MANAGEMENT
Patient was admitted to the Internal medicine floor and Infectious
diseases team were consulted, they concurred with the current treatment
plan of Cefazolin and Vancomycin. After the TEE findings and normal
cardiac catheterization, we decided to move forward with surgery. Due to
the patient’s co-morbid status, Euro score of 15% and high mortality
risk, it was deemed that the surgery should take place in a hybrid
operating room setting. The patient underwent surgery - a
redo-sternotomy in the standard fashion- and a large abscess cavity was
seen surrounding the aortic graft. Following the abscess drainage, the
cavity was washed with antibiotic solution with placement of antibiotic
beads around the graft, and the sternum was closed. The bacterial
culture of pus and tissue collected during the surgery was negative.
The heart team performed a Trans Catheter Aortic Valve Implantation
(TAVI) valve in valve procedure (Figure 1B) and (Video
1) . A 14 French pro-glide sheath and a 6 French pro-glide sheath were
used in the right and left femoral arteries respectively. A Medtronic
CoreValue Evolut R 26 mm valve (CoreValve, Medtronic, Luxembourg) was
used. Post-operative ECHO showed a well-seated aortic valve with a mean
gradient of 8 mmHg and no leaks noted (Figure 2C) and(Video 2) .
Postoperatively, the patient’s recovery was complicated with right heart
failure (RHF) and symptomatic bradycardia that resolved. It was decided
that the patient will remain on lifelong suppressive antibiotic therapy
with daily Cefadroxil 1gm orally.