Three-dimensional Echocardiographic Evaluation of Infective Endocarditis Aortic Valve Pathology in a COVID-19 Recovered Patient
1,2,4–6Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3Department of Cardiac Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Corresponding Author: Rajarajan Ganesan, Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India, phone: +91 9815930510, e-mail: Raja2n@gmail.com
How to cite this article Singh A, Ganesan R, Singh H, et al. Three-dimensional Echocardiographic Evaluation of Infective Endocarditis Aortic Valve Pathology in a COVID-19 Recovered Patient. J Perioper Echocardiogr 2020;8(1):12–14.
Source of support: Nil
Conflict of interest: None
The incidence of nosocomial infective endocarditis (IE) has increased in the last 2 years during the COVID-19 pandemic and the patients might present with overlapping symptoms of heart failure and pneumonia. Simultaneously, COVID-19 is a hypercoagulable disorder that can complicate the postoperative course of a patient undergoing valve replacement. Therefore, the exact pathology of the native valve needs to be evaluated in such patients. We describe a case of a 45-year-old man with a history of non-compressive myelopathy and COVID-19 infection scheduled for aortic valve replacement and subaortic membrane resection. Intraoperative transesophageal echocardiography was instrumental in defining the aortic valve anatomy that changed the management plan.
Keywords: Aortic valve replacement, Infective endocarditis, Transesophageal echocardiography.
Nosocomial aortic valve infective endocarditis (IE) has an incidence of 10–30% of all the reported cases.1,2 There is a high risk of native aortic valve endocarditis (33.33%) in patients with COVID-19.3 Such patients are at increased risk of adverse events and should undergo culture-based antibiotic therapy or valve replacement.4 We describe a 45-year-old man with a history of non-compressive myelopathy and COVID-19 infection scheduled for aortic valve replacement and subaortic membrane resection for severe aortic regurgitation secondary to IE. Intraoperative transesophageal echocardiography (TEE) was instrumental in defining the aortic valve pathology that changed the management plan. The patient had given written informed consent for the publication of this case report.
A 45-year-old man, weight 55 kg, height 163 cm, presented to our outpatient department with high-grade fever (38°C) and shortness of breath (New York Heart Association II). Five months before this, he underwent methylprednisolone pulse therapy for non-compressive myelopathy with brainstem involvement. One week before presentation to the hospital admission, he was treated for moderate COVID-19 infection with injection remdesivir, injection dexamethasone, and discharged home on tablet prednisolone. He had right hemiparesis (4/5 motor power) and reduced tendon reflexes. The jugular venous pulse was not raised, a diastolic murmur (grade IV) was audible on the left parasternal fourth intercostal space with liver palpable at 3 cm below the right costal margin. The electrocardiogram showed normal sinus rhythm and chest X-ray showed right lower lobe consolidation and pulmonary edema. The contrast-enhanced chest tomography was suggestive of post-COVID changes. The preoperative transthoracic echocardiograph showed 1.5 × 0.9 cm vegetation on the aortic valve, severe aortic regurgitation with pressure-half time 120 m/s, holo-diastolic flow reversal in descending aorta, subaortic membrane, dilated left ventricle, and left ventricle ejection fraction 55–60%. The CT coronary angiogram revealed an unruptured left coronary sinus Valsalva aneurysm without coronary artery disease. The blood cultures drawn 3 hours apart did not show any organism growth after 7 days of incubation and the patient was prescribed vancomycin and amikacin. He was scheduled for an aortic valve replacement with subaortic membrane resection under cardiopulmonary bypass (CPB).
In the operating room, after instituting standard monitoring, general anesthesia was induced as per the protocol of our institute. An adult TEE probe X7-2t xMATRIX, 3-10 MHz (Epiq CVx, Koninklijke Philips, N.V) was inserted after securing the airway. The TEE mid-esophageal aortic valve long-axis view showed a freely mobile mass on the undersurface of the left coronary (LCC) or non-coronary cusp, normal right coronary cusp with a subaortic membrane (Fig. 1A). The LCC was visualized incompletely (Fig. 1B), accompanied by a hypoechogenic space along the base of the cusp (Fig. 2A). As we performed the left to right sweep, we could visualize an echogenic structure in continuity with LCC (Video 1). No ventricular septal defect was visualized. The mid-esophageal aortic valve short-axis view showed non-coapting LCC, right coronary (RCC), and non-coronary cusp (NCC) with a color Doppler jet along the commissures (Fig. 2). On the 3D aortic valve long-axis view, we found LCC destroyed with an echogenic structural continuity below the RCC (Fig. 3A and Video 2). This was further confirmed by the 3-D aortic valve short-axis view (Fig. 3B). The diagnosis was modified into IE sequelae resulting in LCC destruction accompanied by aortic root abscess. There were additional findings of mild mitral and tricuspid regurgitation, 1 cm pericardial effusion behind left ventricle and right pleural effusion. Based on the TEE findings and single cusp involvement by IE, the surgeons decided upon the pericardial patch reconstruction of LCC under CPB.
Surgery proceeded following heparinization and institution of cardioplegia using aortic and dual-stage venous cannulation. The cardioplegic arrest of the heart was achieved using combined retrograde-ostial cardioplegia. Intraoperative surgical finding following aortotomy confirmed a tri-leaflet aortic valve, destroyed LCC with other two cusps normal and no evidence of subaortic membrane. An abscess cavity was seen in the left coronary sinus. The LCC was replaced by a neo-aortic cusp constructed using autologous pericardium and an abscess cavity plicated. The patient was weaned off bypass using milrinone 0.5 μg/kg/min and noradrenaline 0.05 μg/kg/min. The post-CPB TEE showed normal aortic valve cusp movement (Videos 3 and 4), trivial central regurgitation (vena contracta 1 mm), mean gradient 7 mm Hg, and coaptation height 7 mm. The left ventricle ejection fraction measured 45%.
The patient was extubated 12 hours of elective mechanical ventilation. The postoperative course of the patient was complicated with ventricular fibrillation and fungal pneumonia. The histopathology report demonstrated bacterial IE; however, his blood cultures remained sterile and were started on a 6-week regimen of vancomycin. He was discharged from the hospital on day 48 and has been under regular surgical follow-up and is doing well.
There has been an increase in the incidence of IE in the last two decades due to frequent use of indwelling catheters, invasive procedures, and older age group patients being admitted in intensive care units.1 This scenario has been worsened by SARS-CoV-2 related inflammatory response and use of steroids.3,5,6 Infective endocarditis can present as a concomitant infection in a patient with COVID-19 with overlapping symptoms of respiratory distress and fever.6 However, there are very few cases reported of COVID-19 related native valve IE.3,5 Sanders et al.5 had performed aortic valve replacement for IE from an infected hemodialysis catheter in a patient primarily presenting with symptoms of COVID-19. Ours was an immunocompromised patient who presented with overlapping symptoms of cardiac and respiratory failure within a week of his initial symptoms. It is difficult to say if the initial symptoms were due to COVID-19 or a missed IE diagnosis. The presence of subaortic membrane is also a frequent nidus for bacterial colonization; however, this was ruled out by TEE.
A complete description of valvular pathology is required for appropriate surgical planning.2 A TEE is superior to transthoracic echocardiogram2 and was performed in the pre-CPB period which showed a single leaflet injury. The surgical plan was modified considering the feasibility of repair and risk of intracranial hemorrhage superimposed to a preexisting brainstem injury.7
The use of whole valve homograft has been used successfully with better survival.8–10 However, single cusp homograft reconstruction for IE has been sparingly reported with high success rates by Katz et al.11 and Singh et al.12 The cusp reconstruction was feasible in our patient because of single leaflet involvement and structurally and functionally normal other two cusps. The TEE was also helpful in diagnosing the adequacy of valve reconstruction. The postoperative goal following valve reconstruction is to have leaflets with normal mobility without residual insufficiency or stenosis. Our patient had trivial residual aortic insufficiency, mean gradient 7 mm Hg, and coaptation height 7 mm, suggesting adequate repair. The inter-cusp coaptation length >4 mm with an individual cusp effective height >9 mm, aortic annulus <25 mm, and the mean transthoracic gradient <10 mm Hg indicate satisfactory reconstruction.13,14
The IE secondary to COVID-19 infection remains a major concern and may present as severe aortic regurgitation. Intraoperative 3D-TEE is instrumental in defining the valve anatomy and assessment of the adequacy of repair during the surgical reconstruction of the affected valve leaflet.
- Video 1: Intraoperative transesophageal echocardiography with an up and down sweep of the left ventricle outflow tract showing flail aortic valve segment of the left coronary cusp without subaortic membrane
- Video 2: Intraoperative 3-dimensional transesophageal echocardiography examination showing flail left coronary cusp in mid-esophageal aortic valve long-axis view
- Video 3: Postoperative transesophageal echocardiography showing normally coapting neo-cusp with residual trivial aortic insufficiency in mid-esophageal aortic valve long-axis view
- Video 4: Postoperative transesophageal echocardiography showing normally coapting neo-cusp with residual trivial aortic insufficiency in mid-esophageal aortic valve short-axis view
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5. Sanders DJ, Sutter JS, Tatooles A, et al. Endocarditis complicated by severe aortic insufficiency in a patient with COVID-19: diagnostic and management implications. Case Rep Cardiol 2020;2020:8844255. DOI: 10.1155/2020/8844255.
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13. Berrebi A, Monin JL, Lansac E. Systematic echocardiographic assessment of aortic regurgitation‐ what should the surgeon know for aortic valve repair? Ann Cardiothorac Surg 2019;8(3):331–341. DOI: 10.21037/acs.2019.05.15.
14. Pushpa J, Bhat A, Prasanna Simha P, et al. Perioperative echocardiography in Ozaki’s procedure: an observational study‐single centre experience. MedPulse Int J Anesthesiol 2019;11:268–273.
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