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.