MANAGEMENT
Adjusted dose of Vancomycin, Ampicillin/Sulbactam and Gentamycin was
commenced for him as empirical therapy of infectious endocarditis with
negative culture (although the negative blood cultures could be due to
antibiotic prescription in his previous admission). Abdominal sonography
and brain computed tomography (CT) did not show evidences of spleen
abscess or mycotic aneurysms. He was discharged after 6 weeks of
antibiotic therapy.
Despite improvement of fever, fatigue and appetite, he still remained
symptomatic with dyspnea. In heart team and after consulting with the
patient and his family, he seemed to be high risk for surgery and aortic
valve in valve procedure was scheduled for him.
Cardiac CT angiography estimated AV annulus perimeter about 2.25
cm.(Figure.2) His previous bioprosthesis was Mitroflow Synergy number
25. Cardiac catheterization showed mild coronary artery disease and 60
mmHg peak to peak gradient of AV. Based on CT and TEE data, Evolute R
valve number 26 was selected. The base of interventricular septum was
sigmoid-shaped and the previous bioprosthesis had no opaque marker in
fluoroscopy and also lots of mobile particles especially a large one
adjacent to the left main coronary artery ostium were the challenges. We
wired left main artery and parked a stent in it in case of if any
embolization or compromise happened, and used the marker of a pigtail in
noncoronary cusp and balloon and guidewire markers to estimate the best
implantation site and the valve was implanted successfully. (Figure.3,
Video.2) All the procedure was guided by TEE and at the end, LVEF was
55%, AV peak gradient decreased to 18mmHg and mean gradient decreased
to 12mmHg post procedure with mild paravalvular leakage, there was no
diastolic MR with moderate primary MR, and sPAP decreased to 45mmHg.
(Figure. 4, Video.3) ECG showed normal sinus rhythm without
atrioventricular block.
Fortunately, the vegetations were successfully trapped behind the frame
of the device and no cerebral, distal and coronary embolization
happened. The patient was completely conscious after a few hours, and
was discharged after a few days surprisingly with a creatinine 1.9
mg/dl. In serial follow up visits, he is active and relatively symptom
free with his normal functioning new bioprosthesis in TTE. (Figure.4,
Video.4)