A RARE POST-SURGICAL EMPYEMA AFTER AN APICAL APPROACH TRANSCATHETER AORTIC VALVE REPLACEMENT

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: First introduced in 2002, the anterograde Transcatheter Aortic Valve Replacement (TAVR) procedure continues to grow in popularity, given its efficacy in patients with high surgical risk suffering from severe aortic stenosis. Although a less invasive procedure than previous techniques, various potential complications can occur causing severe morbidity and death. Post-operative infections occur in for 13-15% of all post TAVR complications. However acute pulmonary complications (APC) after a TAVR procedure only occur in 1.5% of cases. Post TAVR empyema is extremely uncommon. If not emergently diagnosed and treated it may be fatal. CASE PRESENTATION: A 74-year-old male with a past medical history significant for COPD and aortic valve replacement in 2002 underwent a transapical TAVR after presenting with severe aortic insufficiency. 11 days later, the patient developed acute pleuritic chest pain and dyspnea prompting him to return to the emergency department. He was found to be hypoxic requiring 4 liters of nasal cannula and hypotensive requiring Norepinephrine. Initial work-up revealed a leukocytosis of 39.2 K and a large left pleural effusion on CT imaging. A pig-tail catheter was placed with 2 liters of straw-colored fluid removed from the left pleural space. Fluid studies revealed LDH 1163, pH 7.32, glucose of <5, and WBC 2128 suggesting empyema. Fluid cultures were sent and the patient was started on empiric antibiotics. A repeat chest CT found persistent left sided pleural effusion despite pig-tail catheter with concern for complex appearance of residual fluid. Thoracic surgery was consulted who recommended video-assisted thoracoscopic surgery (VATS) with total decortication. During his procedure a large amount of gelatinous and fibrinopurulent debris were found encasing the entire left lung. A sample of pleural peel was obtained and sent for pathology which showed fibrinopurulent exudate and granulation tissue consistent with empyema. After his procedure, the patient's clinical status continued to improve and he remained stable on room air. He was subsequently discharged home. DISCUSSION: Empyema is a rare post-surgical complication following a TAVR procedure, with few reported cases. Patients with underlying pulmonary disease are at increased risk for APCs following a TAVR procedure. APCs are most common from a trans apical approach. Patients suffering an APC following a TAVR procedure have been shown to have poorer outcomes. Because of this, Empyemas are associated with high morbidity and mortality in post TAVR patients. If not urgently treated it may be fatal. CONCLUSIONS: Empyema is an extremely uncommon complication of a trans apical approach TAVR procedure and is associated with high mortality. Physicians must keep empyema on their differential when treating acute hypoxic respiratory failure in patients with a recent TAVR. REFERENCE #1: Baillot, Richard et al. "Surgical site infections following transcatheter apical aortic valve implantation: incidence and management." Journal of cardiothoracic surgery vol. 7 122. 13 Nov. 2012, doi:10.1186/1749-8090-7-122 REFERENCE #2: Mali, Shahriar, and Hasan Haghaninejad. "Pulmonary complications following cardiac surgery." Archives of medical sciences. Atherosclerotic diseases vol. 4 e280-e285. 31 Dec. 2019, doi:10.5114/amsad.2019.91432 REFERENCE #3: Tetsuro Shimura et al. "The incidence, predictive factors and prognosis of acute pulmonary complications after transcatheter aortic valve implantation, Interactive CardioVascular and Thoracic Surgery, Volume 25, Issue 2, August 2017, Pages 191–197, https://doi.org/10.1093/icvts/ivx075 DISCLOSURES: No relevant relationships by Katie Abney, source=Web Response No relevant relationships by Zachary Fyffe, source=Web Response No relevant relationships by Kelly Rodman, source=Web Response No relevant relationships by Jon Simala, source=Web Response