One-Stage Mitral Valve Replacement And Splenectomy In Splenic Infarcts And Infective Endocarditis

摘要

Infective endocarditis associated with spleen infarcts is common and very complicated condition. Splenic lesions in infective endocarditis are presented of infarcts and abscesses. Operative mortality in such patients is high. The septic status, heart failure, hemodynamic instability, renal dysfunction make the success much difficult. Use of abdominal Computed Tomography to locate infectious sources is of paramount importance for the treatment plan. We present one case of infective endocarditis, complicated by infected splenic infarcts and heart failure. On urgent conditions we performed one-stage mitral valve replacement and splenectomy. Introduction Splenic infarcts and infective endocarditis are very complicated clinical entiety. Controversy exists regarding the proper selection, timing, and order of surgical procedures offered to the patient with concomitant infective endocarditis and splenic infarcts or abscesses. Although that by Computed tomography (CT) sometimes can not be made difference between splenic infarct and abscess, it is the diagnostic step for identifying extracardiac infectious sources, including splenic lesions. In clinically stable patient is recommended firstly to be performed splenectomy and then, after all infectious sources are liquidated can be performed valve surgery. When patient with infectious endocarditis presents with rapidly progressing acute heart failure the optimal choice is one-stage valve replacement and splenectomy. We describe a patient with mitral valve endocarditis and heart failure, accompanied by infected splenic infarcts. Case report A 69-year old woman with fatigue, fever, hemodynamic instability, heart failure. Two months before she was treated with i.m. gluteal injections for tingling in the knees. Then fever, fatigue and gluteal abscess occurred. Abscess was excised but the symptoms of infection persisted. She was admitted in infectious clinic where she developed heart failure and was transferred to ICU with haemodynamic instability. From blood cultures grew Staphylococcus epidermidis MRSE. Transesophageal echocardiography showed mitral regurgitation III degree, myxomatous leaflets of the mitral valve with two big vegetations on the atrial side of the leaflets. Tricuspid regurgitation mild to moderate was shown and pulmonary hypertension 40 mmHg. Ejection fraction was 51%. CT demonstrated two big infarcts of the spleen – meazurment 50/60mm and 30/40mm, with the suspicious of splenic abscesses. The typical Roth spots for infective endocarditis were found on ophtalmoscopy. The operative mortality risk calculated by Euroscore was 57,53%. The patient was admitted at the operating room in urgent order. Using a general anesthesia and standard surgical preparation the heart was approached via median sternotomy and extracorporeal circulation was iniated using standart aortic and right atrial canulation. After cardioplegic arrest the mitral valve was exposed and two big vegetations on the anterior and posterior mitral leaflet from the atrial side of the mitral valve were detected, size at about 2/2,5cm each. Advanced erosion of the leaflets was shown too (Fig 1).