MP23. Fulminant Cardiogenic Shock in The Setting of Acute Severe Mitral Regurgitation Caused by Endocarditis, When to Operate and How to Manage Peri-Operatively?
Presented During: Moderated E-Posters
Cleveland Clinic
Cleveland, OH
United States - Contact Me
Belmont Abbey College, BSc, 2008
University of Oxford, BMBCh, DPhil, 2016
Integrated Thoracic Surgery Residency, Cleveland Clinic, 2018 to present
Thursday, May 4, 2023: 6:30 PM - Saturday, May 6, 2023: 2:29 AM
New York Hilton Midtown
Room: Grand Ballroom Foyer
Description
Objectives: There is no current guidelines for cardiogenic shock associated with mitral valve endocarditis that dictate surgical candidacy, timing of the operation, and peri-operative management strategy. Herein, we present an endocarditis case of acute severe mitral regurgitation complicated by multi-organ failure required peri-operative mechanical circulatory support as bridge to surgery.
Methods: 39-year-old male with no significant past medical history presented to an outside hospital with sepsis. Echocardiogram showed ejection fraction 50% and severe mitral regurgitation with 2.4 cm vegetation on the anterior leaflet. Blood cultures were positive for Streptococcus. He was started on antibiotics and hemodialysis for acute renal failure. Additionally, he developed coagulopathy and ischemia of fingers and toes. A week later, patient was transferred to our center on modest dosage of inotropes and pressors, yet with decompensated cardiogenic shock. Patient was placed on peripheral veno-arterial ECMO along with intra-aortic balloon pump. Coagulopathy and shocked liver started to improve however with persistent pulmonary edema. He was taken to surgery within 48 hour.
Results: Intraoperatively the anterior mitral valve leaflet was completely destroyed by endocarditis (Figure). After adequate debridement, patient underwent mitral valve replacement with a bio-prosthesis (size#33). Upon separation from cardiopulmonary bypass, left ventricular function was severely depressed, thus configuration was switched to veno-arterial-venous ECMO. Patient had accelerated recovery of end-organ function, weaned off mechanical circulatory support on day 4 after surgery, then off dialysis and extubated on day 5. He was transferred to regular floor soon after to start physical therapy. Post-operative echocardiogram showed ejection fraction 35% with well seated bio-prosthetic mitral valve. Patient is being prepared to discharge to rehabilitation facility to continue recovery. Patient will still require vascular procedures to address fingers and toes ischemia.
Conclusions: There is no consensus regarding the optimal timing for the management of acute mitral valve endocarditis associated with cardiogenic shock. Our case demonstrates that a narrow window of time may exist for early surgery with peri-operative mechanical circulatory support before irreversible end-organ damage succumbs the patient to fatal outcome
Methods: 39-year-old male with no significant past medical history presented to an outside hospital with sepsis. Echocardiogram showed ejection fraction 50% and severe mitral regurgitation with 2.4 cm vegetation on the anterior leaflet. Blood cultures were positive for Streptococcus. He was started on antibiotics and hemodialysis for acute renal failure. Additionally, he developed coagulopathy and ischemia of fingers and toes. A week later, patient was transferred to our center on modest dosage of inotropes and pressors, yet with decompensated cardiogenic shock. Patient was placed on peripheral veno-arterial ECMO along with intra-aortic balloon pump. Coagulopathy and shocked liver started to improve however with persistent pulmonary edema. He was taken to surgery within 48 hour.
Results: Intraoperatively the anterior mitral valve leaflet was completely destroyed by endocarditis (Figure). After adequate debridement, patient underwent mitral valve replacement with a bio-prosthesis (size#33). Upon separation from cardiopulmonary bypass, left ventricular function was severely depressed, thus configuration was switched to veno-arterial-venous ECMO. Patient had accelerated recovery of end-organ function, weaned off mechanical circulatory support on day 4 after surgery, then off dialysis and extubated on day 5. He was transferred to regular floor soon after to start physical therapy. Post-operative echocardiogram showed ejection fraction 35% with well seated bio-prosthetic mitral valve. Patient is being prepared to discharge to rehabilitation facility to continue recovery. Patient will still require vascular procedures to address fingers and toes ischemia.
Conclusions: There is no consensus regarding the optimal timing for the management of acute mitral valve endocarditis associated with cardiogenic shock. Our case demonstrates that a narrow window of time may exist for early surgery with peri-operative mechanical circulatory support before irreversible end-organ damage succumbs the patient to fatal outcome