[HSF] Prosthetic Valve Endocarditis in setting of severe LV dysfunction

[Ani Anyanwu]

Would be interested in forum members opinion on this case.
 
This 58 yr old with hypertensive nephropathy, on dialysis for five years and on waiting list for kidney transplantation first presented to us December 2005 with an acute MI. Catheter showed occluded LAD which caused a massive anteroseptal MI with severe LV dysfunction. Echo showed mitral valve endocarditis with large vegetation. Cultures grew an enterococcus. Coronaries were otherwise pristine with no collateral LAD filling suggesting the occlusion was secondary to embolisation from the mitral. He underwent MV replacement and vein graft to LAD, also tricuspid repair. LV dysfunction however persisted following surgery and heart continued to remodel with dilated 7cm LV and LVEF ranging 10 to 15%. He was evaluated for heart transplant at another institution earlier this year but turned down (i think because he was too well - VO2 max 23). LV dysfunction was managed medically and for most part he is in NHYA II.
 
Patient now admitted under our care because of prosthetic valve endocarditis. Cultures are positive for Staph Aureus sensitive to methicillin and echo shows probable abscess around trigone and may involve aortic annulus around non-coronary cusp. There is no valvar incompetence (of either aortic or mitral). Infection may have been triggered by a recent transvenous defibrillator (2 months ago) or a dialysis access cathether. Has been on antibiotics in outside hospital for 3 weeks before being transferred to us this week. Transesophageal echo here confirms EF around 10%, also severe RV dilatation and dysfunction. There is also echodensity at tip of RV defibrillator lead and previously described abscess but stable prosthesis. CT Angio shows patent vein graft. Right heart cath is notable for a wedge of 34, PA 40/30, RA 10, SVO2 50%.  Patient is stable, no active heart failure and sepsis well controlled on antibiotics. 
 
Surgical therapy for this condition we expect will require radical debridement of trigone, redo MV replacement, likely Bentall, also will explant defibrillator and dialysis catheter. Patient is likely to bleed and require transfusions hence compounding existing RV dysfunction. 
 
Considering that this is not an operation for heart failure, but surgery in the midst of heart failure, it will invariably worsen rather than improve function of the heart; I would be keen to hear from forum members how they would deal with this case. Would anybody operate and at what do you think is the chance of success (by success I do not mean our usual 'extubated the next morning' criteria' but return to good quality of life) and at what risk of operative mortality? 
 
My current leaning is to offer this patient combined transplantation of the heart and kidney as the strategy most likely to result in mid-term survival - would also be keen to hear thoughts from transplant surgeons and others about this option.
 
Thanks
 
Ani
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