AB261. SOH26AB_0037. Breaking the cycle: management of severe aortic regurgitation in Streptococcus pneumoniae infective endocarditis: a case report

Background: Little is known regarding the management of severe aortic regurgitation in the setting of infective endocarditis involving Streptococcus pneumoniae.

Case Description: A 52-year-old male was admitted by ambulance to a tertiary model 4 hospital, with a week-long history of fever, confusion, and shortness of breath. An initial workup grew Streptococcus pneumoniae from blood and cerebrospinal fluid. He developed respiratory failure requiring invasive mechanical ventilation. Despite appropriate therapy, the patient continued to deteriorate and developed multiorgan failure requiring vasopressor support and renal replacement therapy. A subsequent bronchoalveolar lavage grew Burkholderia complex. On day 7 of his admission, the patient became suddenly difficult to oxygenate with haemodynamically lability. A transthoracic echocardiogram (TTE) demonstrated severe aortic regurgitation. A subsequent transoesophageal echocardiogram (TOE) suggested infective endocarditis, with associated prolapse of the aortic valve leaflet in addition to leaflet perforation. The patient was commenced on intravenous glyceryl trinitrate infusion to decrease afterload and reduce left atrial pressure. Improvement in oxygenation allowed the introduction of oral hydralazine. Inhaled nitric oxide, along with ultrafiltration, was introduced concurrently. Evolving distributive shock led to a noradrenaline requirement, with any subsequent rise in systemic vascular resistance resulting in worsening tissue hypoxia. A wide pulse pressure made balancing coronary perfusion pressure without large increases in afterload challenging. Vasopressin introduction had a limited effect. Daily TTE highlighted progressive left ventricular followed by right ventricular failure. Unfortunately, the patient was unsuitable for cardiothoracic intervention due to multiorgan failure and died in the intensive care unit (ICU).

Conclusions: This case demonstrates the complexities between balancing afterload and pulmonary oedema in the setting of severe aortic regurgitation and multiorgan failure secondary to sepsis.

Keywords: Infective endocarditis; intensive care; aortic regurgitation; multi-organ failure; case report