Case Presentation: A 63 year old female with history of renal cell carcinoma status post nephrectomy, end stage renal diseases on hemodialysis via permacath, hypertension, stroke with right-sided weakness, bilateral blindness from glaucoma and corneal transplant rejection, history of deep vein thrombosis and pulmonary embolism on anticoagulation and recent admission for coagulase-negative staphylococcus (CONS) bacteremia was readmitted for sepsis secondary to persistent CONS bacteremia. She was started on Vancomycin and given the suspicion for line infection it was decided to replace her permacath. It was ultimately exchanged as it was difficult to place a new line. Initial work up with a transesophageal echocardiogram showed an abnormal space of 2.8 x 2.1 cm located above the posterior mitral annulus in left atrium communicating with the left ventricle through the calcified mitral annulus. This was felt to be either a pseudoaneurysm of the left ventricle or left atrial dissection or coronary artery aneurysm. Further imaging with cardiac CT showed 99% calcified proximal right coronary artery stenosis, dehiscence of the posterior inferior mitral annulus with an associated focal collection projecting to the left ventricle. CT surgery opined that this could be a mycotic aneurysm of the left circumflex artery or AV groove pseudoaneurysm. Medical management was advised as she was a high-risk candidate for either a cardiac stent or aneurysmal repair. She subsequently developed hypotension from a new large posterior pericardial effusion (without tamponade physiology) and family decided to pursue comfort care measures.
Discussion: Coronary artery mycotic aneurysm is a rare complication of bacteremia. They can develop after a complex percutaneous coronary intervention, infective endocarditis or septicemia. Initial presentation can result in a myocardial infarction, pericardial effusion or decreased ejection fraction in a patient with sepsis. Proposed pathophysiologic mechanisms are (1) embolic occlusion and sterile infarction of the vasa vasorum, (2) direct bacterial invasion of the arterial wall and (3) injury due to immune complex deposition. Mycotic aneurysms have a considerable potential for rupture, resulting in cardiac tamponade and sudden death, making early recognition and surgical treatment mandatory. Diagnosis is established by cardiac CT, coronary angiography or during open heart surgery. Treatment is a combination of antibiotics and urgent aneurysmal excision with revascularization. However, most patients are poor surgical candidates for revascularization due to multiple comorbidities.
Conclusions: Coronary artery mycotic aneurysm is an uncommon clinical entity with a grave prognosis necessitating early diagnosis and treatment.