Aggressive Native Valve Staphylococcus pasteuri Infective Endocarditis Complicated by Recurrent Coronary and Cerebrovascular Emboli

Figures

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  Visual Summary. Recurrent Embolic Events and Multidisciplinary Management in Staphylococcus pasteuri Infective Endocarditis CT = computed tomography; CTA = computed tomography angiography; ICH = intracranial hemorrhage; IV = intravenous; LAD = left anterior descending artery; MCA = middle cerebral artery; MRI = magnetic resonance imaging; STEMI = ST-segment elevation myocardial infarction; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography.

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  Figure 1. Electrocardiogram on Admission With Normal Sinus Rhythm

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  Figure 2. Findings on Transthoracic Echocardiography Transthoracic echocardiography with (A) zoomed-in parasternal long-axis view, (B) short-axis view of the mitral valve, (C) apical 4-chamber view, and (D) apical 2-chamber view showing a large 3-cm multilobulated echodensity on the posterior leaflet of the mitral valve (red arrow). LA = left atrium; LV = left ventricle.

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  Figure 3. Transesophageal Echocardiography of the Mitral Valve Transesophageal echocardiogram showing (A) transgastric long-axis view of the mitral valve at approximately 90° with a large vegetation attached to the posterior mitral leaflet (orange arrow); (B) mid-esophageal view of the mitral valve at 90° showing a large 2.5 × 3.0 cm vegetation on the atrial aspect of the mitral valve extending onto the subvalvular apparatus with a flail posterior leaflet (orange arrow); (C) 3D bicommissural view of the mitral valve with a large vegetation attached to the posterior leaflet (orange arrow); and (D) mid-esophageal long-axis view of the mitral valve at 135° with severe eccentric and anteriorly directed mitral regurgitation. 3D = 3-dimensional; LA = left atrium; LV = left ventricle.

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  Figure 4. Findings on Preoperative Coronary Angiogram on Day 3 Coronary angiogram with (A) AP Cranial view showing mild LAD disease (B) LAO Caudal view showing moderate distal Left Main disease. AP = anteroposterior; LAO = left anterior oblique.

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  Figure 5. Findings During Asymptomatic STEMI on Day 6 (A) Telemetry strip and (B) electrocardiogram on day 6 showing ST-segment elevation in anterolateral leads.

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  Figure 6. Coronary Angiography on Day 6 Coronary angiogram showing (A) acute thrombotic occlusion of the distal left anterior descending artery (orange arrow) and (B) post–mechanical thrombectomy and balloon angioplasty with a focal haziness (yellow arrow) and TIMI flow grade 3.

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  Figure 7. Intracranial Imaging During Acute Stroke on Day 7 (A and B) Computed tomography angiography head and neck showing a rounded 2-mm focus of enhancement concerning for the aneurysm of the right M2 sylvian branch (green arrow). (C and D) Diffusion weighted images of magnetic resonance imaging brain showing subacute right middle cerebral artery territory infarction with hemorrhagic transformation (yellow arrow).

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  Figure 8. Findings During Second Asymptomatic STEMI on Day 9 (A) Telemetry strip with ST-segment elevation (yellow arrow). (B) Electrocardiogram with ST-segment elevation (yellow arrow) in the anterior leads with premature ventricular complexes. (C) Coronary angiogram showing acute occlusion of the distal left anterior descending artery (red arrow).