Author + information
- Sanaz Piran, MD,
- Penelope Rampersad, MD,
- Darren Kagal, MD,
- Lee Errett, MD and
- Howard Leong-Poi, MD⁎ ()
- ↵⁎7-052 Bond Wing, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
We present a case of a 39 year-old female with a history of intravenous drug use (IVDU), diagnosed with staphylococcus aureus endocarditis. On initial presentation, the transthoracic echocardiogram showed evidence of multivalvular involvement and severe aortic regurgitation. She was started on intravenous cloxacillin and gentamycin, and was transferred for further management. A transesophageal echocardiogram (TEE) demonstrated vegetations associated with all four cardiac valves, and both ventricular chambers (Fig. 1A to 1D, Online Videos 1, 2, 3, and 4). As she remained afebrile on appropriate antibiotics without evidence of hemodynamic compromise, and given her IVDU and extensive multivalvular involvement that would increase her operative risk, she was treated medically.
On day 10, she developed acute pulmonary edema. A repeat TEE showed a large perforation of the anterior leaflet of the mitral valve with severe mitral regurgitation (Fig. 1E to 1F, Online Videos 5A, to 5B). She was subsequently taken to the operating room. Due to extensive valvular destruction that mitigated preservation of any of her native valves, she underwent quadruple-valve replacement, with mechanical valves in the mitral and aortic positions and bioprosthetic valves in the tricuspid and pulmonic positions, and excision of ventricular vegetations (Fig. 2). The patient did well post-operatively and completed antibiotic therapy in a supervised environment.
Extensive endocarditis involving all 4 cardiac valves is a very rare occurrence, being more common in the setting of IVDU (1). Valve replacement is generally a treatment of last resort, due to the high incidence of early and late reinfection. To our knowledge, this is the first reported case of fulminant infective endocarditis involving all 4 cardiac valves and both ventricular chambers, requiring vegetectomy and operative replacement of all 4 cardiac valves.
For accompanying Videos 1, 2, 3, 4, and 5, please see the online version of this article.
- American College of Cardiology Foundation