Septic Coronary Embolism and Myocardial Rupture After Valve-in-Valve TAVR Endocarditis.

BACKGROUND

Septic coronary embolism is a rare but serious complication of infective endocarditis, particularly after valve-in-valve transcatheter aortic valve replacement (TAVR). Mechanical complications such as pseudoaneurysm or myocardial rupture are exceedingly uncommon.

CASE SUMMARY: A 78-year-old man with prior surgical aortic bioprosthesis and valve-in-valve TAVR presented with asthenia and electrocardiographic signs of inferior ST-segment elevation myocardial infarction. Despite normal coronaries on angiography, blood cultures revealed Enterococcus faecalis, and transesophageal echocardiography confirmed aortic valve vegetation. Positron emission tomography-computed tomography showed 18F-fluorodeoxyglucose uptake in the spleen and left ventricular (LV) wall. On day 15, he developed hemothorax and anemia; transthoracic echocardiography revealed an LV free wall pseudoaneurysm. Emergent surgery confirmed LV rupture and communication with the pleural space, repaired via Teflon "sandwich" patch.

DISCUSSION: This case illustrates an unusual presentation of septic coronary embolism leading to myocardial rupture without tamponade, highlighting the diagnostic value of multimodal imaging.

TAKE-HOME MESSAGE: Clinicians should remain vigilant for structural complications of post-TAVR infective endocarditis, where early diagnosis and surgical management are lifesaving.