A case of conservative treatment of mitral valve endocarditis

    Authors

    Keywords

    endocarditis, mitral valve, conservative therapy, vegetation

    DOI

    https://doi.org/10.15836/ccar2022.210

    Full Text

    **Introduction:** In developed countries, infectious endocarditis (IE) is one of the most common causes of mitral valve failure. It is estimated that the annual prevalence of IE is 3 to 9 cases per 100,000 people, and almost 40% are mitral valve infections (1, 2). Despite the promotion of a surgical approach in the treatment of patients with endocarditis, there are conflicting conclusions on the benefit of surgery for IE and its timing (3). **Case report:** 79-year-old patient was hospitalized with clinical and laboratory findings of sepsis. The patient had autoimmune hemolytic anemia and splenomegaly and was recently hospitalized due to a recurrence of autoimmune hemolytic anemia which was treated with methylprednisolone. Blood cultures came positive on Methicillin-resistant Staphylococcus aureus. Transthoracic echocardiography (TTE) revealed large vegetation (18x12 mm) on the posterior leaflet of the mitral valve without signs of valve destruction and severe mitral regurgitation (Figure 1, Figure 2). Since two major and two minor Duke Criteria for definite IE were met, the patient was started on standard antibiotic treatment according to European Society of Cardiology (ESC) Guidelines. Due to newly developed right-sided hemiparesis, an MRI was performed which verified septic emboli and subarachnoid hemorrhage in reabsorption. In such cases, ESC Guidelines propose urgent surgical treatment with I class of recommendation which we decided against due to patient’s frailty and reluctance. The dose of methylprednisolone is gradually reduced. Control blood cultures came sterile after the initiation of antibiotics. Control TTE and TEE showed significant almost complete reduction of vegetation size. The patient became afebrile after 6-week administration of intravenous antibiotics with no laboratory or clinical signs of infection. In consultation with the cardiac surgeon, a strategy of watchful waiting was taken. The patient was transferred to a hospital for prolonged treatment for further rehabilitation. FIGURE 1. Transthoracic echocardiography image of vegetation on the mitral valve. FIGURE 2. Transesophageal echocardiography image of mitral valve endocarditis. **Conclusion:** When deciding on the therapeutic approach of infective endocarditis, the fatal consequences and complications of medical treatment should be taken into account in relation to the risks of surgical intervention. Considering recent literature has drawn conflicting conclusions on the benefit of surgery, every patient should be estimated individually.

    Literature

    1. Cresti A, Chiavarelli M, Scalese M, Nencioni C, Valentini S, Guerrini F, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017 February;7(1):27–35. https://doi.org/10.21037/cdt.2016.08.09
    2. Correa de Sa DD, Tleyjeh IM, Anavekar NS, Schultz JC, Thomas JM, Lahr BD, et al. Epidemiological trends of infective endocarditis: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2010 May;85(5):422–6. https://doi.org/10.4065/mcp.2009.0585
    3. Manne MB, Shrestha NK, Lytle BW, Nowicki ER, Blackstone E, Gordon SM, et al. Outcomes after surgical treatment of native and prosthetic valve infective endocarditis. Ann Thorac Surg. 2012 February;93(2):489–93. https://doi.org/10.1016/j.athoracsur.2011.10.063
    Cardiologia Croatica
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    A case of conservative treatment of mitral valve endocarditis

    Extended Abstract
    Issue9-10
    Published
    Pages210
    PDF via DOIhttps://doi.org/10.15836/ccar2022.210
    endocarditis
    mitral valve
    conservative therapy
    vegetation

    Authors

    Petra Radić*ORCIDSestre Milosrdnice University Hospital Centre, Zagreb, Croatia
    Matias TrbušićORCIDSestre Milosrdnice University Hospital Centre, Zagreb, Croatia
    Ozren VinterORCIDSestre Milosrdnice University Hospital Centre, Zagreb, Croatia
    Krešimir KordićORCIDSestre Milosrdnice University Hospital Centre, Zagreb, Croatia
    Marko BobanORCIDSestre Milosrdnice University Hospital Centre, Zagreb, Croatia
    Ivica ŠafradinORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: petra.radic108@gmail.com

    Full Text

    Introduction: In developed countries, infectious endocarditis (IE) is one of the most common causes of mitral valve failure. It is estimated that the annual prevalence of IE is 3 to 9 cases per 100,000 people, and almost 40% are mitral valve infections (1, 2). Despite the promotion of a surgical approach in the treatment of patients with endocarditis, there are conflicting conclusions on the benefit of surgery for IE and its timing (3).

    Case report: 79-year-old patient was hospitalized with clinical and laboratory findings of sepsis. The patient had autoimmune hemolytic anemia and splenomegaly and was recently hospitalized due to a recurrence of autoimmune hemolytic anemia which was treated with methylprednisolone. Blood cultures came positive on Methicillin-resistant Staphylococcus aureus. Transthoracic echocardiography (TTE) revealed large vegetation (18x12 mm) on the posterior leaflet of the mitral valve without signs of valve destruction and severe mitral regurgitation (Figure 1, Figure 2). Since two major and two minor Duke Criteria for definite IE were met, the patient was started on standard antibiotic treatment according to European Society of Cardiology (ESC) Guidelines. Due to newly developed right-sided hemiparesis, an MRI was performed which verified septic emboli and subarachnoid hemorrhage in reabsorption. In such cases, ESC Guidelines propose urgent surgical treatment with I class of recommendation which we decided against due to patient’s frailty and reluctance. The dose of methylprednisolone is gradually reduced. Control blood cultures came sterile after the initiation of antibiotics. Control TTE and TEE showed significant almost complete reduction of vegetation size. The patient became afebrile after 6-week administration of intravenous antibiotics with no laboratory or clinical signs of infection. In consultation with the cardiac surgeon, a strategy of watchful waiting was taken. The patient was transferred to a hospital for prolonged treatment for further rehabilitation.

    FIGURE 1. Transthoracic echocardiography image of vegetation on the mitral valve.

    FIGURE 2. Transesophageal echocardiography image of mitral valve endocarditis.

    Conclusion: When deciding on the therapeutic approach of infective endocarditis, the fatal consequences and complications of medical treatment should be taken into account in relation to the risks of surgical intervention. Considering recent literature has drawn conflicting conclusions on the benefit of surgery, every patient should be estimated individually.

    Literature

    1. 1.
      Cresti A, Chiavarelli M, Scalese M, Nencioni C, Valentini S, Guerrini F, et al. Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study. Cardiovasc Diagn Ther. 2017 February;7(1):27–35.DOI
    2. 2.
      Correa de Sa DD, Tleyjeh IM, Anavekar NS, Schultz JC, Thomas JM, Lahr BD, et al. Epidemiological trends of infective endocarditis: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 2010 May;85(5):422–6.DOI
    3. 3.
      Manne MB, Shrestha NK, Lytle BW, Nowicki ER, Blackstone E, Gordon SM, et al. Outcomes after surgical treatment of native and prosthetic valve infective endocarditis. Ann Thorac Surg. 2012 February;93(2):489–93.DOI