Discussion
Systemic embolism, which affects about one-third of patients with IE and can involve the central nervous system in up to 65 percent of cases, is the second leading cause of mortality in these patients, after congestive heart failure.6 The majority of patients who present with a neurological problem have at least one additional reason for heart surgery.1
There are questions concerning the role of surgery in IE patients with stroke or ICH due to the possibility of neurological worsening or perioperative cerebral hemorrhage. 1However, AATS guidelines state that once an indication for surgery is established, the patient should be operated on within days, and earlier surgery, within 48 hours, is reasonable for patients with large mobile vegetations (>10 mm) for embolism prevention, particularly following an embolic event during appropriate antibiotic therapy.2,3 Nonetheless, if ICH has been ruled out by cranial CT and neurological impairment is not severe, surgery should not be postponed because it has a low (3–6%) neurological risk, a high probability of complete neurological recovery, and is safe and effective according to AATS standards. 1,3 Cardiovascular function impairment, recurrent stroke or systemic embolism, or uncontrolled infection despite sufficient antibiotic therapy received a Class IIb with Level of evidence C in the AHA recommendations for postponing fewer than four weeks. 4
In 21 patients with IE and cerebrovascular sequelae, Hosono7 et al. associated the amount of cerebral infarction with the date of operation (CVC). They concluded that individuals with a minor cerebral infarction (diameter 15 mm) might safely have heart surgery within 14 days after the commencement of a cerebrovascular incident.
Snygg-Martin8 et al. assessed 60 individuals with IE on the left. They reported a 65% prevalence of preoperative CVC and a 35% prevalence of symptomatic CVC. Patients with symptomatic CVC had surgery after a median of 8 days without neurological worsening, according to Piper et al.9, who prospectively tracked 108 patients with IE with CVC from 1982 to 1993. Patients were classified according to the time interval between recurrent thromboembolic occurrences and cardiac surgery (72 h, 3-8 days, or >8 days). Patients operated on within 72 hours had a considerably better prognosis (p 0.0001) than those managed medically. Patients who underwent heart surgery more than eight days after stroke, as well as those who received conservative treatment, had poor outcomes.
At the time of initial presentation, our patient had a large mobile 1.77cm × 0.92cm vegetation on the PMVL, indicating the need for surgery. However, he received medical treatment alone. In spite of several vegetations, one greater than 15mm in diameter, predisposing embolism, and severe MR, surgery was not conducted following current standards. In light of the aforementioned research and the patient’s significant risk of embolic event, we decided to operate. Additionally, he did not have neurological degeneration or ICH following surgery or during follow-up.
Absence of a splenic abscess can result in recurrent IE and, in rare cases, splenic rupture. Splenectomy is the definitive treatment for this problem, as medical therapy alone has usually failed. To avoid re-infection of the implanted valve, splenectomy is advised prior to valve replacement (VR). Splenectomy with minimally invasive techniques has been proved to be a safe and effective alternative to laparotomy for the treatment of IE. 5
Megan E. Lindsey5 described a 75-year-old man with endocaritis who had a 2.2cm vegetation on the aortic valve accompanied by severe aortic valve insufficiency (AI) and silent numerous bilateral ischemic strokes, as demonstrated by brain MRI, as well as an 8.1 cm splenic abscess. A multidisciplinary team chose to do urgent AVR due to concerns about cognitive impairment and increasing CHF. Due to significant deconditioning and malnutrition, simultaneous splenectomy and AVR were not deemed a realistic choice. As a result, the splenic abscess was drained percutaneously during AVR. Repeat CT imaging revealed a 7 cm accumulation in the spleen after 12 weeks of intravenous antibiotic therapy. As a result, he had a straightforward robotic-assisted splenectomy (da Vinci). His postoperative course was unremarkable, and he was doing well at a two-year follow-up.5
Chou et al.10 described the outcome of interventional operations guided by ultrasonography (US) in a 21-year-old patient with splenic abscess. The patients received appropriate antibiotic medication for at least eight weeks following the surgeries and reported no adverse events during follow-up. As a result, US-guided drainage may be the preferred method of therapy for splenic abscess in order to prevent splenectomy. 10
Additionally, our patient had US-guided splenic abscess drainage following surgery as a substitute for complete splenectomy. As previously stated, follow-up abdominal ultrasound revealed no residual splenic abscess.