60M Acute Left Femoral Artery Embolism Secondary to Large Left Ventricular Outflow Tract and Mitral Valve Vegetations in a Patient with Hypertrophic Cardiomyopathy

 

60M with Acute Left Femoral Artery Embolism Secondary to Large Left Ventricular Outflow Tract and Mitral Valve Vegetations in a Patient with Hypertrophic Cardiomyopathy: A Case Report

Abstract

Background

Systemic embolization is a serious complication of infective endocarditis (IE), particularly in patients with large mobile vegetations. Acute limb ischemia due to septic embolization is uncommon but requires urgent recognition and intervention. We report a case of acute left femoral artery embolism in a patient with hypertrophic cardiomyopathy (HCM) and echocardiographic evidence of large vegetations involving the left ventricular outflow tract (LVOT) and mitral valve.

Case Presentation

A 60-year-old man with hypertrophic cardiomyopathy, type 2 diabetes mellitus, hypertension, hypothyroidism, obesity with obstructive sleep apnea, and chronic smoking history presented with severe left lower limb pain of approximately three days’ duration. Vascular imaging demonstrated left femoral artery thrombosis causing acute limb ischemia. Transthoracic echocardiography revealed a large vegetation in the LVOT and a smaller vegetation on the atrial aspect of the anterior mitral leaflet. The patient underwent emergency left femoral embolectomy. Blood, urine, and embolic tissue cultures reportedly showed no bacterial growth. According to the available clinical information, a septic panel isolated Klebsiella species despite negative conventional cultures. The patient received intravenous antibiotics, anticoagulation, and supportive care and recovered uneventfully from the vascular procedure. Cardiothoracic surgical evaluation recommended stabilization followed by definitive cardiac surgery.

Conclusion

This case highlights acute limb ischemia as a manifestation of systemic embolization in a patient with echocardiographic evidence of infective endocarditis and HCM. It also underscores the diagnostic challenges posed by culture-negative presentations and the importance of integrating clinical, imaging, and adjunctive microbiological data.

Case Presentation

A 60-year-old male resident of Hyderabad and retired employee presented with severe pain in the left lower limb. According to the available records, the pain had an insidious onset and progressively worsened over approximately three days. An outside Doppler examination reportedly demonstrated left femoral artery thrombosis, and the patient was referred for further management.  

His past medical history was significant for:

• Hypertrophic cardiomyopathy (diagnosed in 2010)
• Left ventricular outflow tract obstruction with mitral valve involvement
• Previous infective endocarditis (as documented in the presentation material)
• Type 2 diabetes mellitus
• Hypertension
• Hypothyroidism
• Obesity with obstructive sleep apnea
• Chronic smoking history
• Prior history of left femoral artery thrombus/embolus documented in the medical records  

Physical Examination

On admission, the patient was conscious and coherent.

Recorded vital signs included:

• Pulse rate: 102 beats/min
• Blood pressure: 130/90 mmHg
• Respiratory rate: 20/min
• Temperature: 98.4°F
• Oxygen saturation: 93% on room air

The presentation slides documented absent palpable pulses in the left anterior tibial and dorsalis pedis arteries with preserved limb warmth and no evidence of compartment syndrome or gangrene.  

Investigations

Transthoracic echocardiography demonstrated:

• Large vegetation within the left ventricular outflow tract
• Smaller vegetation on the left atrial aspect of the anterior mitral leaflet

 

Laboratory data 

• Hemoglobin: 10.2 g/dL
• Serum creatinine: 1.12 mg/dL

Microbiological evaluation showed:

• Blood cultures: No bacterial growth
• Culture of embolic tissue obtained during embolectomy: No bacterial growth
• According to additional clinical information provided by the treating team, urine cultures were also negative.
• Per additional information supplied by the treating clinicians, a septic panel identified Klebsiella species despite negative conventional cultures.
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Management

The patient received treatment with:

• Intravenous antibiotics
• Heparin
• Diuretics
• Statin therapy
• Supportive medical management

Because of acute limb ischemia secondary to left femoral artery occlusion, he underwent emergency left femoral embolectomy under general anesthesia on 18 May 2026. Embolic material was submitted for histopathological examination and microbiological culture.  

The postoperative course was uneventful. The patient was extubated on the following day and remained hemodynamically stable.

Cardiothoracic surgery consultation recommended stabilization followed by definitive surgical management. Presentation records indicated a planned reassessment with transesophageal echocardiography and consideration of septal myectomy with mitral valve replacement or double-valve surgery depending on subsequent evaluation.  

Outcome and Follow-up

At discharge, the patient was conscious, hemodynamically stable, and recovering satisfactorily following femoral embolectomy. Long-term prognosis and future cardiac surgical management were discussed with the patient according to the discharge documentation.  

Learning Points

1. Acute limb ischemia may be the presenting manifestation of systemic embolization from infective endocarditis.
2. Large LVOT and mitral valve vegetations carry a significant risk of peripheral embolic events.
3. Negative blood cultures do not exclude infective endocarditis, particularly after antibiotic exposure.
4. Molecular septic panels may provide additional microbiological information when conventional cultures remain sterile.
5. Early multidisciplinary collaboration among cardiology, vascular surgery, infectious disease, and cardiothoracic surgery teams is essential in managing complex embolic infective endocarditis.

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