Discussion
IE remains a deadly disease imposing significant management challenges.1,2 Its epidemiologic profile has changed with an increasing incidence of SA and the generalized implantation of prosthetic material, conditions often associated with complicated clinical course.3
In our case, SA was the isolated pathogen, proving its aggressive profile with the development of multiple perivalvular complications such as abscess formation, fistulation, pseudoaneurysm and AV conduction disturbances. Interestingly, septic embolization, which is a common finding in SA IE, was not documented.
Ideal surgical timing is a rather controversial issue due to the risks related to undergoing surgery with an on-going infectious process.3 HT is the utmost controversial topic, due to the need for immunossupression.4,5 Although guidelines support its use in extreme cases, there is little experience on the field and recommendations are scarce, being rarely performed in IE.1,4,5
The patient had recurrent PVIE with major cardiac tissue destruction, making surgery unfeasible. A multidisciplinary approach was essential, considering the high-risk strategy proposed. HT was life-saving, performed after a surprisingly uneventful course of 8 waiting months, despite severe cardiac an vascular damage.
This interesting course of events and post-transplant favorable evolution highlights the need to carefully select patients for HT as donor shortage is common, imposing long waiting timing for high-risk patients process.5 In the case reported, the apparently resolved systemic infectious process reflected by normalization of inflammatory markers and sterilization of blood cultures probably played a role in favorable post-surgical clinical evolution.
In conclusion, IE is a defying disease associated with potentially fatal complications. This case illustrates the paradigm of a massive perivalvular destruction in IE deemed as “untreatable”. HT in this setting highlights the need to make bold decisions in challenging clinical scenarios in order to avoid fatal outcomes.