A Surgical Case of Infective Endocarditis Complicated by Severe Valvulare Regurgitation and Coronary Artery Embolism in Which Cardiogenic Shock Occurred before Surgery / 日本心臓血管外科学会雑誌

ABSTRACT

A 45-year-old woman with moderate mitral regurgitation due to mitral valve prolapse developed respiratory discomfort after cellulitis and visited our hospital. Electrocardiogram showed ST elevation in V2, V3, V4 and serum creatinine kinase was high. Transthoracic echocardiogram revealed large mitral and aortic vegetation with severe valvular regurgitation and anterior wall motion asynergy. On computed tomography and magnetic resonance imaging, splenic infarction and right renal infarction cerebral infarction on right sided frontal white matter (1 cm in diameter) was revealed. These findings led to a diagnosis of acute heart failure due to severe regurgitation and coronary artery embolism with infective endocarditis, thus we performed an emergency cardiothoracic surgery. After general anesthesia, she suffered severe hypotension despite the injection of a high dose of catecholamine, then developed persistent ventricular tachycardia. We started cardiopulmonary resuscitation, and percutaneous cardiopulmonary support. After obtaining stable hemodynamic status, we performed surgery. The intraoperative examination showed vegetation (2 cm in diameter) on each aortic cusp, large vegetation on the anterior and posterior mitral leaflet, rupture of the posterior leaflet choreae tendineae, and vegetation on the wall of the left atrium. We performed maximal possible debridement of the infected tissue. Subsequently, we performed mitral valve replacement and aortic valve replacement, tricuspid annuloplasty. We finished surgery without cardiopulmonary support. After tight control, the patient was discharged on the 52nd postoperative day. The patient showed no recurrence of infection during 9 months of follow-up. Cases of coronary embolism with infective endocarditis are rare and have high mortality, and their treatment is still controversial.