Mitral Valve Endocarditis Atrial Fibrillation

Author: Kirsten Freeman, MD
Institution: University of Florida
Date Reviewed: July 2022
Original Case: Nahush Mokadam, MD; Edward Verrier, MD; University of  Washington
Learning Domain: Adult Cardiac Surgery
Learning Objective: Heart Valve Endocarditis; Atrial Fibrillation
PowerPoint File: File 2022 MV_Endocarditis_AF - Updated.pptx

Presentation

39-year-old Male 10-year history of Mitral Valve Prolapse:

  • Increasing SOB / DOE
  • Now with Severe MR
  • History of Palpitation
  • Recent fever / chills / sweats  after dental cleaning
    • Positive blood cultures 
    • Gram positive cocci

Past Medical History:

  • GERD / PUD
  • Chronic back pain
  • 6 Pack yr smoking hx, Social alcohol

History and Exam

Pertinent Physical Exam

  • 6’ 8” male
  • Heart rate regular  70, BP 137 / 72 mm Hg    Wt 133 kg 
  • Grade V / VI holo-systolic murmur to axilla
  • Lungs clear

PMH

  • Hyperlipidemia
  • Mild Hypertension
  • Mild GERD
  • Hip arthritis

Medications

  • Niacin
  • Voltaren
  • Flexeril
  • Glucosamine / MVI
  • Omeprazole
  • IV Vancomycin

Labs

  • Hct 37%, WBC 6.05
  • Platelets: 245,000
  • Normal Coags
  • Normal LFT’s
  • Na 134, K 3.8, Cl 100, HCO3 24, BUN 18, Cr 1.1

Electrocardiogram

Chest X-Ray

 

Electrocardiogram Clips

Discussion Points for Conference

  • Underlying myxomatous mitral valve disease / Recent onset of Atrial fibrillation
  • New onset of Gram-positive endocarditis
    • New vegetation
    • Strep Viridans
  • Timing of Surgery
  • Duration of Antibiotics
  • Indications for Maze procedure
  • Potential for Repair vs Replacement with endocarditis

Surgery

  • Mitral Valve :
    • Triangular Resection P2
    • #36 Annuloplasty Ring
  • Cox Maze IV procedure (both right and left)
    • Radiofrequency plus cryoablation
  • Extubated  POD #1 afternoon
  • Discharge POD #7
  • Atrial Fib post op, converted with amiodarone
  • Doing well at 6 months

2020 ACC/AHA Valve Guidelines

 

 

https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923

Learning Points

  • Mitral Valve Endocarditis presents with wide spectrum of pathology
  • Therapy and timing of intervention must be individualized based on presentation and symptoms
  • MV Repair is still feasible in many cases
  • Indications for Maze:
    • Recent onset, paroxysmal, small LA
  • Long term prognosis probably related to recurrence of infection and reliability of patient