Mitral stenosis and cardiogenic shock from an obstructive abscess of the mitral annulus

Abstract

E ndocarditis may be responsible for heart failure and some cases of cardiogenic shock, usually by causing valvular insufficiency. Deep tissue invasion by endocarditis may result in abscesses, which may degenerate into fistulas and dehiscence. We report a case of cardiogenic shock due to an obstructive annular abscess from mitral endocarditis. CASE PRESENTATIONA 48-year-old female hemodialysis patient presented after three weeks of worsening intermittent chest pain and hypotension during dialysis. She also complained of 24 h of fever and chills. Her history included a failed renal transplant 12 years earlier and an inferior myocardial infarction one year previously.For three weeks, the patient had been experiencing episodic retrosternal chest discomfort while undergoing dialysis. These episodes were associated with transient decreases in blood pressure. On the day before admission, the patient experienced further retrosternal chest pain. She was found to be febrile (39°C), and an electrocardiogram demonstrated new T wave inversion in leads V4 through V6. Troponin I was marginally elevated (0.13 μg/L). The patient discharged herself against medical advice, but returned to hospital the following day, when she was informed that her blood cultures were growing Gram-positive cocci.On admission, her temperature was 40.3°C and her blood pressure was 85/50 mmHg. There was a mid-systolic ejection murmur and a holosystolic murmur radiating to the apex. Her white blood cell count was elevated (14×10 9 /L) with neutrophilia. Her troponin I level had become significantly elevated (2.29 μg/L).During the first seven days of admission, the patient experienced intermittent chest pain. Her blood pressure remained stable, but the mild fever persisted. The initial echocardiogram revealed nonspecific, small mitral echo-densities and increased mitral annular lucency, but no obvious vegetations. There was prominent submitral calcification ( Figure 1). No probable evidence of infection was present on vascular ultrasound examination of the right arm fistula. Transesophageal echocardiography (TEE) and other tests were refused by the patient. Cephalosporin-sensitive Staphylococcus aureus was speciated from the blood cultures, and antibiotic therapy was changed from empirical vancomycin to cefazolin.On the eighth day of hospitalization, the patient's condition abruptly deteriorated, with the development of severe hypotension and the onset of pulmonary edema. The hypotension was notably worsened by aggressive ultrafiltration. A repeat transthoracic echocardiogram revealed a large and complex mass involving the mitral annulus and valve from the posterior aspect. The submitral calcification had displaced anteriorly into the left heart and rocked posteriorly with the ventricular systole, akin to dehiscence of a mitral prosthesis. The mitral annulus contained a large, thin-walled lucent cavity consistent A 48-year-old female hemodialysis patient with Gram-positive mitral endocarditis developed progressive hemodynamic collapse. Echocardiography ...

A Simplified Point-of-Care Echocardiographic Method to Detect Critical Mitral Stenosis in the Patient with Undifferentiated Acute Pulmonary Edema

“…When acute pulmonary edema is identified by lung ultrasound, but the point-of-care echocardiography does not reveal clear systolic or diastolic dysfunction, evaluation of the mitral valve should be considered [3][4][5][6][7]. Color Doppler evaluation of valvular pathology has been demonstrated to be accurate when assessing patients in the echocardiography lab [8].…”

“…When acute pulmonary edema is present, but point-of-care echocardiography does not demonstrate systolic or diastolic dysfunction, evaluation of the mitral valve should be performed [3][4][5][6][7]. Mitral stenosis, the obstruction of left ventricular inflow at the level of the mitral valve, is typically a progressive process that can lead to acute decompensation.…”