CONGRESS ABSTRACT

A 71 year-old man presented to our ED with a 10-day history of fever with chills, dyspnea and tachycardia. His past medical history incuded arterial hypertension, type 2 diabetes mellitus, prostatic hyperplasia, a TURB procedure for urothelial cancer and surgery for a pancreatic adenocarcinoma. Six months before admission he underwent a MVR for a severe mitral regurgitation, but due to post-operative SAM an early REDO was performed and a 29 mm mitral bioprosthesis was placed. At home he was started on amoxicilline/clavulanic acid, but a chest RX showed a lung opacity and he was switched to an oral fluorochinolone. In the ED his vital signs were as follows: BP 114/70 mmHg, HR 120; BT 38.5 C. He was asthenic and dyspneic under oxygen therapy on Venturi mask, but alert and fully oriented. His skin was moist and warm. Vesicular murmur was abolished in the left pulmonary base. Cardiac auscultation revealed tachycardia with regular rhythm and without any pathological murmur. The patient was admitted to the ICU for his pneumonia complicated by a septic state. A new thoracic CT scan confirmed a right apical pneumonia and a pleural effusion. Oxygen support was kept on and an empirical antibiotic therapy with Meropenem and Linezolid was started. Given the patient's risk factors, a TOE was performed, revealing a large vegetation on both sides of the prosthetic mitral leaflets, in particular three thread-like lesions (two on the atrial side of the leaflet, of 18 and 15 mm; one on the ventricular side, adherent to the implantation ring of the bioprothesis). The mitro aortic junction and the non coronary cusp basis were also involved. A diagnosis of infective endocarditis of the mitral bioprosthesis was made. Further periprosthetic complications or septic embolism were excluded through a CT scan. MRSE growth at blood coltures required the Endocarditis Team involvement. Antibiotic therapy was upgraded to Rifampicin; cardiac surgeons opted for a conservative management for a few days. Patient's condition improved. However, a new-onset cardiac systolic murmur emerged and a second TOE documented further extension of the endocarditic vegetation to the LVOT, with high mobility and consequently a high risk of embolization of the mass. Therefore, an urgent MVR with a 29 mm bioprothesis was performed. In a week time, the infection was resolved and the patient safely discharged. Imaging before discharge was unremarkable, just like his mitral bioprosthesis functioning.