1Segeberger Kliniken GmbH Herzzentrum Bad Segeberg, Deutschland; 2Universitätsklinikum Gießen und Marburg GmbH Medizinische Klinik I - Kardiologie und Angiologie Gießen, Deutschland; 3Universitätsklinikum Gießen und Marburg GmbH Klinik für Herz-, Kinderherz- und Gefäßchirurgie Gießen, Deutschland; 4Klinikum Oldenburg AöR Klinik für Kardiologie Oldenburg, Deutschland
Case summary
Here we describe a highly complex case utilizing a novel cerebral embolic device to protect the brain while aspirating vegetation formed as result of native mitral valve endocarditis in a female unfit for heart surgery.
History
We report the case of a 63-year-old female presenting with a 39°C fever and syncope. In searching for an origin of the infection, we identified a desolate tooth status as the most likely source. Endocarditis was suspected as a second possible source and confirmed by transoesophageal echocardiography (TOE). In spite of the syncope, cerebral embolic infarctions were not found in the cerebral CT. Empirical antibiotic treatment (intravenous ceftriaxone 2 g daily and subsequently daptomycin (10 mg/kg once daily) was started when blood samples were positive for Streptococcus agalacticae. The clinical status of the patient declined, with hydropic cardiac decompensation complicated by acute kidney injury and paroxysmal atrial fibrillation.
Diagnostic tests
Initial TOE revealed a 14 x 8 mm mobile vegetative mass. A subsequent follow-up TOE 7 days later showed a significant growth of the vegetation (22 x 8 mm).
Procedure
With an STS scoreisolatedMVR of > 30%, the patient was deemed unfit for surgery by the heart team. Therefore, interventional treatment was performed under general anaesthesia. The ProtEmbo® cerebral protection device was placed via a 7F radial sheath under fluoroscopic control. Thereafter, a 12F transseptal needle was advanced, through which a transseptal sheath with super-stiff wire was placed in the left atrium, and a 24F sheath was advanced. Finally, the FlowTriever® system was guided by TOE to a position above the anterior mitral valve to aspirate the vegetation. Intraprocedural TOE showed a good result with mild residual mitral regurgitation. Postinterventional examination revealed no neurological deficits or clinical signs of distal embolization. The interdisciplinary endocarditis board recommended a further three weeks of intravenous antibiotic therapy. Thereafter, all cultures were sterile and the patient’s health status improved significantly. At the follow-up visit four weeks after discharge, the patient presented in significantly improved health without any clinical or laboratory signs of infection. TOE showed consolidation of a residual mass at the anterior mitral valve leaflet with no mobile parts. The mitral valve remained mildly insufficient.
Comments
This highly complex case of native mitral valve endocarditis in a surgically inoperable patient illustrates the possibility of cerebral protection for reducing risk of neurological deficits caused by embolization during the aspiration of mitral valve vegetation. Despite being used off-label, both ProtEmbo and FlowTriever were essential contributors to the successful outcome for this patient.