SESSION TITLE: Cardiothoracic Surgery Cases - Student/Resident
SESSION TYPE: Student/Resident Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM
INTRODUCTION: Infective endocarditis (IE) of four valves is an extremely uncommon phenomenon and successful surgical repair even is rarer.1 Due to the significant burden of diseased tissue, the prognosis is often poor, and the risks of surgery must be carefully weighed.
CASE PRESENTATION: A 48 year old male with murmur since childhood presented with 6 months of dyspnea and fatigue. He was noted to have severe anemia, acute renal failure and new-onset congestive heart failure. Work-up was significant for enterococcal bacteremia. He was treated with broad spectrum antibiotics, later deescalated to ampicillin and ceftriaxone. Upon transfer to a tertiary care facility, echocardiogram showed regurgitation and vegetations of all four valves, with a 1.5 cm aortic root pseudoaneurysm, thickened pericardium and 6 mm ventricular septal defect (VSD). Chest x-ray demonstrated bilateral pleural effusions. The patient denied injection drug use and colonoscopy was normal, but he had extensive dental caries with root involvement; multiple teeth required extraction. Despite his severe illness, the decision was made to proceed to surgery. After sternotomy, the thickened anterior pericardium was removed. Extensive calcified vegetations were excised from the tricuspid valve, right ventricle and VSD; sparing the tricuspid valve leaflets, which were repaired with an Alfieri stitch. The VSD was closed with a bovine pericardial patch. The damaged pulmonary valve was excised via the main pulmonary artery. Next, the aorta was transected and the non-coronary sinus pseudoaneurysm was excised (later repaired with bovine pericardium). The aortic valve was resected via the aorta and the mitral valve was resected via the intraatrial septum; both were replaced by mechanical valves. Lastly, a bioprosthetic pulmonary valve was placed and the right atriotomy was repaired. After bypass discontinuation, the pericardium was excised and pleural effusions were drained. After surgery, the patient did well: echocardiogram showed an ejection fraction of 50%. He was discharged on post-operative day 8 with a 2 month course of IV ampicillin and gentamicin.
DISCUSSION: Due to severe disease and lack of other source, dental pathology was deemed the probable cause of the patient's infection. Although not a constituent of normal oral flora, enterococcus may colonize the mouth in the case of periodontal disease.2 His history of VSD was postulated as a factor allowing spread of the infection to all 4 valves.
CONCLUSIONS: Despite critical illness, patients with multiple valve infective endocarditis have significant potential for benefit from surgical intervention in obtaining definitive source control.
Reference #1: Kim N, Lazar JM, Cunha BA, Liao W, Minnaganti V. Multivalvular endocarditis. Clin Microbiol Infec. 2000;6:207-212.
Reference #2: McCrary BR, Streckfuss JL, Keene HJ. Oral hygiene and the prevalence of oral group D streptococci in medically-physically compromised and periodontal disease patients. J Periodontol.1989;60(5):255-8.
DISCLOSURE: The following authors have nothing to disclose: Amy Bellinghausen Stewart, Anees Razzouk
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