Infective endocarditis of quadricuspid aortic valve

Patient is a 30-year-old male with history of polysubstance use, current tobacco use, upper extremity aneurysm with history of right brachial artery bypass with chronic lymphedema, tricuspid valve endocarditis treated with antibiotics only three years prior to presentation who initially presented with left upper quadrant pain. He was found to be bacteremic with blood cultures growing Enterococcus faecalis. He was initially started on Vancomycin and then transitioned to Ampicillin and Ceftriaxone. Imaging revealed a splenic embolic lesion on CT scan thought to be secondary to abscess or infarct. A Trans Esophageal Echocardiogram (TEE) was obtained which revealed a quadricuspid aortic valve with multiple vegetations on the ventricular aspect of all four leaflets, the largest of which measured 1.3  × 1.4 cm. He was also found to have moderate to severe aortic regurgitation with diastolic flow reversal in the proximal descending thoracic aorta.

His clinical course was complicated by new onset numbness, weakness, and tingling of his extremities as well as slurred speech. MRI Head was consistent with a moderately sized subcortical ischemic infarct. The patient had improvement in functionality following the. Neurosurgery and neurology were both consulted. While they had recommended holidng off on systemic anticoagulation due to the risk of hemorrhagic transformation, they did not feel that a thrombectomy was required. A digital subtraction angiography (DSA) was performed to look for mycotic aneurysms, which was negative, although it did show a distal right V3 segment saccular aneurysm measuring 4.72 × 3.16 × 3.63 mm with a 3.1 mm neck. The patient did not have permanent deficits from the stroke.

Despite the lack of heart failure symptoms, it was determined that surgical intervention was required due to moderate to severe aortic regurgitation, the size of the vegetations and evidence of septic emboli. Given the risk of hemorrhagic transformation with cardiopulmonary bypass and heparin administration, surgical intervention of his aortic valve was delayed for two weeks following the patient’s stroke per the recommendation of Vascular Neurology. Repeat CT scan on the day prior to surgery showed an evolving subacute infarct in the M2 distribution with no evidence of hemorrhagic transformation.

A surgical aortic valve replacement was performed via median sternotomy. An Inspiris Resilia aortic valve® (INSPIRIS) (Edwards Lifesciences LLC, Irvine, USA) was used via a supra-annular technique due to patient preference and concern for Warfarin compliance The surgery was uneventful. Cardiopulmonary bypass time was 88 min and cross clamp time was 60 min. Despite a previous history of tricuspid valve endocarditis, the patient did not have any tricuspid insufficiency or evidence of vegetation on TEE, and thus we did not intervene on the tricuspid valve. The patient was extubated on post-operative day zero and transferred out of the ICU on post-operative day one. Soon after, he was transferred to the medicine-psychiatric inpatient unit that specializes in addiction medicine, allowing the patient to complete a full course of antibiotics while starting his recovery process. He completed 5 weeks of IV antibiotics as an inpatient and was given a single dose of Dalbavancin to cover an additional 7–10 days.

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