The case study describes a rare and maybe fatal consequence of coronary stent infection (CSI), with an emphasis on the rise in occurrence over the last decade [1]. In order to enhance patient outcomes, the authors stress the need for early recognition and proper medical and surgical management. Coronary artery disease (CAD) is a serious global health concern, with an estimated 126 million people worldwide suffering from it. In addition, CAD caused millions of fatalities in 2017 [2]. Percutaneous coronary intervention (PCI) is widely recognized as a transformational CAD treatment, first done by Andreas Grüntzig in 1977 [3]. Since then, various additional procedures and tools have been added to this approach specifically the insertion of bare-metal stents (BMSs) and successive stent generations that elute drugs. The complications occur seldom with PCI but may be fatal [4]. Difficulties including the lack of reflow phenomena and stent thrombosis occur in around 2% of cases, whereas infection of the coronary stent (CSI) occurs in fewer than 0.1% of cases (most of which are restricted to case studies) [5]. In 1993, the first CSI case was reported, including an infection of a Palmaz-Schatz stent in a 66-year-old female patient. Despite having undergone critical cardiac surgery, the patient passed away [6]. A prior study that reviewed 23 cases found that CSI had a 39% mortality rate [7]. Furthermore, CSI has a variety of clinical presentations, which may be misleading.The authors report a challenging case involving a patient with diabetes and hypertension who developed CSI resulting in left empyema and pleuro-pericardial fistula.

Clinical complexity and multidisciplinary approach

The case discusses the complex diagnostic and treatment issues experienced with managing CSI, emphasizing the necessity of a multidisciplinary strategy. Cardiothoracic surgeons, infectious disease consultants, cardiologists, bacteriologists, and critical care experts are all involved in CSI treatment, which underscores its complexity.

Diagnostic modalities

The authors correctly emphasize the use of blood/stent/tissue cultures and cardiac angiography as primary diagnostic tools for CSI. As in this case, HRCT showed large sized well-defined cystic density lesion with irregular enhancing wall in the inferior aspect of heart with cardiac stent in it and communication of abscess cavity to the left pleural cavity. Furthermore, Positron emission tomography (PET) and magnetic resonance imaging of the heart (MRI) are examples of cutting-edge imaging methods that help to provide a more thorough diagnostic approach.

Antibiotic regimen

Patient was started on Meropenem 2 grams oral dose twice daily and Teicoplanin 800 mg oral dose once daily in consultation with infectious disease specialist and the same was continued for 7 weeks after surgery as the cultures were inconclusive and the patient showed clinical improvement.

Surgical intervention

The decision-making process and the meticulous execution of the surgical operation, which included stent removal and fistula closure, are well recorded. The procedure's complexities, such as the use of a percutaneous cannula, meticulous dissection, and the utilization of suitable materials, are valuable to the surgical community.

Unique clinical presentation

Patient was a known case of coronary artery disease and underwent percutaneous transluminal coronary angioplasty and stent to RCA 7 years ago. This was followed by a repeat angioplasty intervention two weeks later due to ventricular tachycardia and recently, the patient presented with monomorphic ventricular tachycardia and subsequently received an automated implantable cardioverter defibrillator (AICD). Notably, a recent report highlights a unique case of pleuro-pericardial fistula with empyema, a complication not previously documented, occurring after long primary intervention period. This finding adds to the clinical variability of coronary stent implantation presentations.

Follow-up

The inclusion of a thorough postoperative follow-up is must, including echocardiographic evaluations at regular intervals, gives a full picture of the patient's recovery and adds to the understanding of long-term outcomes. Immediately after the operation, echocardiography revealed normal right ventricular function and left ventricular systolic function of 50%. Subsequent similar follow-up results confirmed that the patient was appropriately managed.Top of Form

Role of developing cardiology and drug eluting stents

Cardiovascular disorders have been the leading cause of mortality for decades. Percutaneous transluminal coronary angioplasty (PTCA) using Pneumatic and stent devices are of two types and among the most frequently utilized interventions targeting coronary heart disease [8]. The idea of a cardiac catheter revolutionized the treatment of coronary heart disease [9].

The initial metal-free catheters (BMS) were swiftly replaced by newer devices including drug- coatings that elute. Commencing to pharmacological drugs as seen from the surface of the stent was a potential development in the field of cardiovascular stents [9]. However, it quickly became apparent that DES had certain limitations in terms of delivering appropriate amounts of medications in a timely manner. The first DES delivered a modest quantity of drug in a single part, which was inadequate in most cases [10].

The widespread use of drug-eluting stents, which has been lauded for its capacity to lower restenosis rates, has also presented a new set of problems. While these stents have transformed the industry by improving long-term results, they have also become a potential breeding ground for infections. The intricate design and composition of drug-eluting stents, intended to prevent restenosis, may unintentionally generate an environment conductive to microbial colonization. As these stents grow increasingly popular, vigilance in monitoring and responding to potential infections becomes critical. Improved diagnostic methods, a characteristic of contemporary medical breakthroughs, have played a significant influence in revealing the hidden complexity of coronary stent infections. The increased sensitivity and specificity of diagnostic techniques has enabled doctors to identify infections at an earlier stage. However, this revelation has a double-edged sword: early detection implies early response. The problem is not just recognizing the infection quickly, but also navigating the intricate terrain of treatment choices to improve patient outcomes.

The spike in number of CSI may be ascribed, in part, to the growing field of aggressive invasive cardiology, extensive implementation of drug-eluting stents, and the ongoing development of diagnostic methods. The rise of aggressive invasive cardiology, defined by the desire for increasingly intricate treatments to treat coronary artery disorders, has unintentionally created new channels for problems such as stent infections. As doctors perform more complicated operations, the delicate balance between therapeutic advantages and potential hazards becomes clearer. Stent implantation, previously thought to represent a light of hope for patients suffering from coronary artery disease, is now shrouded in the shadow of potential infectious complications.

Unique presentations of various stent infections

The diagnostic criterion for stent infection is the lack of standardization in the definition and diagnostic criteria [11]. Most studies included in this review used clinical, microbiological, and imaging criteria to diagnose stent infection, but there was considerable heterogeneity in the diagnostic criteria used [5,12-16] In addition, the sensitivity and specificity of these criteria are not well established, and there is a need for standardized diagnostic criteria to improve the accuracy and consistency of diagnosis. The optimal management strategy for stent infection remains uncertain due to the lack of high-quality evidence [5]. Treatment strategies are often based on a combination of clinical experience and case reports. This lack of standardized protocols makes it crucial for healthcare providers to collaborate with infectious disease specialists to make informed decisions about antimicrobial therapy. One of the most critical elements influencing outcomes in stent infection is the timing of diagnosis and treatment. Delays in diagnosis and treatment can lead to significant morbidity and mortality, and early recognition and treatment are critical [17]. The majority of patients have coronary artery aneurysms, which may be genuine or pseudo aneurysms and are often associated with in-stent restenosis. A significant portion of instances are due to vessel blockage, but the story has also shown additional issues such soft-tissue density collections, coronary perforations stent movement delays, and coronary-cameral fistulas.

Surgical treatment and role of antibiotics

Surgical treatment proceeded in a precisely planned procedure. As in this case, the decision to remove the coronary stent and conduct lung decortication was influenced by the specific challenges presented by the stent's position and potential involvement of the inferior vena cava (IVC). The damaged right coronary artery (RCA) and a tiny posterior descending artery prompted the decision against revascularization. Simultaneously, pleural cavity examination revealed a collapsed left lung with flakes all over that required decortication.

CSI is best treated with treatment with antibiotics and surgical intervention. Even so, in certain cases, treatment with antibiotics alone was successful [18-20]. In contrast, numerous instances that were managed with antibiotics by itself produced a distinct result [21,22]. Surgical intervention is the most logical course of action for treating CSI since it may offer a definite diagnosis while also eliminating the infection source, correcting aneurysms, and delivering bypass vascular grafts and doing reconstructions wherever necessary. Antibiotics are the mainstay of treatment; nevertheless, the duration and type of antibiotic medication, as well as the need for stent removal, remain disputed [23-25]. The studies in this review included a variety of treatment regimens, with antibiotics alone, antibiotics with stent removal, and antibiotics with stent retention all being reported [26-28]. The duration of antibiotic therapy varied from two weeks to twelve months. Because of the absence of treatment standardization, it is difficult to draw clear conclusions regarding the optimal management plan. First, the variety of bacteria implicated complicates antimicrobial therapy selection. Medical therapy is critical for controlling coronary stent infections. The susceptibility of the detected organism to specific medications, as determined by culture and sensitivity tests, should guide the selection of antibiotics. Furthermore, treatment duration and mode of administration may vary depending on the severity and location of the infection. In rare cases, the patient may need intravenous antibiotics for a lengthy duration to adequately battle the infection [6,21,29].

The microbial players in this intricate drama are primarily Staphylococci bacteria and pseudomonas emerging as the main protagonist followed by Actinomyces oris, Escherichia coli, Staphylococcus aureus resistant to methicillin, Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacter cloacae were identified. Pseudomonas aeruginosa is the second most prevalent bacterium responsible for coronary stent infections, after Staphylococcus aureus [23]. The association between coronary stent infection and elevated mortality has been documented by Bosman et al. [30] and Lim et al. [31] (48.3% and 43.5%, respectively). Two patients were infected with Pseudomonas aeruginosa, an organism that appears to be atypical in the context of a catheter-associated infection. It is possible that the femoral access site has an increased susceptibility to pseudomonal infections. In the vast majority of instances, the infected stent and artery complex were surgically extracted. When angina and fevers are present in patients who have undergone coronary artery stenting, the clinician should be alert for the possibility of a stent-related infection [32].

The cumulative sample size of 44 patients was analyzed across these investigations. Notably, the mean age of the individuals, spanning from 52 to 74 years, predominantly encompassed male participants. The prevailing stent types were DESs are drug-eluting stents in 22 studies, BMS (bare metal stents) in 3 studies, and a hybrid utilization of both DES and BMS in 4 studies. In 23 studies, the microbiological profile was outlined, with Staphylococcus aureus being the dominant identified organism. S. aureus appears to be the most frequently identified pathogen, as it is associated with 26 cases. Pseudomonas aeruginosa is the second most common organism, identified in 3 cases, followed by Enterobacter cloacae, P. aeruginosa, Staphylococcus epidermidis, and Escherichia coli, each found in 1 case. Additionally, in a few cases, no specific organism was reported. These findings highlight the predominance of S. aureus in such cardiac infections, emphasizing its clinical significance in this context. Understanding the types of organisms involved is crucial for effective diagnosis, treatment, and prevention strategies in cardiac infections. The left anterior descending artery emerges as the most commonly affected artery with 21 cases, indicating its higher susceptibility to infections. The right coronary artery in 15 cases, while the left Circumflex artery is involved in 6 cases. The left main artery, though less frequent, is still relevant, with 2 cases. In some instances, the specific artery involved was not reported or specified. The present data underscores the importance of recognizing the varying susceptibilities of different coronary arteries to infections, which can inform clinical decision-making and guide research in this field [33].

The existence of inflammation within the stented area was validated through the utilization of 18F-flurodeoxyglucose positron emission tomography. The patient underwent surgical intervention, and an analysis of the surgical material confirmed the diagnosis. This emphasizes the importance of maintaining a high index of suspicion for stent infection and the diagnostic value of FDG-PET CT in conjunction with CAG [34]. While positive blood cultures are indicative of an infection, they fail to pinpoint the anatomical origin of the pathogen. Initially, cardiac MRI, TEE, CT scan, and CAG were suggested as diagnostic tools for stent infection and complications [23]. However, these modalities are only capable of detecting stent occlusion and, if present, an ulcer. FDG-PET CT was utilized to identify the stented segment as the site of infection; an aberrant FDG uptake was detected, indicative of inflammation or active infection. It has been demonstrated that FDG-PET CT can detect occult inflammation in the body [35]. Acute coronary syndrome (ACS) patients, on the other hand, exhibited an elevated FDG uptake in the culprit lesion [36]. It is exceedingly difficult to differentiate between stent thrombosis and stent infection using PET. It is the diagnosis that is made based on the clinical circumstance and additional coordinated studies. PET imaging in stent thrombosis suggests that FDG uptake is limited to the stented portion of the conduit, but in stent infection, it is widespread and affects the surrounding soft tissue as well as the infection.

Prompt identification and prompt implementation pertaining to suitable medical and surgical treatment emerge as significant predictors of patient survival in the field of CSI. The stakes are enormous, and the opportunity for action is often limited. Failure to identify and treat these infections in a timely way might tilt the scales towards greater morbidity and mortality. Despite advances in medical research, CSI continues to provide formidable hurdles, emphasizing the need of vigilant vigilance and prompt response.

In the mosaic of this case study, the result demonstrates the dynamic and adaptive method used to navigate the challenges of coronary stent infections. The patient's recovery, characterized by better cardiac parameters and the absence of viral signs, emphasizes the need for a thorough and multidisciplinary therapy approach. This also serves as a painful reminder of the continuing development of cardiovascular therapy, which requires constant vigilance and adaptation to improve patient outcomes.

The overarching conclusion can be that coronary stent infections, while frequently presenting as a spurious infection involving the endocardium, myocardium, and adjacent structures, can extend their reach into the pleural cavity and other structures. The importance of rigorous investigation in addition to cardiologists, microbiologists, cardiac radiologists, and cardiothoracic surgeons participating in a multidisciplinary approach emphasizes the path to identification and improved results. The learning goals include not just a description of unusual presentation and the related surgical approach, but also the critical requirement for addressing severe coronary stent infections.

Finally, the authors should be complimented for publishing a thorough and well-documented case study that adds valuable insights to our understanding and treatment of coronary stent infections. The complete description of the case, careful examinations, and successful surgical surgery add significantly to the medical literature. This case serves as a reminder of the continuous difficulties and advancements in cardiovascular treatment.