Case presentation
In September 2021, a 48-year-old gentleman presented to our center with Mitral valve endocarditis and significant Mitral valve regurgitation as a consequence (MR).
He was referred to our clinic due to recent dyspnea with exertion, lower extremities edema, and fever. He had transthoracic and transesophageal echocardiography (TEE).
According to the TEE report, the left ventricle (LV) and right ventricle (RV) were normal in terms of size and systolic and diastolic function, the systolic pulmonary artery pressure (SPAP) was normal, and the Mitral valve leaflets (MVLs) were thickened and myxomatous, with a large mobile 1.77cm x 0.92cm vegetation on the atrial side of the posterior Mitral valve leaflet (PMVL). Additionally, there was 0.6cm x 0.6cm vegetation connected to the chordae of the anterior Mitral valve leaflet (AMVL) and another 0.8cm x 0.4cm vegetation adhered to the A2 scallop. The intervalvular fibrosa (IVF) was intact, and no abscess or Aortic valve (AV) involvement was observed.
He had been admitted to another hospital and treated with antibiotics for IE. During the admissions process, he experienced a sudden right-sided hemiplegia and Broca aphasia. Spiral CT scan of the brain revealed a ”large low attenuated area involving the left parietal lobe, basal ganglia, internal capsule, and right pericallosal white matter, as well as a mild collapse of the left lateral ventricle due to embolic infarction,” while cerebrovascular angiography revealed a mycotic aneurysm. As a result, surgery was postponed despite numerous vegetations, one greater than 15mm in diameter, and significant MR.
Our center was suggested to him. The patient was admitted to the hospital with a fever of 38.6 degrees Celsius, a blood pressure of 140/85 millimeters mercury, a heart rate of 83 beats per minute, a respiratory rate of 16 breaths per minute, and an oxygen saturation level of 96 percent in room air. He was awake and aware, but unwell.
Cardiac auscultation indicated a normal heart rhythm free of murmurs, while chest auscultation revealed no abnormalities. An abdominal check revealed no abnormalities. There were peripheral pulses (2+). Left and right extremities had a force of 5/5 and 1/5, respectively. Table 1 summarizes the laboratory results.
PCR tests for wright, coombs wright, 2ME, and covid 19 were negative. Urinalysis indicated 1+ glucose, 1+ blood, 4-6 WBC/HPF, many bacteria, and 6-8 RBC/HPF without any RBC casts or dysmorphic RBCs. After a two-week incubation period, no bacteria grew in three blood culture samples. Additionally, thyroid and liver function tests revealed that the patient’s thyroid and liver functions were normal.
TTE and TEE performed 15 days later revealed normal LV size and function (LVEF: 55%), mild RV enlargement and normal systolic function, normal right atrium (RA) size, moderate left atrium (LA) enlargement, thickened, myxomatous MVLs with a massive 2.5 cm x1.4 cm vegetation on the atrial side of PMVL, which remained enlarged despite antibiotic therapy and embolization, resulting in flailing PMV. The AV was tricuspid and somewhat redundant, with significant regurgitation in the absence of stenosis. Tricuspid valve regurgitation (TR) was mild, with a TR gradient (TRG) of 30 mmHg and an SPAP of 38 mmHg. The pericardium was normal, and a minor pericardial effusion was seen. (figs. 1-3)
Abdomino-pelvic sonography revealed a cystic lesion with a thick wall harboring internal echo in the spleen’s lower pole, consistent with the establishment of an abscess. The rest of the structures were normal.
A consultation with the heart team was conducted, and it was agreed to proceed with operation.
Coil embolization was used to treat a cerebrovascular pseudo-aneurysm prior to heart surgery.
The patient had Mitral valve replacement (MVR) and Aortic valve replacement, had vegetations on it according to intra-operative TEE, sixteen days following the first TEE (AVR). During the same procedure, a spleen abscess was drained under the guidance of ultrasonography.
Post-pump TEE revealed that the mechanical bileaflet prosthetic MV exhibited normal motion and hemodynamics without paravalvular leakage. Additionally, the mechanical bileaflet prosthetic AV demonstrated satisfactory motion and hemodynamics with mild paravalvaular leaking from the postero-medial side of the sewing ring.
After 21 days incubation of tissue sample culture, pathology revealed fibromyxoid valve tissue with foci of fibrinoleukocytic exudation, vascular and fibroblastic proliferation, and calcification consistent with endocarditis.
Following surgery, he had three weeks of intravenous antibiotic treatment with Ampi-bactam and vancomycin.
Three days later, abdominal ultrasonography revealed a normal-sized, 120 millimeters spleen with a normal echo pattern and no indication of collection.
Two months following surgery, a follow-up TTE indicated normal LV size and function (LVEF: 55%), normal RV size with moderate systolic dysfunction, SPAP of 24mmHg, normal bi-atrial size, normal motion, and hemodynamics of both mechanical prosthetic valves without apparent clot or vegetation.
Three months following surgery, the patient was in good general health and had partially recovered from neurologic impairments.