Title : Infective endocarditis with complex fistulas and pseudoaneurysm: A case report
Abstract:
Introduction: Infective Endocarditis (IE) is a severe condition that, in less than 2% of cases, may complicate with development of fistulous communications between cardiac chambers or great vessels. The formation of fistulas involving the Right Ventricle (RV) and/or the Left Ventricular Outflow Tract (LVOT) represents a particularly rare and severe complication. This condition is typically associated with aggressive pathogens, such as Staphylococcus aureus, Streptococcus species, or fungal organisms, and often signifies a late presentation or extensive infection with substantial tissue destruction.
Clinical Case: A 76-year-old woman with a history of severe aortic stenosis and moderate to severe aortic insufficiency with preserved Left Ventricular Ejection Fraction (LVEF) presented to the emergency department with fever and prostration following a hand laceration 15 days earlier. The patient was admitted with sepsis, and blood cultures identified Staphylococcus epidermidis. Transthoracic echocardiography revealed a mobile mass (21 x 3 mm) on the auricular surface at the base of the posterior mitral leaflet, consistent with vegetation. Transesophageal echocardiography confirmed the vegetation, with moderate to severe mitral regurgitation, and identified a pseudoaneurysm of the anterior aortic root (20 x 14 mm). The pseudoaneurysm had perforated into both the LVOT and RV, creating a significant shunt from the aorta to the RV. Severe aortic insufficiency was also present, characterized by two jets: one originating from the fistula (vena contracta: 7.5 mm) and a central jet. Additionally, a mass (9 x 5 mm) was observed at the aortic annulus. The case was reviewed by a multidisciplinary Heart Team, and the patient was deemed a candidate for surgical intervention. The patient was submitted to mitral and aortic valve replacement with biological prosthesis, tricuspid valvuloplastia and interventricular communication closure. Despite the provided care and intervention, the patient experienced an unfavorable postoperative course and ultimately succumbed to her condition.
Discussion: This case highlights the rare but devastating complication of multi chamber fistulas in infective endocarditis, underscoring the importance of early and proper detection. Despite aggressive surgical intervention, this pathology still presents a high morbidity and mortality.
