I nfective endocarditis (IE) remains a dangerous condition that carries substantial morbidity and a 1-year mortality rate approaching 30%.1 Surgery is potentially life-saving 2 and is essential in 25% to 30% of patients during acute infection and in 20% to 40% during convalescence.3 Although early surgical intervention can improve survival prospects in patients who have severe complicated IE, 4 hemodynamic failure is a strong predictor of operative death.5 Consequently, careful consideration is crucial in advance of high-risk surgery for patients with IE, and it is often provocative of controversy. Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass technique that provides life support for patients with cardiac or respiratory failure by maintaining perfusion and oxygenation as a bridge to definitive therapy, or until native-organ function can be restored. Reports have described the use of ECMO for severe cardiogenic shock, for postcardiotomy shock, and (as an additional tool) for resuscitation from cardiac arrest. 6 There is evidence for the use of ECMO in sepsis, but not in the presence of the mechanical sequelae of endocarditis. 7 We report what we think is the first case of successful ECMO use to stabilize an adult patient who presented with cardiopulmonary collapse from aorto-atrial fistula (AAF) secondary to native-valve IE.
Case ReportIn October 2013, a 35-year-old male intravenous-drug user presented with a oneweek history of fatigue, chest pain, dyspnea, orthopnea, and right-foot pain. He needed urgent intubation, mechanical ventilation, and vasopressors for cardiopulmonary collapse. Physical examination revealed jugular venous distention, rales, a grade 4/6 systolic murmur, a loud diastolic murmur, and a painful erythematous lesion below the medial malleolus on the right foot consistent with an Osler's node (Fig. 1). Laboratory findings included leukocytosis and lactic acidosis. Urine toxicology results were positive for opiates, and blood cultures grew viridans streptococcus. The patient was started on ampicillin and ceftriaxone antibiotic agents on the basis of his blood culture and sensitivity results.A transthoracic echocardiogram (TTE) revealed a 2 × 1.5-cm vegetation on the anterior leaflet of the mitral valve (MV), together with moderate mitral regurgitation and aortic insufficiency (AI). Left ventricular systolic function was preserved. A subsequent transesophageal echocardiogram (TEE) showed a bicuspid aortic valve, the mobile echodensity of which was continuous with the echodensity of the MV (Fig. 2A); further, an aortic root abscess involved the left sinus of Valsalva, which had ruptured into the left atrium, as revealed by color-flow Doppler TEE (Fig. 2B). There was also evidence of a patent foramen ovale (PFO), with left-to-right flow. The patient
