A patient was admitted with chest pain and elevated cardiac enzymes.A transthoracic echocardiogram (tte) showed mild pericardial effusion with mild impairment of left ventricular ejection fraction (50%) due to anterior wall hypokinesia.Coronary angiography revealed a critical calcified stenosis of the mid left anterior descending artery (lad), which was treated using percutaneous coronary intervention (pci) and implantation of three overlapping resolute onyx rx coronary drug-eluting stents (des).The proximal-mid lad was successfully pre-dilatated using fully expanded 2.0 mm and 2.5 mm noncompliant balloons.A 2.5 x 15 mm resolute onyx des (pli-10) was distally implanted followed by a 2.75 x 22 mm resolute onyx (pli-20) delivered in overlap in the proximal segment.Angiographic results were suboptimal with plaque shift being observed, therefore, a third 2.5 x 12 mm resolute onyx (pli-30) was distally implanted in overlap.Proximal and distal post-dilatations were performed with a 3.0-mm and a 2.75-mm non-complaint balloon, respectively.The next day, the patient presented with fever and cough and 48 hours after pci, the patient developed episodes of shortness of breath and atypical chest pain.C-reactive protein as well troponin i values were high.Antibiotic treatment was started.Diffuse st-segment elevation (pericarditis-like) was detected at ecg, which was performed 72 h after pci.Pericardial effusion enlargement with further left ventricular ejection fraction reduction (45%), in the absence of active valve endocarditis, were documented at a new tte assessment.96 h after pci, a cardiac magnetic resonance was performed confirming presence of severe non-tamponade circumferential pericardial effusion with evidence also of a coronary pseudoaneurysm (cpsa) at the level of a previously treated mid-lad segment, with a possible stent discontinuity (fracture).Blood cultures resulted positive for staphylococcus aureus.Intravenous antibiogram-guided therapy with oxacillin was started.A diagnosis of post stenting mycotic (infected) cpsa was formulated.The patient was judged to be at very high surgical risk and a percutaneous treatment strategy was chosen to prevent the risk of psa expansion.Coronary angiography confirmed the large mid-lad psa, showing fracture of overlapping implanted des.Pci with a three non medtronic stents was performed.The stents were placed proximally and distally with a large overlap area with the previous one, fully excluding the psa, without evidence of leaks.Tte also detected an irregular and hypoechoic area within the left ventricular myocardium.A multi-slice computed tomography scan confirmed the cpsa exclusion associated with an extended inflammatory mass deeply located within the myocardium, making a surgical excision not feasible.Conservative antibiotic treatment was administered, but, despite an initial promising response, the patient died 3 months later due to sepsis.It is noted in the article that development of mycotic coronary aneurysm and pseudoaneurysm could be linked to the presence of an infective endocarditis or could represent a primary infection at the site of an implanted coronary stent.
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