A 46-year-old man with a history of intravenous drug use presented with 5 days of fever as high as 102°F. He was ill-appearing, tachycardic, and without a heart murmur. Labs revealed marked leukocytosis and elevated troponin-T to 1.31 ng/ml (0.00–0.10 ng/ml), and blood cultures grew methicillin-susceptible Staphylococcus aureus 12 h after collection. Transthoracic echocardiogram showed a 4-cm mobile vegetation on the aortic valve. Troponin-T peaked the next day at 4.83 ng/ml, and while he remained free of chest pain, EKG revealed new ST-segment elevations in the anterolateral leads concerning for an acute coronary syndrome. Coronary angiogram identified 100% occlusion of both the distal left anterior descending artery (LAD) and the second diagonal branch of the LAD, consistent with coronary artery emboli (Fig. 1). The patient underwent aortic valve replacement and a one-vessel LAD bypass. A perforated aortic valve leaflet and multiple vegetations were seen on gross examination (Fig. 2). He was treated with intravenous cefazolin for 4 weeks.

Figure 1
figure 1

Coronary angiography with distal LAD (red arrow) and second diagonal branch total occlusions (black arrow).

Figure 2
figure 2

Aortic valve vegetations (red arrows) and perforation (black arrow).

The complications of left-sided endocarditis can be fatal. Surgery may be required in cases of persistent bacteremia or septic embolization.1 Embolism of a vegetation to the coronary arteries is rare. Treatment options include thrombectomy, angioplasty with stenting, and bypass surgery.2 , 3