Advanced Practice Provider cardiology/critical care Texas Children's Hospital Texas Woman's University Houston, Texas, United States
Disclosure(s):
Molly Conklin, MSN, AGACNP-BC: No financial relationships to disclose
Background: ACHD patients are highly susceptible to infectious endocarditis (IE) or bacterial infection of the inner lining of the heart known as the endocardium.
Methods: ACHD are more vulnerable to IE due to their abnormal heart structures and non-native heart valves. This case study describes a 27-year-old male patient with a history of Tetralogy of Fallot (TOF) who underwent multiple surgical interventions including TOF repair with VSD closure and RV-PA conduit replacement who presented to a small hospital with fever, fatigue and night sweats. Initial misdiagnosis delayed appropriate intervention, and the patient rapidly decompensated into septic and cardiogenic shock and rhabdomyolysis, highlighting the importance of early recognition and immediate intervention in ACHD patients with endocarditis due to the high risk of rapid decompensation. Blood cultures confirmed streptococcus mitis, TTE and TEE confirmed the diagnosis of valvular vegetation of the non-native Melody valve, and ECHO confirmed severe biventricular dysfunction. S. mitis is commonly found in human saliva, oral mucosa or sputum and is typically benign in healthy adults with normal cardiac anatomy and native heart valves. Despite immediate treatment with targeted antibiotic therapy, his condition deteriorated to refractory shock, and he required mechanical circulatory support with peripheral ECMO cannulation and inotropes. After clinical stabilization, source control of the infection was achieved when the patient underwent surgical removal and replacement of the infected valve.
Outcome: After these methods, he significantly improved and was able to make a full recovery, his inflammatory and infectious markers improved, lactic cleared, CK/ CKMB returned to normal, ECHO confirmed that his cardiac function significantly improved and there were no residual vegetations noted. The patient was extubated, decannulated, and rehabilitated back to his normal baseline status. This case presentation aims to depict the difficulty of recognizing and managing endocarditis in ACHD patients.
Conclusion: This goal of this presentation is to provide education on endocarditis prevention, identify the importance of recognition of symptoms and early diagnosis, and encourage initiation of individualized treatment plans for this complex patient population to prevent rapid deterioration to septic and cardiogenic shock that may cause irreversible damage or death.
