Coronary embolism and coronary occlusion in bacterial endocarditis.

Embolic occlusion of the peripheral vessels is common in bacterial endocarditis, especially during the terminal stages, but occlusion of the coronary artery in this disease is unusual at any time. Virchow (1856) described coronary embolism in a case of recent endocarditis. Saphir (1933) surveying earlier reports of coronary embolism from all causes, found 35 cases reported since Virchow's original paper. Of these, only 15 came to necropsy. Appelbaum and Nicholson (1934) in an analysis of the pathological anatomy of 168 cases of occlusion of the coronary arteries cited four instances of coronary embolism in bacterial endocarditis, in three of which there was recent myocardial infarction as the result. In a survey of 2877 necropsies, Levy et al. (1934) found six examples of coronary emnbolism, but without mentioning the source. Among 12,300 consecutive necropsies, Garvin and Work (1939) reported three cases in which bacterial endocarditis was present and in two of them myocardial infarction had taken place, although in one the coronary arteries were affected by atheroma. Lutembacher (1939) and Caplan and Alpern (1943) each described a case of coronary embolism from bacterial endocarditis producing myocardial infarction. De Navasquez (1939) examined the heart histologically in 20 unselected cases of bacterial endocarditis and found emboli resembling fragments of vegetations in 80 per cent of them. In only one was there a visible infarct. He considered that the scarcity of myocardial infarcts was due to the small size of the occluded vessels, which in his series varied from 50 ,u to I 0 mm. in diameter. The case of bacteriai endocarditis described here is of interest, not only because coronary embolism is itself uncommon but because it presents the picture of a dual mishap to the coronary circulation, namely cardiac infarction from coronary embolism and later massive ischimia from sudden occlusion of a coronary orifice by a vegetation on the aortic cusp. Lamb (1913) described a case of occlusion of a coronary artery by a pedunculated vegetation of the aortic valve.