Methods/results
We report the case of a 31-year-old female with a history of IVDU and chronic hepatitis C who presented to the hospital with a fever and back pain. She had previously left an outside hospital against medical advice, where she had been found to have MSSA bacteremia. Upon arrival at our ED, a CT angiogram found septic pulmonary emboli, raising suspicion of IE. Transthoracic echocardiogram (TTE) showed a tricuspid valve (TV) vegetation with severe tricuspid regurgitation. The patient underwent bioprosthetic TV replacement, followed by 6 weeks of cefazolin. She also received two epicardial pacing leads and a permanent pacemaker during the procedure for heart block. After discharge, the patient was only seen once before being lost to follow-up.
7 months later, the patient returned to our ED with fatigue, fevers, night sweats, chronic back pain, shortness of breath, and reported heroin usage prior to presentation. TTE revealed recurrent TV vegetation with severe regurgitation and secondary ventral septal defect (Figure 1. A, B). She was admitted to the cardiology service in the ICU and despite maximal medical management, deteriorated with severe cardiogenic and septic shock due to persistent bacteremia. Ten days into ICU care she became anuric in spite of inotropic support. Cardiac surgery service was consulted as hospice care was being considered. Upon evaluation, the patient was deemed very high risk and a poor candidate for redo sternotomy and tricuspid valve replacement without infection source control. We planned a staged approach with the initial stage of valvectomy for source control and ECMO for hemodynamic stability to definitive treatment. After a redo sternotomy and tricuspid valvectomy, she was placed on venous arterial ECMO with right femoral arterial cannulation, allowing time for possible infection clearance, right heart decompression, and hepatic decongestion (Figure 1. C, D). After 7 days, repeated blood cultures showed bacteremia clearance and return to hemodynamic stability with resolving renal failure. The patient was taken back to the operating room and underwent 29 mm bioprosthetic valve replacement, ventral septal defect (VSD) repair, and new epicardial lead placement (Figure 1. E, F).
The patient had a prolonged subsequent at the hospital due to developing sacral debutis pressure ulcer, placement concerns due to extensive history of polysubstance use disorder, depression/anxiety, and post-traumatic stress disorder, and the requirement of intravenous antibiotics. At the end of her hospitalization, the patient agreed to be discharged to a long-term acute care hospital, after which she would continue with methadone and buprenorphine treatments as well as receiving significant physical therapy, speech therapy, and nutritional support. This study was approved by IRB (ID: 2000020356) on 4/4/2022 and written with the informed consent of the patient.