Luther et al. Journal of Medical Case Reports 2011, 5:408 http://www.jmedicalcasereports.com/content/5/1/408 cells/L, neutrophils 10.7 × 109 cells/L) and he had a raised C-reactive protein level of 101 mg/dL. The results of three consecutive blood cultures samples were nega- tive even after five days in the culture media. His trans- thoracic and trans-oesophageal echocardiogram (ECG) results demonstrated vegetation involving the native posterior mitral valve leaflet (Figure 1) with moderate mitral regurgitation and a moderately stenosed tissue aortic valve. Vancomycin, Gentamicin and Rifampicin were given under microbiology guidance. Five days later, our patient became more unwell, and was found to be in worsening cardiac failure. A repeat echocardiogram showed the known vegetation on the mitral valve and new vegetation on the aortic valve of 1.5 cm (Figure 2) causing moderate aortic regurgitation. Our patient was subsequently transferred to our center for valve surgery. Whilst awaiting surgery, our patient developed severe central crushing chest pain with associated anterior seg- ment ST elevation on his ECG (Figure 3). Our patient had no previous history of angina, and was a non-smo- ker with no other cardiac risk factors. A coronary angio- gram performed five years ago prior to his valve surgery revealed unobstructed coronaries. The most likely expla- nation for this ST segment elevation myocardial infarc- tion (STEMI) was coronary embolisation of either part of the vegetation or thrombus attached to the vegeta- tion. Thrombolysis is relatively contraindicated in this scenario. PCI risked mycotic aneurysm formation and either further systemic or coronary embolisation. There- fore, urgent surgical intervention was planned; however, our patient deteriorated rapidly and unfortunately died. Discussion Coronary embolisation is a rare cause of AMI and needs to be considered in patients with atrial fibrillation, Figure 1 Echocardiogram (apical view) showing vegetation in the native posterior mitral valve leaflet (white arrow). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle. Page 2 of 3 Figure 2 Echocardiogram (parasternal long axis view) showing large vegetation in the tissue prosthetic aortic valve (white arrow). LA = left atrium; LV = left ventricle; MV = mitral valve; RV = right ventricle. prosthetic heart valves, dilated cardiomyopathy, and IE, where either thrombus or vegetation can embolize into the coronary circulation. Although systemic embolisa- tion can occur in up to 50% of cases of IE [4], coronary embolisation rate is about 0.3% [5]. There appears to be an increased risk of embolisation with vegetations that are > 1 cm in diameter, as in our patient’s case [6]. Suc- cessful strategies that have been used to manage coron- ary embolisation in non-endocarditic patients include thrombolytics [7], PCI and thrombus aspiration [8]. There is no clear evidence available about the best treatment option for patients with coronary embolisa- tion in the setting of acute IE [9]. Thrombolytic treat- ment of septic coronary embolisation is associated with an increased risk of cerebral vascular hemorrhage due to bleeding from silent cerebral microinfarctions or mycotic aneurysms [10]. Indeed AMI caused by sep- tic embolisation is a relative contraindication to the use of thrombolytic agents. PCI involves coronary bal- loon angioplasty and stent deployment, and this risks mycotic aneurysm formation at the dilatation site. This occurs as the balloon crushes vegetation against the vessel wall [11]. Implanting foreign stent material into an infective site can lead to stent infection, and this can require stent excision and debridement [12]. In addition, PCI risks further distal vegetation embolisa- tion [13]. As reported in a previous case report, ‘the impulse to follow conventional strategies for coronary reperfusion should be tempered by thoughts of possi- ble consequences’ [11]. Surgical intervention in left-sided IE is in fact recom- mended in the context of systemic embolisation [14]. However, evidence of successful surgical intervention in the context of coronary embolisation is scarce, with a