2022 FSA Podium and Poster Abstracts

P002: CASE REPORT: PERIOPERATIVE ECHOCARDIOGRAPHY FINDINGS FOR SUCCESSFUL OPEN MITRAL VALVE REPLACEMENT FOR INFECTIVE ENDOCARDITIS WITH RARE COMPLEX ABSCESS
Eva Chen, MD; Mario Pimentel, MD; Santiago Luis, MD; Cleveland Clinic Florida

Introduction: Acute bacterial endocarditis of the native mitral valve complicated by abscess formation is rare and associated with significant morbidity and mortality. Prompt diagnosis and antibiotic therapy are critical, and surgical valve replacement is indicated for abscess formation or large vegetation size. We present a case of successful open mitral valve replacement for infective endocarditis with complex abscess formation involving the leaflets and annulus, which led to abscess rupture and leaflet perforation.

Case Report: A 70-year-old male with PMH of CAD s/p CABG and PCI, HFpEF, PAD, ESRD, and chronic osteomyelitis presented with fever, chills, and acute respiratory failure. He was diagnosed with infective endocarditis based on MSSA bacteremia and TEE findings of new severe mitral valve regurgitation and a mobile mass involving the posterior leaflet and posterior annulus measuring 2.4cm x 1.5cm. Echocardiography demonstrated preserved biventricular function, and coronary catheterization showed patent coronary grafts and stents from prior revascularization. Appropriate intravenous antibiotics were initiated.

Due to the extent of native mitral valve destruction and vegetation size, the patient underwent mitral valve replacement on cardiopulmonary bypass via re-operative sternotomy. Induction and maintenance of general anesthesia were unremarkable, and hemodynamic monitoring included arterial and central venous cannulation with pulmonary artery catheter. Intraoperative TEE confirmed abscess formation on both anterior and posterior mitral leaflets, with anterior leaflet abscess rupture and transvalvular jet into the left atrium. Surgical findings revealed perforation of the middle scallop of the posterior leaflet, with a friable abscess extending to the posterior annulus. The mitral valve was successfully replaced with a bovine bioprosthetic valve, and TEE showed trace residual mitral valve regurgitation.

Discussion: Endocarditis of the native mitral valve complicated by abscess is rare. This case presents echocardiography findings of abscess formation on both mitral valve leaflets and the posterior annulus, leading to abscess rupture and leaflet erosion causing significant hemodynamic compromise and acute clinical decompensation. Perioperative TEE aided in prompt diagnosis of infective endocarditis and guided the decision for surgical valve replacement over repair. Despite the surgical risk of repeat sternotomy and the patient’s cardiovascular comorbidities, the mitral valve was replaced successfully.

3D view of abscess on the anterior mitral valve leaflet on intraoperative TEE (left ventricular view). 

Color flow across ruptured abscess on the anterior mitral leaflet on intraoperative TEE (left ventricular view). 

3D view of abscess on the posterior leaflet on intraoperative TEE (left atrial view). 

Abscess on the posterior mitral leaflet during surgery.

References

• Reyaldeen R et al. More Than a Simple Vegetation: The Trifecta of Mitral Valve Leaflet Perforation, Windsock Aneurysm, and Mitral Valve Abscess. 2020. Available at https://www.cvcasejournal.com/article/S2468-6441(20)30172-9/fulltext. Accessed February 23, 2022.
• Nappi F et al. Mitral endocarditis: A new management framework. The Journal of Thoracic and Cardiovascular Surgery 2018;156:1486-95. Doi: 10.1016/j.jtcvs.2018.03.150
• Wong P et al. Severe mitral regurgitation caused by annular abscess fistulating into the left atrium. Heart 2005;91:790. Doi: 10.1136/hrt.2004.054361