Chapters Transcript Video Fever All Through the Night Good morning, everyone. It's a little bit uh ner nervous to present uh as a first presenter today, but I'm so happy to be here. Um I hope you enjoy my today's case. So today I'm presenting um an interesting case of a patient um where uh the the heart approach was uh an integral modality to um success. So, uh today's today's case is fever all through the night. A 20 year old with history, sterno is a case presentation, a 20 year old uh male uh with past medical history of aortic stenosis and bicuspid aortic valve, complaining of about two weeks of your symptoms, fever, congestion, uh and diarrhea um presented to the emergency department. He began to experiencing a chest pain the night before. So that's what kind of prompted him to go to emergency department and he was found to be hypoxic hypotensive with an elevated troponin. Um He was also found to be COVID positive um on physical exam. The prudent findings were uh he was short of breath on constitutional exam. Um his lungs were breath, sounds were decreased bilaterally. He had a systolic and diastolic murmur. Um And that's pretty much what they, what they heard on physical exam, he uh these are his initial vitals. Uh He had a fever of 39.1 heart rate uh was 112 years per minute. Blood pressure was 91/40. Uh his respiratory rate was 22 and he was saturating 95% on 3 L. His EKG and actually telemetry was unusual for a young um um patient and that's kind of what prompted the team. The second they saw the CKG in triage to quickly escalate the patient's care. Um So on, um on the telemetry, which I don't have a picture here, he was intermittently going between um Winy bag, uh second degree a blocks and a complete hard block, basically all kinds of uh different activity for the young gentleman that we should not be seeing. Um That was really unusual. So this prompted the team quickly um as the labs were coming back was also abnormal. His proponent was 561. Um His CK was 557. His serum pro BNP was a near 10,000 lactate was elevated 2.8. He was also anemic to 9.5. Um and his W BC count was 22. Um He was hyponatremic as well. Um His blood cul cultures were also drawn um and they a little bit later started growing hepar influenza which is gram negative bacillus and he was COVID positive. Um His chest X ray uh had mild increase uh in pulmonary vascular congestion, but otherwise uh no acute findings. He had ac T uh chest ab pelvis very quickly. Um And that shows partial vis visualization of what we're seeing, bilateral um lower lobe pneumonia as it was read um and mild into interstitial edema and trace bilateral pleural effusions, sorry one second. So very quickly, uh the team um called the Stat Ed stat cardiology consult. Um And we obtained an echo transthoracic echocardiogram as everyone was suspecting infective endocarditis with that presentation. So, um basically, what we're seeing is thick and aortic root. Uh We're seeing Bispo aortic valve. I know it's very difficult to visualize it. But if you sit there and examine, um we basically have here um uh sever type one fusion of left and right coronary cusps. And uh we're seeing some mobile vegetations coming in and out which we'll see later. A little bit more details. So very, very abnormal findings and also, of course, cannot miss it. We we're seeing severe aortic regurgitation which is suspected to be acute. Uh patient was placed under general anesthesia, uh immediately taken to uh emergency department as he started um be desaturating very quickly. Um So his care had to be escalated very quickly to the surgical team. Um So within that same um kind of period of time, uh since his presentation to the emergency department later that evening, he was taken to uh to or for um to uh for a procedure which we'll see later. Um He was put under general anesthesia. We, he arrested on induction, he required 30 seconds of CPR uh one M of epinephrine and we achieved R after um after those interventions. So this is what we're seeing um in, in the basically interupt. So we're seeing right away here, um very thickened leaflets, um thickened a crude, uh We're seeing mobile components um on both of the leaflets. Uh And we're seeing possibly coming in here and the view some eolus the echo lucent material um in, in the, in the aorta crude as well, which we'll investigate a little bit later. Uh He um once they obtained this image very quickly, surgeons proceeded with uh with an interven uh when they opened the patient's chest and started um examining the area. They also noted that that the entirety of the non coronary leaflets um had pus under the leaflets, the leaflets were completed deh as well, which we're not really able to see here, but that's what they noticed. Um Once they opened the patient as the T is being obtained, uh we see that my in interval fibrosis, uh there's my, there's eolus material there as well with suspicion for pus and sur surgeons did confirm that there was pus in the um in the aortic root in the interval fibrosis area. A very thickened leaflets, multiple mobile components. Um We're seeing here as well uh in as we're looking at the intra fibrosis, completely peeling off with the echo lucency uh in it. Um We're seeing vegetations also on the tricuspid valve side as well as well as on uh on, on the mitral side as well. So we are now also seeing uh severe module regurgitation just to confirm one more image here. Um eco lucency uh in the aortic root, uh thickened aortic root um and mobile components. So, uh from the surgical note, um this is a post intervention node there. The group abscess below a non coronary sinus was unroofed and sent for cultures. There was Frank Pulin, uh it was copiously Deb bribed and irrigated. The abscess cavity was reconstructed completely. An additional bovine pericardial patch was used to repair the abscess cavity inferior to the left coronary leaflet and patient received 21 millimeter on a mechanical aortic valve. So this is how uh before the chest was being closed and the procedure was finishing. This is how uh the ultimate result looked. So we're still seeing, I mean, we're seeing a lot of post surgical material, we're seeing uh eolus season and aortic crude, we're still seeing there's some flow going into that uh reconstructed bovine pericardial uh bovine patch. So this is something you know that we should think of that potentially, if there's a flow still going into that area that that can potentially cause a problem for the patient of the future, which we'll see um later uh mitral valve still show severe regurgitation with the flow reversal uh in the right upper pulmonary vein and just one more uh picture before coming out from the procedure. Um So post op report, there was an annex uh mechanical aortic valve that was well seeded. Uh me and gradient was 10 normal LV function, milder v dysfunction, moderate tr they call it moderate, moderate Mr and uh mobile E density remains in the right atrium as was seen, the path was sent and uh started growing interestingly, a different uh bacteria. Now, numerous gram positive COCC I were growing blood cultures are continue to show uh hemos para influenza as well in the blood cultures. Patient was doing well until uh he was recovering initially. Uh His white count was going down until post op day nine. When we've noticed that patients white, white, white count spiked up from around 18 to 22. A patient became more short of breath, more hypotensive. Um So this is immediately prompted to obtain um ac T scan. So we're seeing that uh here uh there is this large c circumferential uh pericardial effusion uh with areas of um attenuation with town units of around 35. So this is suggestive that this is blood in that area. So um he also has worsened pleural effusions um uh from before he had what was left like trace. So this imme and he was uh and uh echo was quickly obtained, they saw RV LA, so they immediately took him for a reoperation. So, what did the surgeon see when they opened um the chest again? So when the retractor was placed, there was a large area of hematoma and mediastinum. So uh both broad uh bright blood and uh dark blood, an exploration of the root. It was evident that the patch in myocardium has become completely separate again. As you see that large cavity uh in the area, the patch was removed as well as previously placed mechanical valve due to a large defect outside of the aortic analyst extending into the left ventricle. The defect appeared to be communicating directly with LVOT and there was a related fistula and hematoma as well, some more images and some more nodes. Uh since so, because of this, uh surgeon also also reported uh interop that uh the there was so much necrotic tissue around that area that they had to remo remove a lot of the to to perform basically a myomectomy, remove a lot of uh myocardial, remove a lot of tissue and uh the valve had to be removed. Um So once the valve was removed, um uh he uh there was an additional what appeared to be necrotic tissue in the area and this was the bribed as well. Um And there was questionable uh viable. The there was a lot of non viable myocardium and very small uh viable myocardium left in that area. And there was an evidence of vicar septal defect at that time. So we're seeing the ventricular septal defect, I kind of paused on it to see the flow. So the aorta group was extremely deteriorated and destroyed. Um And then the aorta might occurred and was removed uh completely uh due to destructive process. Uh because it all that destruction went all the way on the intra uh fibrosis and uh anterior mitral leaflet, the LVOT tract uh also had to be um completely removed. Uh And during that time, I other marital curtain was reconstructed with a large Bovi and pericardium. And uh and uh and also anterior my leaflet had additional um pieces of endocarditis noted on that at that time and mitty val had to be resected. So, basically, a hemi commander procedure was performed at that time. Um And this is basically once the curtain was reconstructed, the number. Um uh the remainder of the L VA T tract was also reconstructed uh the coronary arteries and then they were re reins the most uh to do its native position on the aortic homograph. And this is uh basically uh before we were coming out. Uh The last images uh that were taken, um the heart was packed and left open for it to assist with the recovery. Uh And, but we're still seeing unfortunately, because the my, the, the root uh a lot of my cardi had to be debri we're still seeing that flow. As you, as you see, there's a flow going from the left matricular cavity into that space, uh which we see the result of it later. Um And again, this is just uh I'll skip it for the time. Um So basically what happened? He was hospitalized first operation uh on X well performed uh abscess worsened, had to be taken emergency emergency. The or uh at that time LDUT was reconstructed. Mial volunteer was reconstruct. Reconstruct. I heard the group replacement. Well, I heard the homograph and VSD was repaired. So now uh patient is doing well. Um uh on uh in the coup in a couple of days, his chest uh was closed. Uh The Butin was weaned. Uh blo blood count. Uh W BC count is down trending. He's extubated, he's feeling amazing, doing great. So right before um a chest closure, this was um an image that was obtained. A te was performed basically at that time and this is what we're seeing. So as we're seeing, uh again, we see it looks like the interval fibrosis area and the root uh having a, again, an a a pseudoaneurysm, there's flow going into it. There, there is actually A VSD again opened up. Um And we're seeing flow through it. Um The thickening is hard to comment because these are post operative changes. There's also a mobile component in that space and that eolus space. So what would be the next step? This is where we basically arrive at a very difficult decision for a heart, heart uh team approach. Do we re operate now uh to fix that uh tissue uh as the surgeons comment multiple times, um patients uh uh myocardium and the who the whole area was very necrotic, very friable. Um It was very difficult to debri and actually remove all the necrotic tissue. Should he be discharged with the close follow up and you know, re reimaging later. Uh should we repair his VSD? Maybe bring him back in one or two weeks and repair his VSD. Should he be evaluated for a transplant? Uh He's failing all the procedures. Uh Right now, he's still having um necrosis of that area. Uh Third reoperation seems to be a little bit too much for the patient. So, um so the uh after multiple numerous discussions and, and literally the whole hospital, uh you being on board for this case from every multimodality uh from id uh nephrology, every sub specialty, cardiac specialty and cardiac surgery images uh had long discussions. It was decided that I will actually discharge him and see him back in two weeks for repeat tee, repeat imaging and uh for the decision making because the patient was doing really great. Unfortunately, he did not make it to, he was discharged on 28. he represented to emergency department on 212. And uh at that time, um he started committing a shortness of breath. He had low po intake. He was vomiting found to have elevated lactate to 8.7 transaminitis to 15 hundreds. He was in a new a flutter. He started um at that time, he was started on the but Iine Cardi drips and he was admitted for RV failure and cardiogenic shock immediately. The next day, he was doing so poorly. Uh with worsening hemodynamics not responding to any um troops. He was amo cannulated during uh that amo cannulation we obtained uh we performed the tee and um we're seeing this, this looks like the there's a worsening destruction of the root. Uh There's ad body defect with the QPQS on echo was 1.8. Uh at that time. Um We're seeing, we're seeing some of components on tricuspid leaflets here as well. Uh uh on the septal leaflet um basically looks really much worse and there's def there's mobile components in, in the uh in the interval fibrosis area again. So, uh it's just to obtain a 3D to show the flow from the LV um to the right atrium. Uh The just a little bit more pictures how the root looks, it completely peeled off, root and interval helo fibros are peeling off as well and uh patient as well. Uh Just to show here, uh the intra aal septum is coming apart. Uh And patient also has a small PFO which is uh fortunate. The least of his problems were obtained. Um uh G with emo after we cannulated him, um got a tee, we took him for AC T scanner. Uh And basically, so this was right, actually, this was before a cannulation. We took him for AC T scan first. Um So we, we seeing this large defect um and, and just a few more images to show uh the root, completely peeled off large defect. We measured that it was large with so and te now, so he was then um after a couple of days, I was doing slightly better on ECMO, his uh he was slowly weaned off ECMO, uh his aortic valve started to open, he started to respond a little bit better to uh uh supportive therapy. So the decision was made to actually take him to or uh in three in two days um to repair his body VSD tricast valve. Uh And he was acma decal uh with the chest open at that time again. Um So intra op findings uh on a third re operation, he had large approximated 2 to 3 centimeter diameter abscess, creating ventricular septal defect which we already saw. Uh he um the there with the winds uh wind sack of the right atrium tissue located at the cephalo position to the tricuspid valve with extension to actually tricuspid valve annulus, which was completely destroyed. Um And uh basically the uh the large pericardial patch was used to repair uh the pericardium as well. And the caspit valve had to be reconstructed here, this is how um basically uh a few you looked post those interventions and uh myocardium was full. Uh The fully and homograph a group was identified. Um There was plated sutures placed uh and there were the deep bites. Again, the surgeon again said there, there was a lot of negro tissue. So he had to take a deep bite uh along the homograph to reconstruct the attachment to the left ventricle uh to attach left ventricle to the homograph. The patch was uh go uh and uh and the layer of pericardial was used, they were to to basically to hold them together. Uh Then a portion of the patch has been left uh uh long to allow the closure of the ruptured aortic pseudoaneurysm uh that appeared to be extended into transverse sinus. And this is just last images. The large bovine additional patch uh was also utilized to cover the entire defect and the right ventricular uh and right atrial side when talking to the surgeon, uh a lot of material here was used again uh to re operate on this defect. So chest was closed in a couple of days. Um patient was unfortunately had a uh a stroke cold. Um He um neurology was following, he fortunately for him uh recovered from that stroke cold without any residual deficits. Um microbiology, uh blood cultures were negative for two times two for five days. Since the initial blood cultures, pretty much everything was negative uh whole pedal, of course, was performed. Uh sputum cultures, um blood cultures, tissues were negative. Um The uh the fungal cultures were negative as well and the plan was to continue cetra and uh 2 g for um Q 24 for four weeks uh post last or, and he's doing great. Actually, we've seen him in the clinic. Um And this is his most recent tee uh that basically uh the everything looks great. There's Tracy R, there's post operative changes in the root, just M th I IOR root. Uh No A I. Um And this is just some of the last pictures, um looks amazing, uh preserved ejection fraction, a few last pictures. So, um and this was as we know, he endocarditis story. Uh basically, to emphasize uh you know, I tried to focus on the imaging aspect here, but it took a whole uh basically village how we would say a whole hospital to care for this patient. Numerous discussion from A PP nursing uh support staff uh to physician from every specialty to multiple hospitals he was in in the transfer from different hospitals, amazing uh work of uh CT surgeons and their amazing talent. Um And basically, this is just again, this case emphasizes how important the heart team approaches in taking care of the patient. Um Thank you. Published November 13, 2024 Created by Related Presenters Angelina Zhyvotovska, MD Cardiology, Internal Medicine View full profile
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