A 49-year-old man presented to our hospital complaining of dull, central chest pain after 1 week of subjective fever. Fourteen years prior to this presentation, the patient underwent coronary artery bypass grafting, and 10 years prior suffered right knee septic arthritis due to Methicillin-sensitive Staphylococcus aureus (MSSA) which was complicated by a mycotic right femoral pseudoaneurysm. The patient had no immunosuppressive medications or medical conditions.\nIn the week prior to presentation, the patient had taken non-steroidal anti-inflammatory drugs for right knee pain after a mechanical injury and had ceased aspirin due to concerns about gastrointestinal haemorrhage. The patient had experienced subjective fevers and knee pain, however, had full range of movement with no tenderness, warmth, or erythaema.\nOn arrival, his electrocardiogram (ECG) showed sinus tachycardia with inferior ST elevation (). Physical examination revealed a blood pressure of 128/88 mmHg, heart rate of 112 b.p.m. and temperature of 36.7°C. Cardiovascular examination was unremarkable and examination of the right knee demonstrated normal range of motion without pain and no effusion. An urgent coronary angiogram was performed demonstrating severe native triple vessel disease, a patent left internal mammary artery graft and an aneurysmal but patent saphenous vein graft from the posterolateral branch to posterior descending branch of the right coronary artery (PDA) (). The Saphenous vein graft skip to the PDA was believed to be the infarct-related artery. No intervention was performed and the patient was managed with aspirin, clopidogrel, beta-blockade, angiotensin receptor antagonist, spironolactone, and intravenous nitrate infusion. Pathology is available in .\nSix hours later, the patient developed fever (38.4°C) with no localizing signs of infection identified; a septic screen was performed. Leucocytosis on the urinalysis led to commencement of IV augmentin (1000 mg + 200 mg QID) and gentamicin (320 mg), which were then changed to flucloxacillin (2 g QID) after blood and urine cultures grew MSSA.\nDue to ongoing chest pain, intervention with covered stents to the aneurysmal graft was considered but decided against because of the persistent bacteraemia and fever. Without revascularization, the patient developed inferior hypokinesis on echocardiogram and Q waves in the inferior leads on ECG. He remained persistently febrile until Day 5 of IV flucloxacillin.\nThere were no other symptoms or signs to suggest another source of infection. The abdomen was soft and non-tender. As MSSA was detected in urine during the initial work up a renal tract US was performed which revealed echogenic kidneys, and the treating cardiology and infectious disease teams attributed this to the systemic sepsis.\nTransthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) showed no evidence of infective endocarditis. Vasculitis and rheumatological screens were negative. Given the strong suspicion of a mycotic aneurysm, a labelled white cell scan was performed on Day 7 post-presentation, which failed to demonstrate an infective focus, or infection within the aneurysm.\nThe patient was discharged on IV flucloxacillin for 6 weeks, and dual antiplatelet therapy with a view to cardiology and infectious disease follow-up for consideration of treatment of aneurysm with percutaneous treatment in the future.\nFour days after discharge, the patient represented with left-sided pleuritic chest pain. Blood cultures were persistently negative. His repeat echocardiogram demonstrated moderately reduced left ventricular (LV) function, with thin walled, akinetic inferior and posterior walls consistent with a completed inferior infarct. The expanding aneurysm of the saphenous vein graft was now visible (on TTE and TOE) as a large pulsatile chamber along the posterior and inferior wall, with flow principally seen in diastole, and compressing the inferoposterior LV wall during diastole consistent with expanding aneurysm of the saphenous vein graft ().\nThe cardiothoracic surgery team performed a redo coronary artery bypass grafting with successful identification and resection of the mycotic aneurysm. Cultures of the operative specimen were negative, though the histological microscopic appearance confirmed the presence of the mycotic aneurysm.\nThe patient’s post-operative recovery was complicated by one admission for management of heart failure, after which he has remained stable and independent in the community as of August 2019. The most recent echocardiograph revealed normal LV systolic function with infarcted inferior and posterior walls, severe left atrial enlargement, and mild mitral regurgitation.
A 56-year-old Caucasian man presented from an outlying facility 2 h after acute onset of substernal chest pain at rest with diffuse ST segment depression. Sixteen years ago he had triple vessel CABG with two subsequent cardiac catheterization procedures and percutaneous coronary interventions in the last few years.\nOn presentation, the physical examination was unremarkable. Electrocardiogram had shown diffuse ST segment depression. Laboratory data were unremarkable, including cardiac biomarkers. He underwent cardiac catheterization with coronary and SVG angiography. It revealed severe native vessel coronary artery disease with 100% occlusion of all three native vessels. Left internal mammary artery graft to the left anterior descending artery was patent. SVG to right coronary artery (RCA) angiography revealed two aneurysms, one in the mid-body of the vein graft measuring 3 cm, followed by another 5 cm large aneurysm at the distal segment []. There appeared to be a leak of the contrast into the right atrium (RA) from the distal aneurysm. The aneurysm also had a posterior descending artery (PDA) runoff through the prior placed stent to the PDA at the anastomosis.\nThe patient was hemodynamically stable and reviewing the coronary anatomy we did not find any lesions that were amenable to intervention. He was monitored on the cardiac floor and had further imaging studies for better visualization of the SVG leak. A poorly defined right atrial mass was also appreciated in the subcostal view of the transthoracic echocardiogram for which he underwent a transesophageal echocardiogram (TEE). TEE revealed the aneurysm measuring 5.0 cm × 5.3 cm with Doppler flow within and extending from the structure into the RA []. A chest computed tomographic scan with contrast revealed a partially thrombosed aneurysm measuring 2.8 cm × 3.0 cm about 3.4 cm distal to the RCA graft origin and a large aneurysm measuring 5.0 cm × 4.2 cm distal to the first aneurysm both in the SVG to the RCA. The aneurysm also demonstrated a fistulous connection to the RA [ and ].\nThe cardiovascular surgical consultation was requested regarding further management options given the above findings. Percutaneous treatment including covered stent placement across the aneurysmal segments of the SVG was discussed. After a thorough discussion with the patient, he decided conservative management at the point.