DP54: A KEEN EYE MAKES THE DIFFERENCE: THE TEE THAT UNCOVERED A HIDDEN MAIVF ABSCESS WITH HIGH-FLOW FISTULIZATION
Ali Yasback, MD1; Amal Akhtar, DO2; Osvaldo Conde, MD1; Raul Bermudez-Velez, MD1
1HCA Florida Kendall Hospital; 2South Georgia Medical Center
Introduction/Background: Mitral-aortic intervalvular fibrosa (MAIVF) abscess represents a severe complication of infective endocarditis (IE) characterized by perivalvular extension into the fibrous body between the mitral and aortic valves. This condition is associated with substantial morbidity and mortality, with reported mortality rates exceeding 40% despite surgical intervention.
The periaortic dissemination of infection follows a dynamic clinical course; inflammation leads to MAIVF thickening, which progresses to abscess and pseudoaneurysm formation. Complications include eventual abscess rupture which can cause fistula formation, acute valvular insufficiency, conduction abnormalities, and systemic embolization. Management involves surgical valve repair and proves especially difficult in elderly patients with multiple comorbidities and prohibitive operative risk.
Methods: We present the case of an 84 year old male with a history of diabetes, epilepsy, and aortic stenosis who presented to our ED in septic shock and was admitted to the ICU. As the source of infection couldn’t be found, two TTE were done to rule out endocarditis which demonstrated mild mitral annular calcifications concerning for vegetations but could not identify an abscess or fistula.
During his inpatient stay, he developed disorientation and right sided weakness and was urgently taken for mechanical thrombectomy of proximal left posterior cerebral artery under general anesthesia. The following day, a TEE was done to better appreciate the posterior aspects of the heart and due to our attending’s keen eye and attention to detail, he was able to point out a mitral regurgitant jet directed posteriorly, mobile vegetations on the base of the posterior mitral leaflet, and evidence of aortic root abscess with associated fistula consistent with a MAIVF abscess.
Results: Following the results of the TEE, the cardiothoracic team was consulted for evaluation and possible valvular reconstruction. The patient was deemed high-risk and unsuitable for intervention given advanced age, frailty, recent embolic stroke, and several other comorbidities. He was managed conservatively with prolonged intravenous antibiotics and discharged home with a PICC line. Three days after his discharge, he presented to the ED in cardiac arrest and unfortunately passed, despite extensive resuscitative efforts.
Discussion/Conclusion: IE carries up to a 20-25% inpatient mortality rate, a number that drastically increases to close to 40-50% in cases with related complications [1]. The two most common causes of mortality in patients with IE are acute heart failure secondary to valvular damage, and embolic events [1]. Although early surgical intervention is recommended per AHA guidelines and has been shown to decrease mortality rates[2,3], several factors may preclude early intervention including the need for heparinization during bypass in the setting of recent hemorrhagic CVA. Ultimately the right approach is a multidisciplinary one that includes the family in an informed, shared-decision making model.
This case not only highlights the difference a TEE can make after multiple negative TTEs when clinical suspicion is high (one meta analysis showed only a 61% sensitivity of TTEs in detecting vegetations [4]); but more importantly, the importance of attention to detail as the abscess & fistula could have been overlooked.