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)