Abstract
Prosthetic valve endocarditis with mechanical complications causing pulmonary edema is fatal, therefore it needs to be diagnosed early and should be treated surgically in emergency setting. Transesophageal echocardiogram is crucial for recognizing the mechanical complications, which can be encountered on daily practice, but the coexistence of complications occurring on different mechanism is rather uncommon. Herein, we report a 21-year-old gentleman presenting with acute heart failure, whose imaging tests showed a combination of dehiscence of mechanical aortic valve prosthesis, aortic dissection, pseudoaneurysm and hematoma causing right ventricular collapse.
A 21-year-old gentleman presented to emergency department in our hospital with dyspnea, fatigue in April 2022. His medical history included implantation of mechanical aortic valve prosthesis in February 2022 due to infective endocarditis caused by methicillin-resistant staphylococcus aureus. He was discharged after 6 weeks of antibiotic regimen at the end of the March 2022. On admission, he was in New York Heart Association class IV. He had a temperature of 37.6° C, a pulse rate of 107 beats/minute, a respiratory rate of 24 breaths/min, and a blood pressure of 105/65 mmHg. Physical examination revealed 4/6 systolic murmur on all cardiac auscultation sites, left-sided S4, tachypnea, bibasilar crackles and jugular venous distention. His electrocardiogram showed sinus tachycardia. Chest x-ray demonstrated increased cardio-thoracic index and interstitial pulmonary edema with pleural effusions. Complete blood count demonstrated severe anemia with a hemoglobin level of 10.7 g/dl. The white blood cell count and platelet count were normal. High sensitivity C-reactive protein was 208 mg/L, procalcitonin was 1.43 ng/mL. Kidney function tests demonstrated elevated levels of creatinine 1.9 mg/dL. Additional test results included pro-BNP 11626pg/mL and high-sensitivity troponin T 856 pg/mL. Transthoracic and transesophageal echocardiogram disclosed normal left ventricular systolic function, dehiscence of aortic prosthesis, severe paravalvular regurgitation, pseudoaneurysm of sinus Valsalva, image of dissection flap and a round, heterogenous mass (75 x 55 mm) consistent with hematoma causing obstruction to the right ventricular inflow (Figure A – D; Video 1 - 3). Contrast enhanced thorax CT confirmed the aortic dissection, pseudoaneurysm of the sinus Valsalva and hematoma inside it (Figure E - I). Ceftazidime 2x2 g/day, vancomycin 1g/day and gentamicin 2 x 160 mg/day were initiated. Under general anesthesia, he underwent excision of the aortic prosthesis, repair of the pseudoaneurysm with a pericardial patch and construction of the neoannulus. A 21 mm Sorin conduit with mechanical prosthesis was implanted. He was extubated next day, and was admitted to the ward in order to receive the antibiotics for 6 weeks. His blood cultures remained sterile.
This case illustrates the importance of prompt imaging in a patient with prosthetic valve and acute heart failure for the diagnosis and treatment of mechanical complication of prosthetic valve endocarditis. Transesophageal echocardiography was necessary for the recognition of local complications, and contrast enhanced CT contributed to delineating the complex anatomy around the prosthetic valve. As 2015 ESC guidelines for the management of infective endocarditis states1, surgery is indicated at emergency setting if the patient has infective endocarditis with severe regurgitation, obstruction or fistula causing refractory pulmonary edema or cardiogenic shock. With prompt diagnosis and surgery, the clinical status of the patient was stabilized.