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\begin{document}

\title{Successful surgical treatment approach for mitral valve vegetation of
infective endocarditis after severe soft tissue infection with
mediastinitis.}



\author[1]{Kenichiro Uchida}%
\author[1]{Yosuke  Takahashi}%
\author[1]{Toshihiko Shibata}%
\author[1]{Yasumitsu Mizobata}%
\affil[1]{Osaka City University Graduate School of Medicine School of Medicine}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Transesophageal echocardiography is mandatory if you do suspect
infective endocarditis. By approaching via a small right thoracotomy,
vegetectomy and mitral valvuloplasty following severe mediastinitis were
successfully accomplished without any complications.~

\par\null%
\end{abstract}%



\sloppy


\textbf{Title page}

\textbf{Successful surgical treatment approach for infective
endocarditis following severe mediastinitis.}

\textbf{Kenichiro Uchida, MD, PhD, FACS.}

Osaka City University, Graduate School of Medicine, Department of
traumatology and critical care medicine

1-5-7 Asahimachi, Abeno-ku, Osaka-City, Osaka, Japan, 545-8586

\textbf{Yosuke Takahashi, MD, PhD.}

Osaka City University, Graduate School of Medicine, Department of
Cardiovascular Surgery

1-5-7 Asahimachi, Abeno-ku, Osaka-City, Osaka, Japan, 545-8586

\textbf{Toshihiko Shibata, MD, PhD.}

Osaka City University, Graduate School of Medicine, Department of
Cardiovascular Surgery

1-5-7 Asahimachi, Abeno-ku, Osaka-City, Osaka, Japan, 545-8586

\textbf{Yasumitsu Mizobata, MD, PhD.}

Osaka City University, Graduate School of Medicine, Department of
traumatology and critical care medicine

\textbf{Corresponding Author:}

Kenichiro Uchida. E-mail:\emph{cvs.uchida@gmail.com}

1-5-7 Asahimachi, Abeno-ku, Osaka-City ,Osaka, Japan

545-8586 Tel.\begin{CJK}{UTF8}{gbsn}　\end{CJK}\selectlanguage{english}81-6-6645-2121~ Fax.\begin{CJK}{UTF8}{gbsn}　\end{CJK}\selectlanguage{english}81-6-6646-3064

\par\null

\textbf{Abstract}

Transesophageal echocardiography is mandatory if you do suspect
infective endocarditis. By approaching via a small right thoracotomy,
vegetectomy and mitral valvuloplasty following severe mediastinitis were
successfully accomplished without any complications.~

\par\null

\textbf{KEYWORDS}

infective endocarditis; mediastinitis; sepsis; mitral valve; small right
thoracotomy.

\par\null

\textbf{INTRODUCTION}

Infective endocarditis is commonly lethal, and currently there are
several guidelines recommending indications for surgical
interventions.\textsuperscript{1-4} However, there are many unsolved and
debatable problems related to the appropriate timing of surgery, the
surgical approach and minimizing the risk of comorbidities. Usually,
there is evidence of mobile vegetation of over 10 mm in size, for which
the guidelines recommend immediate surgical
vegetectomy,\textsuperscript{1} however, sometimes the patient's
condition does not allow surgical intervention to proceed.

\textbf{CASE REPORT}

A 57-year-old Asian man with a medical history of hypertension and type
II diabetes mellitus was hospitalized because of fever, left shoulder
pain and mild unconsciousness. He also had frozen shoulder syndrome and
had undergone brachial plexus block anesthesia administered by a local
physician about one week before admission. Physical examination showed a
significant skin rash and warmth around his neck, anterior thoracic wall
and left upper arm with tenderness. No cardiac murmur or abnormal
respiratory sounds were heard on auscultation. His blood pressure was
142/108 mmHg, heart rate was regular at 122 beats/min, respiratory rate
was 30 breaths/min, and his body temperature was 38.3\selectlanguage{ngerman}°C. Serial
hematologic workup is showed in Table 1.

Contrast enhanced computed tomography (CECT) on admission revealed
expansive fluid collection dorsal to the sternal notch, between the
pectoralis major and minor muscles, and around the axillary nerve
(Figure 1). No valve regurgitation or signs of vegetation were observed
on transthoracic echocardiography (TTE) at this time.

After patient admission, we immediately performed surgical debridement
with an adequate incision from the suprasternal notch to the axilla and
brachial lesion. After washing out pus-like fluid collection, we
irrigated the site for the next 4 days. As the targeted bacteria was
revealed to be methicillin-sensitive \emph{Staphylococcus aureus} (MSSA)
and surgically debrided site became uncontaminated, we applied negative
pressure wound therapy (NPWT). We also deescalated the antibiotic
therapy to cefazoline from initial teicoplanin, doripenem hydrate and
clindamycin and was continued 8 weeks after admission.

At 4 days after admission, as Osler's node on the patient's left thumb
and Janeway spot on the dorsal side of his left hand were detected
(Figure 2), we performed the TTE again and found only mild mitral
regurgitation. However, subsequent TEE performed the next day revealed a
vegetation of 12×15 mm in size at the border of the left ventricular
posterior wall and posterior mitral leaflet annulus (Figure 3).

The site and size of the vegetation were clear indications for surgery,
however as the patient had no signs of heart failure or major thrombotic
event, we decided to prioritize treatment of mediastinitis prior to
planned cardiac surgery. The original surgical wound was sutured at day
36, after treatment with interval irrigation and NPWT. The cerebral
magnetic resonance image performed prior to surgery had no signs of
mycotic aneurysm or infarctions.

The vegetectomy and additional mitral valvuloplasty were performed 40
days after it was detected and diagnosed as infective endocarditis.

The operation began with the patient in a left half-lateral position,
and femoral arteriovenous cardiopulmonary bypass was established. We
approached from the right 4th intercostal space with an 8-cm incision.
After opening the left atrium via right-side left arteriotomy, we
detected a huge vegetation between the mitral annulus and left
ventricular posterior wall that surrounded the papillary muscle and its
P1 segment of the posterior mitral valve leaflet (Figure 4). The
vegetation was resected and the P1 was concomitantly repaired with
quadrangular resection using interrupted sutures. Because mitral
regurgitation was still present, we performed an annuloplasty with a
28-mm Physio-ring II (Edwards Life Sciences, USA) along with A1-P1
edge-to-edge suturing. The resected vegetation specimen measured 12×15
mm, and culture of the specimen revealed the same MSSA.

The patient was continued on an additional 3 weeks of antibiotic therapy
and was discharged from hospital 20 days after the surgery without any
complications.

\textbf{DISCUSSION}

Infective endocarditis is a severely infectious disease with high rates
of mortality and morbidity.\textsuperscript{5-7} Although the
recommended timing of surgery for IE is documented in guidelines for
prevention and treatment of infective endocarditis\textsuperscript{1,8},
we usually have to decide appropriate timing for surgery on the basis of
each patient's characteristics, conditions and comorbidities. The
greater than 10 mm size and site of the vegetation were clear
indications for urgent surgical vegetectomy\textsuperscript{1,9},
however it was difficult to proceed directly to surgical vegetectomy for
three reasons. First was the timing of bleeding complications that were
a contraindication for cardiac surgery. Second, since the infected site
was concomitant with the mediastinitis, we wanted to prevent worsening
of the mediastinitis after open heart surgery. Third, the patient was in
septic shock and also suffered acute kidney injury following the septic
shock.

Generally, a right thoracotomy approach offers better exposure to the
mitral apparatus in patients with a small left atrium, allowing easy
repair or replacement of the mitral valve.\textsuperscript{10-12} This
advantage results in reducing the volume of blood transfused and the
length of stay in the intensive care unit.\textsuperscript{11,12)}

Several current papers discuss the sensitivity and specificity of TTE
and TEE.\textsuperscript{13-15} The sensitivity of TTE for native valve
vegetation seems to be approximately 70\%.\textsuperscript{15} As we
could not detect vegetation on TTE initially, therefore we herein
re-emphasize the necessity of performing TEE in patients highly
suspected of having infective endocarditis and especially in those with
positive blood cultures for Staphylococcus. The patient had no caries on
his mouth and no current episode of dental treatment. The only cause we
could determine for this soft tissue infection was brachial plexus block
anesthesia performed by a local physician performed to control the
patient's frozen shoulder syndrome.

\textbf{CONCLUSION}

We successfully treated a patient with infective endocarditis following
severe mediastinitis. By considering appropriate timing for cardiac
surgery and approaching via a right thoracotomy, vegetectomy and mitral
valvuloplasty were safely performed and the patient was discharged
without any complications.

ACKNOWLEDGEMENTS

None.

CONFLICT OF INTEREST

The authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a
potential conflict of interest. There was no external funding in the
preparation of this manuscript.

ETHICAL APPROVAL

Written informed consent was appropriately obtained from the patient.

AUTHOR CONTRIBUTIONS

KU: involved in patient care as well as the drafting, review, and
revision of the initial manuscript. YT: involved in patient's treatment
decision as well as the review and revision the initial manuscript. TS
and YM: involved in patient care as well as the review and revision of
the initial manuscript. All authors approved the final manuscript
submission and agree to be accountable for all aspects of the study.

\textbf{References}

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\textbf{FIGURE LEGEND}

\textbf{FIGURE 1.}~~Preoperative contrast-enhanced computed tomography
image shows massive intra-soft tissue fluid collection from the neck to
pectoralis major and minor muscles that extends to the axillary line,
dorsally to the sternal notch (\emph{Yellow arrow}).

\textbf{~}

\textbf{FIGURE 2.}~~Photographs showing Osler's node on the patient's
left thumb and Janeway spot on the dorsal side of the left hand found at
admission (\emph{Yellow arrow}).

~

\textbf{FIGURE 3.}~~Images of the vegetation detected on transesophageal
echocardiography. The vegetation was present at the border of the
posterior wall of the left ventricle and surrounded the papillary muscle
and chordae of the posterior mitral leaflet (\emph{Yellow arrow}).

~

\textbf{FIGURE 4.~}Image of the intraoperative findings. The huge
vegetation was attached between the mitral annulus and left ventricular
posterior wall that surrounded the papillary muscle and its P1 segment
of the posterior mitral valve leaflet (\emph{Yellow arrow}).

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