2023 FSA Podium and Poster Abstracts
P046: ANESTHETIC MANAGEMENT OF AN ADULT WITH ISOLATED PULMONARY VALVE ENDOCARDITIS REQUIRING POST-OPERATIVE PERICARDIOCENTESIS: A CASE REPORT
Onassis C Naim, MD1; Sarah Dunn1; Benjamin T Houseman1; Kevin Lukose1; Frank Rigueiro2; 1Memorial Healthcare system; 2Indiana University
Background: Infective endocarditis following dental procedures is an unusual phenomenon with an incidence rate of 2 to 7.9 per 100,000 individuals per year and a 10-30% mortality. Typically, left-sided heart valves are affected. However, right-sided endocarditis is commonly reported involving the tricuspid valve. Only 1.5-2% of cases involve the pulmonic valve, and the majority of these cases involve a congenitally abnormal pulmonary valve. Here we report the management of a patient who developed infective endocarditis of a pulmonic valve and heart failure following a dental procedure.
Methods: EMR chart review was done to collect data for this retrospective abstract.
A 45-year-old female who developed endocarditis of the pulmonary valve after a dental procedure 6 months prior to admission. Per AHA guidelines, conservative management was attempted with gentamicin and ceftriaxone. However, due to worsening functional status, NYHA II, secondary to severe pulmonic regurgitation (pulmonary artery diameter 4.1cm, regurgitant volume 74mL, 45% regurgitant fraction) and right heart failure (severely dilated right ventricle, RVEDVi 146mL/m2, RVESVi 56mL/m2, RVSVi 90mL/m2, RVED area 32.8cm2) with normal systolic function, RVEF 62% (Fig.1), a decision was made to proceed with surgical valve replacement.
Following uneventful induction of anesthesia and endotracheal intubation, a central venous catheter and transesophageal probe were inserted. Tranexamic acid was given to reduce bleeding risk. Replacement of the pulmonary valve with a 29mm Inspiris valve was uneventful, and no blood products were needed. She received 30,000 units heparin and protamine 300mg for reversal. She was transferred to the CV ICU intubated on infusions of propofol, electrolyte-A, and sodium chloride 0.9% and was extubated 3 hours postoperatively.
She continued to have severe pulmonary insufficiency that was managed by furosemide, colchicine and ibuprofen (Fig 2). On postoperative day 4, she developed a worsening pericardial effusion and became tachypneic (Fig 3). On post-operative day 6, the patient underwent pericardiocentesis, with removal of 700mL bloody appearing fluid, and had a pericardial drain placed for 64 hours. She was discharged home on post-operative day 9. She followed up with cardiology 5 days after discharge and again 3 months after discharge.
Conclusion: Only a small number of cases of infective endocarditis of a native pulmonary valve have been reported in the literature. The majority of these have been associated with intravenous drug use, although one case was reported following dental work. Frequently, these patients suffer from embolic disease, which was not the case in our patient. It is unclear why this patient developed endocarditis following her dental procedure.
There were no intraoperative complications. Despite the development of a pericardial effusion requiring pericardiocentesis, the patient was discharged home uneventfully.