Identification Profile of Aortic Endocarditis with Complications of a Coronal-aortic Triangle Abscess in a Stemi Patient

Abstract

We report the case of a 44-year-old man, a chronic smoker with a 28 pack-year history, regular consumer of alcohol, cannabis, and hashish, followed for coronary artery disease and having undergone two angioplasties, who was admitted for typical chest pain with ST-segment elevation, suggestive of an acute ST-elevation myocardial infarction (STEMI). Coronary angiography performed during hospitalization revealed severe stenosis of the ostium of the proximal left anterior descending artery and the first marginal branch, severe stenosis of the mid-left anterior descending artery and distal right coronary artery, as well as a proximal occlusion of the circumflex artery. Given the atypical clinical course, notably persistent inflammatory syndrome, fever, and the appearance of a new murmur, transthoracic and then transesophageal echocardiography were performed. These examinations revealed heterogeneous, hypoechoic thickening at the mitro-aortic trigone compatible with a partially ruptured abscess, as well as a mobile image on the aortic annulus. Overall, the findings suggested aortic infective endocarditis complicated by a partially ruptured mitro-aortic trigone abscess, occurring in the context of rheumatic mitral and aortic heart disease. Initially unnoticed, it was first revealed by a STEMI presentation. The patient received comprehensive treatment for his ischemic heart disease, including dual antiplatelet therapy, anticoagulation, statins, an ACE inhibitor, and a beta-blocker, in addition to empirical penicillin-based antibiotic therapy, later adjusted according to the antibiogram. A surgical bypass was planned, but the patient’s prognosis rapidly worsened with the onset of septic shock and hemodynamic failure, leading to death. This case highlights the importance of considering an infectious or structural cause in young patients presenting with STEMI and normal coronaries, and underscores the critical diagnostic value of transesophageal echocardiography in detecting perivalvular complications.