Page 18 - Delaware Medical Journal - February 2018
P. 18
Not Your Average Widow Maker: Cardiac Arrest with Coronary Artery Septic Embolism
Tamer Amer, DO
Coronary artery embolism is a rare cause of myocardial infarction with no obstructive coronary atherosclerosis
management.
A 56-year-old female with a past medical history of depression presented to the Emergency Department as an out of hospital cardiac arrest with bystander CPR. EMS reported ventricular Cardiac Life Support (ACLS), return of spontaneous circulation was obtained. Post-arrest EKG revealed profound ST elevations in the anterior and inferior leads. She was emergently transferred to the cardiac catheterization lab where an acute occlusion was found in her left anterior descending coronary artery, which received percutaneous intervention with two bare metal stents. Targeted temperature management was then initiated. Her post cardiac catheterization echocardiogram revealed a large mobile anterior Subsequent CT imaging showed bilateral cerebral parenchymal
hemorrhages, bilateral multifocal pneumonia and bilateral areas
of attenuation within her kidneys. Despite risk for continued cerebral intraparenchymal hemorrhage, it was felt that the risk of in-stent thrombosis necessitated continued dual antiplatelet therapy. Unfortunately, her neurological examination deteriorated with visual changes concerning for cortical blindness. Repeat imaging revealed bleeding mycotic aneurysm triggering neuro interventional evaluation and subsequent mycotic artery embolization of her right posterior cerebral artery. Her course further complicated with acute left radial artery occlusion, which was evaluated by vascular surgery and treated with heparin drip.
Further history obtained from family revealed ongoing issues with dental abscesses and blood cultures growing Streptococcus gordonii further supported this as her original source for endocarditis. Treatment was continued with Ceftriaxone. A cardiothoracic surgery consultation for evaluation of mitral valve replacement
was pursued. The surgeon recommended source control with oral maxillofacial surgery, resulting in alveoloplasty and extraction of all the patient’s teeth. Unfortunately, prior to surgical optimization and needed cardiothoracic surgery intervention, the patient acutely decompensated and family transitioned her to comfort care.
This case illustrates the importance of having a high index of suspicion for cardioembolic phenomenon in patients who present with endocarditis and the need for early surgical intervention in patients, particularly in those who have exhibited a propensity for embolization. In addition, this unfortunate series of events highlights the gravity of quality dental care, which is a substantial need in our country.
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Del Med J | February 2018 | Vol. 90 | No. 2
