SUCCESSFUL ROBOTIC MITRAL VALVE REPAIR OF ENDOCARDITIS WITH LEAFLET PERFORATION IN A HIGH RISK PATIENT

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Indications and timing of surgery for infective endocarditis are theoretically well framed but in practice, may be difficult to employ based on the patient's clinical status, co-morbidities and overall operative risk. We present a patient with methicillin susceptible staphylococcus aureus (MSSA) endocarditis in whom complex decision making was done for appropriate treatment. CASE PRESENTATION: A 39-year-old year old female with sickle cell disease and end stage renal disease on hemodialysis presented with septic arthritis and resulting MSSA bacteremia. Initial transesophageal echocardiogram (TEE) revealed a 1.4 x 0.6 cm mobile density on the A3 leaflet with associated P2 leaflet prolapse and perforation, as well as severe mitral regurgitation (MR). Multiple masses was also seen on the tip of the dialysis catheter and in the superior vena cava. The decision was made initially to defer cardiac surgery until multiple other sources of infection could be controlled, including dialysis catheter removal, abscess drainage of an old arteriovenous graft and septic arthritis debridement. Bacteremia cleared within a week of oxacillin treatment. Repeat TEE at the end of 6 week of antibiotics revealed resolution of A3 leaflet vegetation, but a new 0.8 cm mass was seen on the P2 leaflet with prolapse again with severe MR. Despite her multiple co-morbidities and severe de-conditioning from her prolonged hospital stay, the decision was made to proceed with surgery and to pursue robotic mitral valve repair with an annuloplasty ring and leaflet perforation closure over a traditional sternotomy approach. Her postoperative course was uneventful. DISCUSSION: Surgery was indicated in our patient due to the severe valve dysfunction with leaflet perforation and a staphylococcus aureus vegetation > 1cm. There is no consensus on the exact timing of surgery, especially in a severely debilitated high risk patient with multiple extra cardiac foci of infection. In our patient surgery was initially delayed to allow for optimal infection control along with an attempt to improve her global preoperative status. But failure of antibiotic treatment made surgery inevitable. The mortality or morbidity of open mitral valve repair is 32% per the Society of Thoracic Surgeons risk calculator, while studies report as low as 2% mortality with robotic repair. Minimally invasive surgery offers lower transfusion requirements, sternal wound complications along with a shorter hospital stay. Ring annuloplasty and leaflet repair was chosen over traditional valve replacement as ESRD predisposes to accelerated valve calcification and to avoid long term anticoagulation in this young patient with hemoglobinopathy. CONCLUSIONS: Robotic valve repair with experienced operator is the preferred option for high risk surgical patients. A multidisciplinary team approach with advanced surgical management is vital in complex endocarditis. Reference #1: Kang D Timing of surgery in infective endocarditis Heart 2015;101:1786-1791. Reference #2: Gillinov AM, Suri R, Mick S, Mihaljevic T. Robotic mitral valve surgery: current limitations and future directions. Ann Cardiothorac Surg. 2016;5(6):573–576. doi:10.21037/acs.2016.03.13 DISCLOSURES: No relevant relationships by Arnar Geirsson, source=Web Response No relevant relationships by Daniel Gomez, source=Web Response No relevant relationships by Gini Priyadharshini Jeyashanmugaraja, source=Web Response No relevant relationships by Kristin Stawiarski, source=Web Response No relevant relationships by stuart zarich, source=Web Response