**8.4. Coronary septic emboli**

Coronary embolization from a septic focus has been relatively well reported in the literature [74, 124] and usually originates from valvular vegetations in the setting of IE [125]. Septic coronary embolism has also been reported to occur intraoperatively during mitral valve surgery performed in the setting of IE [126]. Coronary arterial SE should be entertained in cases of known or suspected left-sided IE and evidence of concurrent acute myocardial ischemia (e.g., abnormal ECG or elevated cardiac enzymes). Echocardiography (preferably TEE) can reliably demonstrate the presence of valvular vegetations, in addition to documenting other changes characteristics of myocardial ischemia [127]. Coronary occlusion secondary to SE can also be confirmed via coronary angiography, with the potential for percutaneous coronary intervention at the same time [128]. Acutely occluded major coronary arteries or branches may require surgical revascularization at the time of valve surgery. Patients with aortic valve endocarditis, in whom preoperative coronary angiography may be contraindicated due to concerns of dislodging debris, may require empiric grafting [2]. An example of a mycotic coronary artery aneurysm associated with IE is shown in **Figure 7**.

**Figure 7.** Mycotic aneurysm of the right coronary artery. The patient underwent venous bypass grafting. Source: Stawicki et al. [2]. Used under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
