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Successful Treatment of Clostridial Aortic Root Abscess in a Patient With Pulmonary Arterial Hypertension
March 2014, Vol 145, No. 3_MeetingAbstracts Critical Care | March 2014
Successful Treatment of Clostridial Aortic Root Abscess in a Patient With Pulmonary Arterial Hypertension Amitesh Agarwal, MD; Alex Duarte, MD University of Texas Medical Branch at Galveston, Galveston, TX
Chest. 2014;145(3_MeetingAbstracts):169A. doi:10.1378/chest.1818940
Abstract SESSION TITLE: Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM PURPOSE: Treatment of Pulmonary arterial hypertension (PAH) with chronic intravenous prostanoid through a chronic tunneled catheter has been reported to be associated with bacteremia and sepsis; however bacterial endocarditis is rarely reported. Here we report a patient with idiopathic PAH receiving chronic intravenous prostacyclin that developed acute Clostridium perfringens aortic valve endocarditis. METHODS: A 48 year old female with idiopathic PAH, treated with intravenous epoprostenol via subclavian catheter for five years presented with aortic valve endocarditis with regurgitation. Initially she was treated with broad spectrum antibiotic and subclavian catheter was removed. Blood cultures from the catheter tip were sterile but she remained febrile. On day 7, transesophageal echocardiography demonstrated an aortic root abscess with suspected aortic dissection. Emergent aortic root surgery was performed while continuing epoprostenol by pulmonary artery catheter. She was successfully extubated on post-operative day 2 and vasopressors and inotropes discontinued on POD 4. On POD 10, Clostridium perfringens was isolated from the culture of the aortic leaflet and six weeks of metronidazole prescribed. RESULTS: Patient was discharge home on inhaled iloprost (Ventavis). Three years after surgery, she remains stable on on inhaled iloprost, bosentan, and sildenafil.
CONCLUSIONS: Complicated bacterial endocarditis requiring surgery in setting of pulmonary hypertension is a rare phenomenon and carries a high mortality rate of about 50%. It is a challenge to manage intra and post op hemodynamics in such cases due to elevated pulmonary vascular resistance and decrease right ventricle function with decrease systemic resistance in septic shock. In summary, we describe successful treatment of C. perfringens aortic root abscess in a patient with PAH acquired after a bout of gastroenteritis. CLINICAL IMPLICATIONS: Successful medical and surgical management of an emergent, high risk cardiac procedure based on physiological principles may be achieved. DISCLOSURE: The following authors have nothing to disclose: Amitesh Agarwal, Alex Duarte No Product/Research Disclosure Information
Successful Treatment of Clostridial Aortic Root Abscess in a Patient With Pulmonary Arterial Hypertension Amitesh Agarwal, MD; Alex Duarte, MD University of Texas Medical Branch at Galveston, Galveston, TX
Chest. 2014;145(3_MeetingAbstracts):169A. doi:10.1378/chest.1818940
Abstract SESSION TITLE: Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: Saturday, March 22, 2014 at 04:15 PM - 05:15 PM PURPOSE: Treatment of Pulmonary arterial hypertension (PAH) with chronic intravenous prostanoid through a chronic tunneled catheter has been reported to be associated with bacteremia and sepsis; however bacterial endocarditis is rarely reported. Here we report a patient with idiopathic PAH receiving chronic intravenous prostacyclin that developed acute Clostridium perfringens aortic valve endocarditis. METHODS: A 48 year old female with idiopathic PAH, treated with intravenous epoprostenol via subclavian catheter for five years presented with aortic valve endocarditis with regurgitation. Initially she was treated with broad spectrum antibiotic and subclavian catheter was removed. Blood cultures from the catheter tip were sterile but she remained febrile. On day 7, transesophageal echocardiography demonstrated an aortic root abscess with suspected aortic dissection. Emergent aortic root surgery was performed while continuing epoprostenol by pulmonary artery catheter. She was successfully extubated on post-operative day 2 and vasopressors and inotropes discontinued on POD 4. On POD 10, Clostridium perfringens was isolated from the culture of the aortic leaflet and six weeks of metronidazole prescribed. RESULTS: Patient was discharge home on inhaled iloprost (Ventavis). Three years after surgery, she remains stable on on inhaled iloprost, bosentan, and sildenafil.
CONCLUSIONS: Complicated bacterial endocarditis requiring surgery in setting of pulmonary hypertension is a rare phenomenon and carries a high mortality rate of about 50%. It is a challenge to manage intra and post op hemodynamics in such cases due to elevated pulmonary vascular resistance and decrease right ventricle function with decrease systemic resistance in septic shock. In summary, we describe successful treatment of C. perfringens aortic root abscess in a patient with PAH acquired after a bout of gastroenteritis. CLINICAL IMPLICATIONS: Successful medical and surgical management of an emergent, high risk cardiac procedure based on physiological principles may be achieved. DISCLOSURE: The following authors have nothing to disclose: Amitesh Agarwal, Alex Duarte No Product/Research Disclosure Information