A 37-year-old male with an active history of IDU and alcoholism presented with a two day history of low-grade fever and an episode of massive hemoptysis. The hemoptysis was characterized as being bright red in color and approximately 350 mL in volume. Surgical history was significant for open-heart surgery two years prior for tricuspid valve replacement due to infective endocarditis. On admission, he was febrile (38.4  C), but hemodynamically stable. On general inspection, the patient was jaundiced with a visible sternotomy scar on the chest. Basal lung crackles were appreciated on auscultation.
The patient was admitted with the impression of recurrent IE versus tuberculosis or pneumonia as top differentials. Laboratory results were remarkable for anemia with a hemoglobin level of 8 g/dL, prolonged prothrombin time at 16.8 s, elevated C-reactive protein (CRP) level at 160.5 mg/L, elevated erythrocyte sedimentation rate (ESR) at 90 mm/h and elevated serum procalcitonin at 4.49 ng/mL. Blood cultures grew Staphylococcus aureus colonies. Serologic tests were positive for hepatitis B virus (HBV) and hepatitis C virus (HCV), but negative for human immunodeficiency virus (HIV). A chest x-ray showed patchy areas of reticulation with ground-glass opacities in both lower lung zones and mild obliteration of the left costophrenic angle (Fig. 1). An echocardiogram was obtained and showed normal systolic function, normal ejection fraction of 55-60% and no regional wall motion abnormality. Remarkable findings included multiple vegetations attached to the tricuspid bio-prosthesis, the largest of which was attached to the valve ring on the ventricular side measuring 25 mm in length. Moreover, another mobile vegetation was attached to the right ventricular outflow tract wall measuring 20 mm in length. Computed tomography (CT) of the chest revealed a 2.7x2.4 cm lobulated lesion in the right lower lung lobe, with an iso-dense attenuation to the contrast medium and apparent topographic continuity with the pulmonary vessels (Fig. 2). The diagnosis of recurrent infective endocarditis of the tricuspid valve with ruptured right lower lobe pulmonary pseudoaneurysm was made.
A multi-disciplinary team meeting was convened, and it was decided to manage the case with coiling of the pulmonary artery aneurysm followed by a redo tricuspid valve replacement. Two days into the admission, the patient successfully underwent aneurysm coiling by interventional radiology through a right transfemoral approach, using the Seldinger technique with an 18G needle and subsequent insertion of a 5F arterial sheath. Coils (Interlock , Boston Scientific) were inserted into the aneurysm and stasis was achieved (Fig. 3). Eight days later, the patient underwent scheduled open cardiac surgery under general anesthesia for a re-do tricuspid valve replacement. Intracardiac vegetations were found on the previously implanted artificial tricuspid valve and two other larger ones on the ventricular aspect. The whole 29 mm prosthetic valve (Pericarbon More, Sorin Group) was removed along with the vegetations (Fig. 4) and replaced with a 27 mm biological valve (MOSIAC 310 CINCH, Medtronic). The valve was secured to the anulus by a 2/0 non-absorbable suture (polyester suture) and closure of the right atriotomy was achieved using a 4/0 suture (polyester suture), followed by removal of the aortic cross clamp. The patient was subsequently weaned off cardiopulmonary bypass with no complications and transferred to the cardiac care unit in stable condition. Post-surgery, the patient had a normal sinus rhythm with a heart rate of 80/ minute and blood pressure of 110/70 mmHg, and he was started on gentamicin, cefazolin and rifampicin for six weeks. After 14 days, patient recovered successfully, and his laboratory tests were within reference range (CRP 0.40 mg/L, ESR 35 mm/h, procalcitonin <0.02 ng/mL) and was subsequently discharged after clinical and radiological improvement. He was followed up in the cardiac surgery clinic, and enrolled in a rehabilitation program to manage his drug addiction. After one year of follow-up, the patient is currently doing well from a clinical standpoint, no recurrence of hemoptysis or fever. Follow-up by echocardiograph and chest x-ray showed no vegetations, good cardiac function and no changes or issues were noted with the intra-aneurysmal coils.