Successful surgical treatment of a long ingrowing intra-coronary septic vegetation

Abstract

A 39-year-old man was referred to our hospital as infective endocarditis with multiple organ failure and disseminated intravascular coagulation syndrome. Transoesophageal echocardiography and coronary computed tomography angiography revealed a long ingrowing vegetation into the right coronary artery. Emergency surgical resection of the vegetation and aortic valve replacement was performed successfully without distal embolism of the vegetation.

CASE REPORT

A 39-year-old man was emergently referred to our hospital as infective endocarditis with multiple organ failure (MOF) and disseminated intravascular coagulation syndrome (DIC). He was admitted to the previous hospital for high fever 3 days before the referral. Transthoracic echocardiography (TTE) showed an oscillating mass around the aortic valve. Methicillin-sensitive Staphylococcus aureus (MSSA) was detected by blood and urine culture at the previous hospital. There were petechia mainly on his trunk and Osler’s nodes on his both hands and feet. No obvious neurological deficits were observed.

The patient presented with renal dysfunction [serum creatinine; 160 mmol/l, estimated glomerular filtration rate (eGFR); 36 ml/min/1.73 m²], liver dysfunction [aspartate aminotransferase (AST); 112 IU/l, alanine aminotransferase (ALT); 83 IU/l], and thrombocytopaenia (platelet count; 35 000/μl) and coagulopathy [prothrombin time-international normalized ratio (PT-INR; 1.26) that met the DIC criteria. Laboratory data showed elevated serum troponin I. TTE showed 11 mm × 8 mm oscillating mass close to the right coronary ostium and reduced the motion of the inferior wall. Emergency transoesophageal echocardiography (TOE) revealed a bicuspid valve and a vegetation attached close to the right coronary ostium that partially extended into the right coronary artery (RCA) (Figure 1A). Contrast-media enhanced computed tomography (CT) showed right renal infarction and splenic infarction. A vegetation of about 3 cm in length extending from right coronary ostium into the RCA was revealed by coronary CT angiography (Figure 1B, 1C, 1D). Magnetic resonance images of the brain revealed multiple embolic infarctions.

In addition to uncontrollable infective endocarditis with multiple infarction, MOF, and DIC, on-going myocardial ischaemia suggested by the elevation of serum troponin I and the vegetation extending into the RCA revealed by CT and TEE were considered as an indication for emergency surgery. He was preoperatively started on MSSA-sensitive antibiotics (Cefepime).

Following the establishment of cardiopulmonary bypass and aortic clamp, cardiac arrest was obtained by antegrade cardioplegia. The aortic valve was a Sievers’s classification type 0 bicuspid valve with anterior-posterior cusps. A vegetation was attached to the ventral side commissure (Figure 2A). A part of the vegetation extended to the right coronary ostium and the coronary artery (Figure 2B). The vegetation extending to the RCA was pulled out over the entire length by grasping and pulling with 2 forceps while performing retrograde coronary perfusion. Extracted vegetation from the RCA was about 3 cm in length and 3–4 mm in diameter. Aortic valve replacement was performed with a mechanical valve (22 mm, ATS Open Pivot^® AP360™ Heart Valve, Medtronic, Minneapolis, MN, USA). Intra-operative TEE revealed improved inferior wall motion. No obvious residual vegetation in the RCA was found. Renal dysfunction, liver dysfunction, and DIC improved within several days after operation. MSSA was positive in the culture of vegetation and pericardial effusion collected during the operation. All blood cultures after operation were negative. No major complications were observed perioperatively.

The patient was transferred to cardiology department to continue antibiotic treatment. Intra-venous administration of Cefepime 1.0 g × 3/day was done for 2 weeks after the operation, and the regimen was changed to Cefazolin 2.0 g × 3/day for another 4 weeks as renal dysfunction improved. The patient presented at out-patient clinic for follow-up without any symptoms or laboratory data suggesting the recurrence of infection even after termination of antibiotic therapy. As of 6 months after surgery, he is doing well.

DISCUSSION

Coronary artery obstruction is a rare manifestation of infective endocarditis and often confirmed after onset of cardiogenic shock or cardiac arrest, or in autopsy cases [1, 2]. Operative mortality for ‘active’ infective endocarditis has been reported to be relatively high [3]. As Nazir et al. [4] reported, acute myocardial infarction is an additional risk in active infective endocarditis with the 30-day mortality of 43%. Treatment for coronary obstruction is diverse because the patient background and the condition at the time of diagnosis are varied.

In the present case, the surgical risk was considered to be high for the comorbidities. The presence of MOF and DIC was of course an independent indication for emergency surgery. The long ingrowing vegetation into the coronary artery was also considered to be an exclusive indication for surgical resection because catheter intervention had an extremely high risk of distal embolism. Fortunately, the entire length of vegetation ingrowing into the RCA could be pulled out under retrograde infusion of the cardioplegia. Regarding the initial cardioplegia, we performed antegrade cardioplegia. But to reduce the last-minute potential risk for coronary embolization, retrograde initial cardioplegia was also considered as an option.

Reviewer information

European Journal of Cardio-Thoracic Surgery thanks Takashi Murashita and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.

REFERENCES