infective endocarditis ( ie ) is a disease caused by infection of the inner layer of the heart wall , i.e. , the endocardium .
it develops in the heart valves ( most frequently in the aortic valve ) , ventricles , and atria [ 1 , 2 ] .
infective endocarditis related to an implanted foreign body ( a stimulator electrode or a cardioverter - defibrillator ) should also be mentioned when discussing this matter .
congenital heart defects , previous rheumatic diseases , and mitral valve prolapse syndrome constitute factors predisposing to ie [ 1 , 2 ] . individuals dependent on intravenous drugs or subjected to medical procedures requiring long - term vascular access ( chronic hemodialysis , chronic parenteral nutrition , prolonged intensive care unit ( icu ) stay ) are at risk of developing ie [ 4 , 5 ] .
infective endocarditis simultaneously affecting the left and right side of the heart occurs in approximately 15% of cases .
prosthetic valve endocarditis ( pve ) constitutes 1040% of the total number of ie cases [ 1 , 2 , 7 ] .
this paper presents the case of a patient requiring implantation of aortic , mitral , and tricuspid valve bioprostheses as a result of ie and reimplantation of the aortic valve bioprosthesis on the 46 day after the initial surgery due to ie recurrence .
the aim of this study is to present the case and assess the treatment results of a patient requiring implantation of three valve bioprostheses due to ie ; the procedure was complicated by the necessity to replace the aortic valve prosthesis because of pve .
a 19-year - old patient was admitted to a toxicology ward with significant sleepiness and unclear speech in the middle of a drinking bout which had lasted for the previous 3 months ; he had been addicted to alcohol for the past 5 years as a result of  as he claimed  mitigating the symptoms of tourette syndrome .
after several days , the patient started exhibiting clinical symptoms of pneumonia with rapid deterioration of his general condition ; he required intubation and continued mechanical ventilation .
the patient was transferred to the intensive care unit of the jzef stru city hospital in poznan .
after admission , he was intubated , mechanically ventilated , and sedated with a continuous infusion of midazolamum and fentanyl .
transthoracic echocardiography ( tte ) revealed grade 4 mitral insufficiency , the presence of 1.2  1.6 cm vegetation on the anterior cusp with rupture of the tendinous cords of this cusp , and vegetation 1.0 cm in length on the posterior cusp .
the cusps of the aortic valve exhibited features of marginal thickening with the presence of vegetation and grade 1 insufficiency .
the tricuspid valve was insufficient with a grade 1 central regurgitation jet and suspected vegetation .
empiric antibiotic therapy was applied ( imipenem , vancomycin , clindamycinum ) , even though bacteriological analysis of venous blood , urine , and bronchial secretions showed them to be sterile .
dental consultation revealed the presence of numerous inflammatory foci in the oral cavity , which resulted in the extraction of 8 carious teeth .
after 7 days of antibiotic therapy , due to the presence of mobile vegetations on the valves and the associated risk of embolization , the patient was transferred to an operating room at the cardiac surgery ward .
the surgical procedure was performed using extracorporeal circulation ( ecc ) via a median sternotomy .
the ascending aorta was cannulated ; venous cannulas were placed in the caval veins via the right atrium .
after aortic cross - clamping and the administration of a crystalloid cardioplegic solution into the coronary ostia , the right ventricle was opened , and the tricuspid valve was removed .
subsequently , the interatrial septum was incised , and the bicuspid valve was removed ; the aortic valve was removed through the incision in the aorta .
all three removed valves exhibited features of dysfunction in the form of insufficiency , cusp perforation , and vegetation . during the next stage of the operation , single sutures on teflon pledgets were used to implant the valve bioprostheses : medtronic hancock ii porcine 29 in the mitral position , edwards lifesciences c - e perimount 21 in the aortic position , and medtronic hancock ii porcine 33 in the tricuspid position . according to the literature
, pve occurs as frequently on biological as on mechanical prostheses [ 3 , 8 ] , but because of the patient 's alcoholism and the resulting high risk of non - adherence to anticoagulation therapy , a decision was made to implant biological valve prostheses .
aortic cross - clamping time was 161 minutes , ecc time was 224 minutes , and total surgery time was 340 minutes .
the patient was transferred to a recovery room in good general condition , hemodynamically stable , requiring moderate doses of catecholamines . on the third postoperative day , after the mediastinal drains were removed , the intubated and mechanically ventilated patient was transferred to the intensive care unit .
the cultures from blood ( drawn twice ) and from all the valves removed during surgery were sterile , but antibiotic therapy was continued regardless . on the 14 day of icu
the patient was transferred to the cardiology ward , where he was diagnosed with sepsis confirmed by numerous bacteriological tests .
pseudomonas aeruginosa ( > 1000 000 colony forming unit ( cfu)/ml ) was cultured from the tip of the central venous catheter , urine , and bronchial secretions .
similar results were obtained in the culture tests of peripheral venous blood ( drawn several times ) . targeted antibiotic therapy
no clinical improvement of the patient 's condition was achieved ; the fever and weakness did not subside .
transesophageal echocardiography ( tee ) revealed the presence of vegetation on the aortic valve bioprosthesis .
computed tomography ( ct ) of the chest , head , and abdomen as well as x - ray of the chest did not show any features of inflammatory lesions or metastatic abscesses .
after echocardiographic examination and cardiac surgical consultations , a decision was made to replace the previously implanted aortic valve bioprosthesis .
on the 46 day after the initial surgery , the patient was once again transferred to an operating room .
after connecting the patient to ecc , aortic cross - clamping , and the administration of cardioplegia to the coronary ostia , the right atrium and the interatrial septum were opened in order to check the condition of the mitral and tricuspid bioprostheses ; no vegetation was found .
after the aorta was opened , a conglomerate of vegetation was revealed on the non - coronary cusp of the subsequently removed aortic valve bioprosthesis .
an edwards lifesciences c - e perimount 21 aortic valve bioprosthesis was reimplanted in its stead .
aortic cross - clamping time was 92 minutes , and ecc time was 140 minutes .
the patient was then transferred to a recovery room in stable condition , where he was extubated after 19 hours .
pseudomonas aeruginosa was cultured from the aortic valve bioprosthesis removed during surgery , while bacteriological tests of blood drawn several times in the postoperative period were sterile .
on the 12 day after reoperation , the patient was transferred in good condition to a cardiac rehabilitation hospital with a recommendation to continue oral anticoagulation for 3 months and antibiotic therapy .
control echocardiographic examination , conducted on the 30 day after leaving the cardiac surgery ward , revealed normal function of all the bioprostheses .
the so - called modified duke criteria are applied for diagnosing ie [ 1 , 2 , 9 ] .
the minor criteria include the existence of a heart condition or other causes predisposing to ie ( drug addiction , chronic hemodialysis , prolonged icu stay ) , fever over 38c , vascular phenomena ( arterial emboli , septic pulmonary infarcts ) , and immunological phenomena ( osler 's nodes , roth 's spots , glomerulonephritis , hemorrhages ) . in order to diagnose ie
, two major , one major and three minor , or five minor criteria need to be met ; however , tee still remains the conclusive examination , with a sensitivity and specificity of approximately 95% .
the patient was in the small group of cases with lesions in three heart valves requiring surgical treatment .
the authors have experience in conducting this type of procedure . there were no complications during or directly after surgery .
unfortunately , so - called early left - sided prosthetic valve endocarditis ( pve within the first postoperative year ) occurred some days after the operation .
patients reoperated due to pve constitute 1040% of all cases of ie [ 1 , 2 , 7 ] .
the risk increases to 1520% if the multiple - valve defect is caused by ie [ 6 , 12 , 13 ] . in 2013 , there were 111 procedures involving three valves in poland , with a hospital mortality of 13.51% .
this is why echocardiographic assessment ( mainly tee ) is so important in cases of ie , as a decision concerning the implantation of more than one prosthetic valve is of great importance for the patient .
 the patient was admitted to the department of cardiac surgery of the j. stru city hospital in poznan due to infective endocarditis involving the aortic , mitral , and tricuspid valves . 
 implantation of three biological valve prostheses proceeded without complications . 
 starting on day 23 , the patient 's general condition deteriorated , with high fever . despite postoperative antibiotic therapy , 
 transesophageal echocardiography revealed the presence of vegetation on the bioprosthetic aortic valve . on the 46th day after the initial surgery , 
 the patient required replacement of the aortic bioprosthesis , which exhibited the presence of numerous vegetations . 
 the bioprosthetic mitral and tricuspid valves were not affected by the degenerative process . on the 12th day after the reimplantation of the bioprosthetic aortic valve , 
 the patient was discharged from the hospital in good general condition . 
Introduction
Case report
Discussion
Disclosure