DP23: SPLENIC ABSCESS POST AORTIC VALVE REPLACEMENT IN A TYPE D TRANSPOSITION OF THE GREAT ARTERIES PATIENT
Tilman Chambers, MD1; Sarah Dunn, MD2; Gustavo Gerenstein2; Mark Korenge, MD2; Andrea Xavier, MD2; Benjamin T Houseman, MD, PhD2
1Memorial Healthcare System; 2Envision Physician Services
INTRODUCTION: Type D transposition of the great arteries (DTGA) is rare (2 to 5 per 10,000 in the US) (PMID 16397457). During the corrective arterial switch operation (ASO) (Figure 1), the native pulmonary valve becomes the neo-aortic valve. The neo-aortic valve is frequently regurgitant in the new high pressure system and is at increased risk for infective endocarditis (PMID 15364851). Here we describe the perioperative management of complications of S. Gordonii infective endocarditis in a patient corrected DTGA.
CASE REPORT: A 27-year-old-male with a history of DTGA s/p ASO at 2 days of life presented with left upper quadrant abdominal pain, nausea, diarrhea, fatigue, and an unintentional 20 lb weight loss over a period of three weeks. Medical history was significant for obesity (BMI 40), marijuana use, hypertension, mild to moderate aortic regurgitation, depression and anxiety. He was found to have a splenic, renal, and distal ACA territory infarcts from a 2.5 cm vegetation on his aortic valve (Figure 2). Initial blood cultures grew S. Gordonii, a commensal oral bacteria. He was started on Eliquis, Penicillin G, and scheduled for mechanical aortic valve replacement and debridement of infective endocarditis. A 2 cm x 2.5 cm infective aortic vegetation was removed and a 25 mm Onyx Aortic Valve was successfully implanted. Intraoperatively he received 3 PRBCs, 4 FFP, 4 platelets, 700 Cell Saver, 1 cryoprecipitate, 20 U DDAVP, and factor VIIa. He was transferred to the CV-ICU and discharged with home healthcare on day ten. One month later he was re-admitted with a splenic abscess that did not respond to drain placement and medical therapy. On hospital day 7 he underwent urgent splenectomy, and on hospital day 9 he developed persistent bleeding that required embolization in IR and resuscitation with 4 units of pRBCs. He was discharged home on hospital day 15 with posaconazole, azithromycin, and omadacycline for broad spectrum antibiotic coverage.
DISCUSSION: Patients with corrected DTGA are at increased risk for a number of cardiac complications, including infective endocarditis by atypical organisms such as S. gordonii. Seeding of multiple organs by this organism, while uncommon, has been described previously in a patient following dental extraction (doi:10.1016/j.ijcard.2022.10.120). A registry of 1,061 patients who underwent ASO for DTGA in the Netherlands showed that 8% of patients had at least 1 incidence of infectious endocarditis, heart failure, MI, or cardiac arrest by 35 years of age. (Https://doi.org/10.1016/j.jacadv.2023.100772).
In our case, the patient was reluctant to seek medical attention and likely delayed care until symptoms were quite severe. Once he was referred to a center with expertise in adult congenital cardiac care, aggressive targeted therapy was initiated. Knowledge of the unique risks in these patients drives unique therapeutic interventions, and retrospective studies have shown a significant decrease in overall morbidity and mortality when these patients are referred to centers with expertise in adult congenital care (PMID 34269382)
Figure 1 (Source: https://www.aboutkidshealth.ca/arterial-switch-procedure)
Figure 2