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.