A 52-year-old male patient presented to the emergency department with a typical acute chest pain of 1 hour’s duration. The patient was sweaty and anxious on the physical examination and had a systolic blood pressure of 90 mmHg and a diastolic blood pressure of 50 mmHg. Electrocardiography showed ST-segment elevations in DII, DIII, and aVF leads, as well as ST-segment depressions in V1–V3 leads (). His medical history showed double-vessel coronary artery bypass graft surgery (CABG) 2 months earlier due to stable angina pectoris, for which he regularly took diltiazem, acetylsalicylic acid, and atorvastatin. Additionally, there were no cardiovascular risk factors except for family history. The patient’s coronary angiography and bypass reports were, however, not available.\nPrimary PCI was performed based on a diagnosis of acute inferoposterior myocardial infarction within the first hour of chest pain. Coronary angiography showed that the SVG to the right coronary artery (RCA) was occluded with a thrombus (). The left internal mammary artery graft was open and raced with the left anterior descending coronary artery. Additionally, the mid-portion of the circumflex (Cx) obtuse marginalis was 80% stenotic and the Cx and the RCA were totally occluded (Video 1). The lesion on the SVG was passed with a floppy wire and aspirated via manual thrombectomy (Export Catheter, Medtronic Inc., Minneapolis, Minnesota) (). The huge thrombus content was also aspirated (). Tirofiban, a glycoprotein IIb/IIIa inhibitor, at an intracoronary dose of 10 μg/kg was administered. Moreover, severe stenosis was detected in the SVG to RCA anastomosis, and a 2.75×38-mm XIENCE PRO drug-eluting stent (Abbott Vascular, California, USA) was implanted. Post-dilatation with a 3.5×15-mm Emerge NC balloon (Boston Scientific, USA) was performed, and a distal thrombolysis in myocardial infarction (TIMI) flow grade III was provided (/Video 2). An intravenous infusion of 0.15 μg/kg/min of tirofiban was given for 18 hours. After the procedure, the chest pain was relieved and the ST-segment elevation was improved (). The angiographic imaging of the coronary arteries before the surgery was evaluated, and the Syntax Score was calculated to be 30.5 (Video 3). The patient underwent echocardiography, which showed an ejection fraction of 40%, hypokinesia in the inferior and posterior walls, and mild mitral regurgitation. Atorvastatin, nebivolol, prasugrel, acetylsalicylic acid, and ramipril were prescribed, and the patient was discharged without any complications.\nControl angiography and PCI on the 80% mid-portion stenosis of the Cx obtuse marginalis were planned. One month later, a 2.75×24-mm XIENCE PRO drug-eluting stent (Abbott Vascular, California, USA) was implanted in the stenotic region. The stent patency of the SVG to RCA anastomosis was optimal (Video 4). One month later, stress myocardial perfusion scintigraphy was performed and no sign of ischemia was detected. The patient has been followed without any symptoms for 10 months.
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.