WHEN LESS IS MORE: UTILIZATION OF A MULTIDISCIPLINARY APROACH IN THE TREATMENT OF NATIVE TRIPLE-VALVE INFECTIVE ENDOCARDITIS

Abstract

TOPIC: Palliative Care and End of Life Issues TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis (IE) is an insidious disease with significant hospital mortality rates. While many advances have been made to manage this disease, mortality rates still remain high. These rates worsen with the involvement of multiple valves. We report a case of native triple-valve IE were an appropriate interdisciplinary approach allowed the patient to focus on maximizing his desired outcomes. CASE PRESENTATION: An 85-year-old male with a past medical history of hypothyroidism presented with symptoms of generalized malaise, progressive dyspnea, intermittent blurred vision and left sided axillary pain for five months. Initial vitals showed tachycardia and patient was notably hypoxic. Blood cultures obtained on admission showed Streptococcus gallolyticus (bovis). Transthoracic echocardiography (TTE) revealed several vegetations involving the mitral, tricuspid and aortic valves (Figure 1-3). 4 months prior to admission, the patient had presented to the outpatient clinic with a syncopal episode. Work up at the time included a TTE which revealed a normal ejection fraction and no cardiac pathology. Given the development of new onset heart failure with cardiogenic shock in the setting of multi-valve infective endocarditis, a multidisciplinary team approach was taken. Cardiology, cardiothoracic surgery and palliative medicine work together to address the patient and his families goals. After informed discussion the patient decided against pursuing invasive cardiac surgery, and opted for palliative medical management. He was eventually transitioned to at home hospice. DISCUSSION: Triple valve endocarditis while extremely rare, it is associated with high rates of morbidity and mortality. According to existing literature (1,2), multi-valve IE has been recognized as an independent survival risk factor increasing mortality rate by 3% and a four fold higher rate of in-hospital mortality. The rate of complications such as congestive heart failure and acute renal failure are also higher with involvement of multiple valves, often warranting surgical intervention (3). In these situations the recovery is often prolonged with significant morbidity to the patients. In these situations it is best to approach clinical decision making with the patients goals of care in mind. Often in medicine we jump to aggressive treatments without fully taking the patients long-term goals in mind. Our treatments need to be evaluated to see if their outcomes and associated morbidities align with patients goals. With conversation based on these principles we can provide the patient with the highest level of benevolence, and ensure they receive the outcomes they truly wish. CONCLUSIONS: Triple valve surgery is extremely challenging and confers a poor prognosis. It is necessary to weight the risks and benefits of every intervention we take and make sure they align with the patients values and goals. REFERENCE #1: Sheikh, Azeem S, et al. "Triple-Valve Infective Endocarditis." British Journal of Cardiology, Apr. 2016, pp. 23–65., doi:10.5837/bjc.2016.015 REFERENCE #2: Kim N, Lazar JM, Cunha BA, Liao W, Minnaganti V. Multi-valvular endocarditis. Clin Microbiol Infect 2000;6:207–12. https://doi.org/10.1046/j.1469-0691.2000.00065.x REFERENCE #3: Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:2440-92. 10.1161/CIR.0000000000000029 DISCLOSURES: No relevant relationships by Anand Buch, source=Web Response No relevant relationships by Tapan Buch, source=Web Response No relevant relationships by Ajinkya Buradkar, source=Web Response No relevant relationships by Pooja Kharbanda, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Humza Quadir, source=Web Response No relevant relationships by Ryan Quirk, source=Web Response No relevant relationships by Mohammed Ul Haq, source=Web Response