…”

“…Specialized studies have confirmed that fungal endocarditis is more common in patients with prosthetic valves, indwelling venous catheters, post heart surgery, or in cases of immunocompromised patients, such as in the case of patients with IVDA. The guidelines recommend antimicrobial therapy, including intravenous antifungal medications, followed by the long-term use of a suppressive oral antifungal agent because of an increased risk of recurrence [ 25 , 47 ].…”

“…The postoperative course was complicated by a complete atrioventricular block that required the implantation of a permanent pacemaker. He was later transferred to a treatment center for the remainder of the 6-week micafungin therapy, followed by lifelong oral fluconazole suppression [ 25 ].…”