We read the case report titled “Coronary artery mycotic aneurysm in a patient suffering from subacute endocarditis: a case report and literature review” by Hali et al. (1) with great interest. In their study they reported a 42-year-old man who was referred with a 2-month history of feverishness and embolic ischemic left cerebellar infarction. He was diagnosed with infective endocarditis (IE) based on the results of echocardiography and blood culture by Viridans Streptococci organism. One of his echocardiographic findings was a bicuspid aortic valve (BAV) without aortic dilation. Before the surgery, a contrast-enhanced computed tomography (CT) scan revealed an irregular dilation of the left main coronary artery extending from the left coronary sinus to the proximal part of the left anterior descending artery. A diagnosis of coronary artery mycotic aneurysm (CAMA) was considered for him, but not without concerns.
Septic condition and contrast-enhanced CT findings such as aneurysmal dilatation of the left main coronary artery with a diameter of 12.7 mm with an irregular border raised clinicians’ suspicion about CAMA in this patient; however, our concerns regarding this diagnosis are strong. It is more probable that the patient is suffering from both BAV and CAA, caused by congenital underlying causes that have unfortunately been followed by endocarditis at this age.
CAMA is a rare and potentially fatal diagnosis that based on what is currently known, is considered a clinical diagnosis for patients.
A study conducted by Restrepo et al. (2) on 55 CAMA patients showed that CAMA mostly occurred in men, the right coronary artery was the most affected vessel, and about 53.3% of the time, Staphylococcus aureus was the responsible organism. Some imaging findings may also be helpful to make us more fully suspect CAMA. A large lobulated or saccular shape aneurysm with mural thrombosis and thickened wall with tissue stranding around affected vessels in contrast-enhanced CT, in combination with an infective setting like fever, bacteremia, infective endocarditis, septic emboli, or recent interventional procedure, can raise our suspicion for CAMA diagnosis. However it is possible that the involvement of the left coronary system with the Viridans Streptococci organism, without any wall thickening or tissue stranding around the affected vessel, could suggest a different diagnosis as being more likely than CAMA.
Given the fact that the aortic valve and the proximal portion of the coronary arteries share a common embryonic origin, a study was performed to assess the coincidence of these two congenital anomalies by Meindl et al. (3). The study found that patients with BAV are twice as likely to have coronary artery ectasia (CAE), regardless of aortic dilation.
It is crucial to be aware of the potential complications of CAMA, including coronary artery rupture, cardiac tamponade, fistula formation, distal embolization-induced ischemia/infarction, and sudden cardiac death, with a consecutive mortality rate of about 43%–53% according to the rarity literature's review (4).
We are concerned about the accuracy of the patient’s CAMA diagnosis due to their benign progression during the first year of follow-up.
Statements
Author contributions
PK: Writing – original draft, Writing – review & editing. TD: Conceptualization, Supervision, Validation, Writing – original draft, Writing – review & editing, Investigation.
Funding
The authors declare that no financial support was received for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
References
1.
Hali R Sharifkazemi M Yaminisharif A Bagheri J Shahbazi N . Coronary artery mycotic aneurysm in a patient suffering from subacute endocarditis: a case report and literature review. Front Cardiovasc Med. (2023) 10:1188946. 10.3389/fcvm.2023.1188946
2.
Restrepo CS Gonzalez TV Baxi A Rojas CA . Infected (“mycotic”) coronary artery aneurysm: systematic review. J Cardiovasc Comput Tomogr. (2020) 14(6):e99–104. 10.1016/j.jcct.2019.01.018
3.
Meindl C Achatz B Huber D Baessler A Hubauer U Meisinger C et al Coronary artery ectasia are frequently observed in patients with bicuspid aortic valves with and without dilatation of the ascending aorta. Circ Cardiovasc Interventions. (2016) 9(10):e004092. 10.1161/CIRCINTERVENTIONS.116.004092
4.
Aggarwal P Saxena P Bhan A . Successful management of a giant unruptured mycotic coronary artery aneurysm after coronary angioplasty. Indian Heart J. (2016) 68(Suppl 2):S44–6. 10.1016/j.ihj.2016.08.006
Summary
Keywords
coronary artery mycotic aneurysm, bicuspid aortic valve (BAV), coronary artery ectasia (CAE), infective endocarditis (IE), congenital anomalies
Citation
Kalhor P and Davarpasand T (2023) Commentary: Coronary artery mycotic aneurysm in a patient suffering from subacute endocarditis: a case report and literature review. Front. Cardiovasc. Med. 10:1286416. doi: 10.3389/fcvm.2023.1286416
Received
31 August 2023
Accepted
14 November 2023
Published
28 November 2023
Volume
10 - 2023
Edited by
Leonardo Roever, Federal University of Uberlandia, Brazil
Reviewed by
Weichieh Lee, Chi Mei Medical Center, Taiwan
Updates
Copyright
© 2023 Kalhor and Davarpasand.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Tahere Davarpasand tahereh.davarpasand@yahoo.com
Disclaimer
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.