Surgeons' re-operative valve replacement practices in patients with endocarditis due to drug use

Abstract Background Here, we outline the case of a US Veteran’s Health Administration (VA) patient with a history of recent bioprosthetic aortic valve replacement (AVR) and recent intravenous drug use (IVDU) who was found to have three-valve infective endocarditis (IE) resulting in septic shock. We highlight this case because it represents an uncommon case of three-valve IE in the setting of recent bioprosthetic valve replacement and IVDU, and it raises the need for continued awareness of mental health and drug rehabilitation in the US military veteran population. Case summary A 62-year-old gentleman with recent bioprosthetic AVR presented with dyspnoea and lower extremity oedema and was found to have a heart failure exacerbation. He developed sepsis and was found to have three-valve endocarditis, as well as aortic root abscess and pacemaker lead infection. He was treated with broad-spectrum antibiotics and evaluated for surgical intervention. After discussion with the surgical team, the patient decided not to pursue surgery due to prohibitively high perioperative mortality risk. The patient was transferred to hospice and expired within 2 weeks. Discussion Three-valve IE is sparingly documented in published literature and can be difficult to treat. Providers must be cognizant of prosthetic valve endocarditis as an uncommon but known complication of valve replacement surgery. Intravenous drug use is a common risk factor for endocarditis and is prevalent in the US military veteran population. Prosthetic valve endocarditis should be treated with broad-spectrum antibiotics, and in general, if it leads to new significant valvular abnormalities, the valve should be replaced.

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Surgeons’ Re-Operative Valve Replacement Practices with Patients with Endocarditis Due to Drug Use

10.20944/preprints202008.0531.v1 ◽

2020 ◽

Author(s):

Julie Aultman ◽

Oliwier Dziadkowiec ◽

Dianne McCallister ◽

Michael Firstenberg

Keyword(s):

Decision Making ◽

Drug Use ◽

Valve Replacement ◽

Heart Valves ◽

Intravenous Drug Use ◽

Surgical Decision ◽

Attitudes And Practices ◽

Survey Results ◽

Surgical Decision Making

Background: This study discerns surgeons’ attitudes and practices in the determination of heart valve replacement for patients with endocarditis due to intravenous drug use (IVDU-IE). We aimed to identify factors contributing to surgeons’ decision-making process for initial and recurrent surgical heart valves, and the availability of institutional guidance. Methods: An IRB approved, anonymous mixed-methods survey instrument was designed and validated with 24 questions. Cardiothoracic surgeons in the U.S. and globally were recruited with a total of 220 enrolling in the study with 176 completing every question on the survey. Results: A cluster analysis revealed that although surgeons can be divided into sub-groups based on their previous experience with valve replacements, these groups are not perfectly homogenous, and the number of identified clusters is dependent on technique used. ANOVA analysis revealed that the variables that most clearly divided the surgeons into subgroups were, in order of importance, years of practice, number of valve replacements, and geography. Conclusions: Our analysis showed heterogeneity among cardiothoracic surgeons regarding how they make clinical decisions regarding re-operative valve replacement related to IVDU-IE Therefore, an opportunity exists for an interprofessional team to develop guidelines to decrease variability in surgical decision-making regarding valve replacement associated with IVDU-IE

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Uncertainty of Treatment of Serratia marcescens Endocarditis

International Journal of Medical and Pharmaceutical Case Reports ◽

10.9734/ijmpcr/2019/v12i230100 ◽

2019 ◽

pp. 1-5

Author(s):

Melanie Goodberlet ◽

Michael Schontz ◽

Kevin McLaughlin ◽

Julie Kelly

Keyword(s):

Mitral Valve ◽

Aortic Valve ◽

Drug Use ◽

Serratia Marcescens ◽

Valve Replacement ◽

Case Reports ◽

Treatment Options ◽

Treatment Strategies ◽

Intravenous Drug ◽

Intravenous Drug Use

Aim: To discuss two patient cases of Serratia marcescens endocarditis and the paucity of literature regarding treatment options. Presentation of Case: Patient 1 was a 29-year old male who presented with native mitral valve Serratia marcescens endocarditis presumed secondary to intravenous drug use. He was empirically treated with vancomycin and piperacillin/tazobactam then transitioned to meropenem and gentamicin 1 mg/kg every 8 hours. He was maintained on vancomycin monotherapy for days 4-14. Gentamicin was restarted on hospital day 14 at 7 mg/kg every 36 hours for 6 weeks. He underwent mitral valve replacement on hospital day 20. He was readmitted on day 42 with splenic lesions and enlarging mycotic aneurysms. Patient 2 was a 38-year old male with native aortic valve Serratia marcescens endocarditis with septic emboli presumed secondary to intravenous drug use. He was treated with vancomycin and cefepime then was transitioned to ceftriaxone and levofloxacin. The patient underwent aortic valve replacement on hospital day 3 and was transitioned to meropenem and levofloxacin for 6 weeks. Discussion: The treatment strategies for both patients demonstrates that the optimal treatment strategy for Serratia marcescens endocarditis remains unclear. The gentamicin dosing for patient 1 demonstrates “synergy” and extended-interval dosing. Despite both dosing strategies being used, the patient continued to exhibit complications of the infection. Patient 2 demonstrates successful treatment of the infection with surgical intervention and a carbapenem/fluoroquinolone regimen. Conclusion: These cases demonstrates that much remains unclear in the treatment of Serratia marcescens endocarditis and more studies and case reports are needed.

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