Cardiogenic Shock with Acute Myocardial Ischemia after Successful Conservative Treatment for Infective Endocarditis: Case Report

A febrile 81-year-old patient admitted for back pain was diagnosed with Streptococcus viridans infection. Thoracic echocardiography revealed infective endocarditis (IE), aortic valve vegetation, and mild aortic regurgitation, despite an ejection fraction of 60% and normal left ventricular wall motion. Antibiotic therapy was initiated with penicillin G (2,400,000 IU/day) and gentamycin (120 mg/day). On day 14, white blood cell counts had decreased from 10,700 to 5200/L and C-reactive protein from 10.2 to 1.3 mg/dL, without embolization. On day 20, she developed acute myocardial infarction corroborated by elevated CK-MB (102.4 IU/L). Coronary arterial angiography revealed triple vessel disease, including left main trunk stenosis. The non-coronary cusp of the aortic valve was perforated and herniated toward the left ventricle. Concomitant aortic valve replacement and coronary artery bypass grafting at the three sites were successful. Postoperative course was uneventful, and the patient did not require antibiotics or warfarin at a 6-month follow-up visit.