A Delayed Staged Treatment Strategy In A Double-valve Septic Endocarditis Patient With Influenza, Severe ARDS And An Aortic Aneurism
Martins Kalejs1, Ivars Brecs1, Kristians Meidrops1, Roberts Leibuss2, Anna Klesmite3, Eva Strike1, Peteris Stradins1
1Pauls Stradins Clinical University hospital and Riga Stradins University, Riga, Latvia, 2Pauls Stradins Clinical University hospital, Riga, Latvia, 3Riga Stradins University, Riga, Latvia
Despite advances in diagnostic microbiology and management of sepsis, it still has a high rate of morbidity and mortality, hence complicated bacterial endocarditis remains a dreadful diagnosis. According to the current guidelines left side endocarditis with large vegetations and poorly tolerated valve disfunction is a class I indication for urgent surgical treatment.
In this case report we describe a staged approach of surgical treatment of a patient with complex left side endocarditis and large aortic root aneurism, complicated with type A influenza and severe ARDS.
Male 38 years old was hospitalized with signs of severe bacterial infection. A blood culture approved Streptococcus oralis caused sepsis. Echocardiography revealed severe aortic and mitral valve regurgitation with large vegetations and an ascending aorta aneurism 6.2 cm in diameter, confirmed by CT scan. Patient quickly worsened and clinically presented respiratory tract superinfection symptoms, and a positive RNA test of type A influenza, severe ARDS developed. At this time point emergency surgery was deemed to be too high risk. Patient was assessed 3.25 points by Murray score and a V-V ECMO was implanted. It allowed extubating the patient and awake ECMO was continued for six days until partial lung recovery. When planning the amount of intervention, surgical risk was assessed using Euroscore II, predicting 19.39% risk for a double-valve replacement and 41.29% if replacing aorta also. After discussions, as a first stage, mitral and aortic valve replacement was performed. In the postoperative period V-V ECMO was required for another 5 days. Patient was discharged home on the 15th postoperative day. After 6 months patient was readmitted for elective aortic root replacement with an Euroscore II of only 3.42%, which proceeded uneventfully.
As it has been well noted in the guidelines, in certain conditions it is reasonable to postpone surgery for endocarditis to stabilize the patientís condition in order to increase the chances of survival.
We demonstrated a case of successfully reducing severe influenza caused ARDS with help of V-V ECMO before urgent surgery.
Stepwise approach to complex surgery is reasonable in severely morbid, high risk patients.
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