A Complicated Case of Triple Valve Infective Endocarditis in an IV Drug User with a Bicuspid Aortic Valve Requiring Three Separate Salvage Operations: A Case Report and Literature Review.

Shahzad Khan,David Oelberg,Dmitry Yaranov,Athanasios Smyrlis,Eric Jimenez

doi:10.1155/2015/291079

Shahzad Khan, David Oelberg + Show 3 more

Open Access

https://doi.org/10.1155/2015/291079

Copy DOI

Abstract

Infective endocarditis (IE) is an infection of the endocardium that involves valves and adjacent mural endocardium or a septal defect. Local complications include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal. Diagnosing IE can be straightforward in patients with the typical oslerian manifestations such as bacteremia, evidence of active valvulitis, peripheral emboli, and immunologic vascular phenomena. In the acute course, however, the classic peripheral stigmata may be few or absent, particularly among intravenous drug abuse (IVDA) patients in whom IE is often due to a S. aureus infection of right-sided heart valves. We present a complicated case of a very aggressive native aortic valve MSSA (methicillin sensitive Staphylococcus aureus) IE in a young adult male with a past medical history of bicuspid aortic valve and IV drug abuse. His clinical course was complicated by aortic valve destruction and development of third-degree AV block, as well as an aorto-left atrial fistula requiring emergent operation for AV replacement and patch repair. The patient required two reoperations for recurrent endocarditis and its complications.

Highlights

Infective endocarditis (IE) is an infection of the endocardium that could involve or affect the valves and adjacent structures of the heart
Upon discharge he followed with his doctors regularly and did not have any further cardiac complications. This was a highly complex case due to the severe pathology with multiple valve involvement as well as the patients’ social and behavioral issues. His management was challenging as he initially failed to present to the infusion center and antibiotic course was interrupted while he was likely using the IV access for IVDU
The patient did not comply with outpatient follow-up consistently and he was initially not willing to take Warfarin; a mechanical valve was not an option

Summary

Background

Infective endocarditis (IE) is an infection of the endocardium that could involve or affect the valves and adjacent structures of the heart. IE can be caused by a wide variety of microorganisms fungal or bacteria (Streptococcus viridans, Streptococcus gallolyticus, Staphylococcus aureus, HACEK group) Not common, it can be a fatal pathological condition if not identified and treated especially in those that are older and have congenital or valvular heart defects or other comorbidities that delay or impede the healing process. Bicuspid aortic valve is the most common congenital malformation It affects 1-2% of the general population and has a 3 : 1 predilection of males to females and is a welldescribed risk factor for IE [4]. Lamas and Eykyn demonstrated that 7–25% of the IE population had a past medical history of a congenital bicuspid aortic valve They found that these patients are more likely to have a worse prognosis such as developing heart failure, valvular destruction, and/or perivalvular/myocardial abscess [5]. Abscess formation in the aortic annulus can be complicated by complete heart block or bundle branch block in up to 45% of cases

Case Presentation

Findings

Discussion