Abstract
Periannular extension and abscess formation are rare but deadly complications of infective endocarditis (IE) with high mortality. Multimodality cardiac imaging, invasive and noninvasive, is needed to accurately define the extent of the disease. Debridement, reconstruction, and valve replacement, often performed in an emergent setting, remain the treatment of choice. Here we present a case of severe IE in a 29-year-old intravenous drug user who after undergoing debridement of the abscess, annular reconstruction, and mitral valve replacement (MVR) presented with recurrence of shortness of breath and pedal edema. Transthoracic echocardiogram (TTE) showed a 6.2 × 5.5 cm cavity, posterior to and communicating with the left ventricle through a 3 cm wide fistulous opening, in proximity of the reconstructed mitral annulus. The patient underwent a redo MVR with patch closure of the fistulous opening, with good clinical outcome. This case highlights the classic TTE findings and the necessity for close follow-up in the perioperative period in patients undergoing surgery for periannular extension of infection. A cardiac magnetic resonance imaging can be considered, preoperatively, in such cases to identify the extent of myocardial involvement and surgical planning.
Highlights
Periannular extension of infection in infective endocarditis (IE) is a serious complication with significant mortality even after prompt surgical management
Tissue necrosis and pyogenesis may lead to formation of an abscess cavity which under increased pressure is prone to rupture causing fistulae formation [6]
Transesophageal echocardiogram (TEE) is the diagnostic tool of choice for diagnosis of perivalvular involvement but is less sensitive in detecting diseases of mitral valve compared to aortic valve (57% versus 86%) [7, 8]
Summary
Periannular extension of infection in infective endocarditis (IE) is a serious complication with significant mortality even after prompt surgical management. Debridement of abscess cavity followed by patch closure and valve replacement often performed emergently is mainstay of treatment. The patient underwent transesophageal echocardiogram (TEE) that showed vegetation originating from anterior commissar and extending into the mid scallop of the posterior leaflet. The patient underwent debridement and simple closure of the abscess cavity (1.8 × 1.5 cms) followed by mitral valve replacement (MVR) with a 27 mm St. Jude mechanical valve. TTE showed communication between the left ventricle and the pericardial cavity through a 3 cm fistulous opening in the region of the posterior mitral annulus. This cavity measured 6.2 × 5.6 cms compared to 1.8 × 1.5 cms prior to the valve replacement (Figure 1). The patient recovered well and was discharged home a week after the surgery with close follow-up
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