MP20. Emergency mitral valve surgery for active infective endocarditis associated with purulent pericarditis

New York Hilton Midtown 

Objective:
Active infective endocarditis caused by MRSA usually requires emergency surgery because of the rapid extension of infection.
Case Video Summary:
We demonstrated a 28-year-old lady who transferred to our hospital due to bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA) and dyspnea. Transthoracic echocardiogram demonstrated mitral regurgitation with big fragile vegetations and dissection of the posterior left atrial wall and pericardial effusion. Brain CT demonstrated cerebral infarction. At emergency surgery, pericardiotomy revealed purulent pericarditis. Infection extended the posterior mitral valve (P2) widely, posterior mitral annulus, and dissecting space of the left atrial wall. After resection and removing the infected tissues, reconstruction of the left atrial wall, mitral annulus, and posterior leaflet repair using several pieces of xenopericardium were achieved step by step (as demonstrated in the first half of the video). IntraopTEE demonstrated no MR. After additional antibiotic therapy for 3 weeks, she was discharged from the hospital. She complained fever again, and TTE showed vegetation at the anterior leaflet 3 months after surgery, necessitating a redo surgery. Redo surgery revealed vegetation at the anterior mitral leaflet, persistent infection at the reconstructed mitral annulus and posterior left atrial wall at initial surgery (as demonstrated in the latter half of the video). After removal of infected tissue, reconstruction of the left atrial wall and mitral annulus with pieces of xenopericardium was achieved again without leaving infected tissue or space. Then, mitral valve was replaced with a mechanical valve considering her age. She survived 15 years after surgery enjoying dancing and playing golf. Latest TTE showed no perivalvular leakage of mitral mechanical valve and good left ventricular function (LVEF of 67 %).
Conclusions:
Active infective endocarditis caused by MRSA usually requires emergency surgery because of the rapid extension of infection. And the reconstruction of mitral annulus and left atrial wall associated with purulent pericarditis is quite rare.