Cardiac transplantation for prosthetic valve endocarditis in a previously transplanted heart

Abstract

Native valve endocarditis is a rare complication after heart transplantation.1,2,3 A 54-year-old male underwent cardiac transplantation for end-stage ischemic cardiomyopathy in March 1992. The immediate postoperative course was complicated by primary graft failure requiring high-dose inotropic support and the intra-aortic balloon pump. Acute renal failure developed and continuous arteriovenous hemodialysis was undertaken for 8 days. The patient received triple immunosuppression with cyclosporine, azathioprine, and prednisone, without induction therapy. The patient became febrile and severe mitral regurgitation and mitral valve vegetations were noted 36 days after the transplant by echocardiography. Blood cultures grew methicillin-resistant Staphylococcus aureus (MRSA). A CT scan of his head revealed 2 lesions consistent with septic emboli. He remained febrile despite treatment with vancomycin and fuscidic acid with adequate blood levels. An aminoglycoside was not used because MRSA in this institution is resistant. Because of uncontrolled sepsis with blood cultures persistently growing MRSA, the patient underwent mitral valve replacement with a St. Jude prosthesis 42 days after the transplant. At operation massive vegetations were found on the mitral valve leaflets and the infection was eroding the annulus. Postoperatively, he developed acute renal failure and required 3 further days of continuous arteriovenous hemodialysis. The same antibiotics were continued postoperatively. Seventeen days later, severe mitral regurgitation developed due to a paravalvar leak. The patient remained febrile and 1 blood culture was positive for MRSA. Transesophageal echocardiography demonstrated a paravalvar leak with adjacent vegetations. Because of ongoing sepsis and severe heart failure, retransplantation was undertaken 103 days after his original transplant. He received triple immunosuppression with 3 doses of OKT3. Cyclosporine levels were run at one-half the usual level, azathioprine at 50 mg per day, and prednisolone at 10 mg per day. The explanted heart showed dehiscence of 50% of the sewing ring of the mitral valve prosthesis and MRSA was cultured from the annulus. Eleven days after his retransplant procedure Candida albicans was grown from a pleural drain. Four months after his second transplant he developed signs and echocardiographic features of constrictive pericarditis. An attempt was made to perform a pericardiectomy but this proved technically impossible. Pericardial fluid contained white blood cells and C. albicans was grown. He underwent a course of amphotericin followed by fluconazole. Eight months following his retransplantation he developed lower back pain and nuclear magnetic resonance imaging revealed a discitis of the fourth lumbar disk, a 7-cm abdominal aortic aneurysm, and an abscess in continuity with these 2 lesions. He underwent resection of this mycotic abdominal aortic aneurysm and subsequently, removal of the infected disk material (MRSA was grown) which did not involve the epidural space. He received vancomycin postoperatively. He has evidence of moderately severe chronic constrictive pericarditis and has had intermittent low-grade fevers for which no cause has been found despite extensive evaluation. No organisms have been cultured from his blood, blood count and erythrocyte sedimentation rate are normal, and repeated transthoracic and transesophageal echocarFrom the Heart and Lung Transplant Unit, The Prince Charles Hospital, Brisbane, Australia,a and the University of Alabama at Birmingham, Department of Surgery, Birmingham, Alabama.b Submitted June 19, 1996; accepted February 12, 1999. Corresponding author: David C. McGiffin, MB, BS, FRACS, Professor of Surgery, University of Alabama at Birmingham, Division of Cardiothoracic Surgery, UAB Station, LHRB 780, Birmingham, Alabama 35294-0007. Office telephone: 205-9346580. Fax: 205-975-2526. Copyright © 1999 by the International Society for Heart and Lung Transplantation. 1053-2498/99/$–see front matter PII 1053-2498(99)00011-X