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.