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Interact CardioVasc Thorac Surg 2008;7:138-140. doi:10.1510/icvts.2007.163014 © 2008 European Association of Cardio-Thoracic Surgery
Splenic rupture complicating aortic valve replacement for bacterial endocarditis
a Department of Cardiothoracic Surgery, University Hospital of Wales, Heath Park, Cardiff, UK Received 19 July 2007; received in revised form 28 October 2007; accepted 30 October 2007
*Corresponding author. Tel.: +44 29 2074 7747; fax: +44 29 2074 7747.
We present a rare case of bacterial endocarditis of the aortic valve complicated by intracranial haemorrhage, splenic and renal infarcts. Aortic valve replacement was complicated by delayed splenic rupture. The successful surgical management of this case is described as well as a review of the literature.
Key Words: Splenic rupture; Endocarditis; Stroke; Valve replacement
A 31-year-old female presented with sudden onset headache, hemianopia and collapse. Neurological examination revealed a left-sided hemianopia and a cranial computerised tomographic (CT) scan demonstrated a right occipital haemorrhage with mass effect (Fig. 1). She was then transfused with platelet concentrate because of a low platelet count. An echocardiogram showed severe aortic valve regurgitation with large vegetations, and blood cultures were positive for staphylococcus aureus thus confirming the diagnosis of bacterial endocarditis. A CT head angiogram excluded active bleeding and showed a relative paucity of vessels around the brain haematoma and no evidence of any intracranial mycotic aneurysm. A CT chest and abdomen (Fig. 2) showed a large splenic infarct as well as bilateral renal infarcts.
The patient was transferred to the department of cardiac surgery four days after the onset of symptoms and was in cardiac failure with New York Heart Association class IV dyspnoea, hypotensive on no inotropic support. Cardiac surgery was indicated due to haemodynamically severe aortic regurgitation and to prevent further embolic events because of large persistent vegetations on the aortic valve. An aortic valve replacement with a cryo-preserved aortic homograf (21 mm; sub coronary technique) was done and at that time she had been on intravenous antibiotics for three days. The predictive operative mortality was a logistic EuroSCORE of 23% (additive EuroSCORE 10%). Histological sections of the aortic valve demonstrated destructive valvulitis due to bacterial endocarditis. Postoperatively she was haemodynamically stable, extubated within the first 6 h and transferred to the ward on the 3rd postoperative day. Postoperative management included continued organism sensitive intravenous antibiotics and no anticoagulation because of the persistent left-sided hemianopia in order to prevent any recurrence of intracranial haemorrhage. On the 17th postoperative day, although she had a normal coagulation profile and was not on warfarin, she suddenly developed hypovolemic shock with tachycardia, hypotension associated with severe abdominal pain, and without further imaging examinations was taken urgently to theatre for exploratory laparotomy. Intra-peritoneal bleeding due to ruptured splenic infarct was found at surgery necessitating splenectomy and packing of the splenic bed was required due to diffuse bleeding. Removal of the surgical swabs and delayed closure of the wound was performed 48 h later. She made a slow postoperative recovery; required ultrasound guided drainage of a pelvic collection, and was discharged home on the 35th postoperative day. One and half years later she remains well.
Cerebrovascular events are not an uncommon presentation in patients with bacterial endocarditis and in one series was noted in 28.5% of patients undergoing cardiac surgery [1]. The perioperative mortality risk is 1.7-fold higher and the long-term mortality risk 1.23-fold higher in stroke patients in comparison to patients without stroke [1]. There is no consensus as to the ideal timing of cardiac surgery, if indicated. The initial priority to date has been to establish whether the patient has suffered a haemorrhagic or more commonly ischemic stroke. Delaying surgery for as long as three weeks has been advocated by Gillinov et al. [2] whereas Horstkotte et al. [3] suggest that early operative intervention within 72 h of presentation is warranted in patients with thromboembolic events. Patients with complicated stroke (haemorrhage, meningitis or brain abscess) have a high operative mortality; 38.9% vs. 8.5%, but in this series there was no increased risk of further neurological complications when compared to patients with uncomplicated stroke [1]. Complete neurological recovery can be expected in up to 57% of survivors [1]. Therefore, the risk of further cerebral haemorrhage as a result of cardiac surgery seems to be an acceptable low-risk [1]. Splenic involvement is a well-known complication of infective endocarditis and splenic rupture was first reported in 1919 by Lake et al. [4], and may occur in patients not undergoing surgery but who have been anticoagulated with warfarin or heparin. At least 22 deaths have been reported in the literature in the 38 reported cases of splenic rupture in infective endocarditis patients (with or without valve replacement) thus a mortality rate approaching 58% [5]. In one case report a 61-year-old developed splenic rupture on the 11th postoperative day after mitral valve replacement and he was successfully treated with splenic arterial embolization followed by splenectomy [6]. There are three pathophysiological mechanisms of splenic rupture in bacterial endocarditis: rupture of a mycotic aneurysm, rupture of a suppurating intrasplenic vessel with haematoma formation, subcapsular dissection, delayed capsular tear, or rupture of a splenic abscess. Splenic abscess may arise as a result of occlusion of a splenic vessel by embolized vegetations, associated bacteraemic seeding or by direct seeding of the spleen by an infected embolus [7]. In a series of 20 patients (from 108 with left sided endocarditis and valvular surgery) with infectious endocarditis requiring valve replacement complicated with splenic infarcts and abscesses, 50% underwent splenectomy post cardiac surgery with an associated perioperative mortality of 30%. Indications for splenectomy included persistent sepsis, large lesions over 2 cm or peripheral lesions and splenic rupture. The one patient who developed splenic rupture post cardiac surgery succumbed to uncontrollable haemorrhage from the splenic bed intra-operatively [8]. Spontaneous splenic rupture with fatal outcome in patients with infective endocarditis can also occur despite early antibiotic treatment and surgical replacement of the affected valves. Splenic rupture should be included in the differential diagnosis of postoperative abdominal pain following cardiac surgery as it is not only a recognised complication of bacterial endocarditis but has also been described following intraoperative trans-oesophageal echocardiography due to laceration of the splenic hilum [9] and as a complication of acute pancreatitis after coronary artery bypass surgery [10]. The literature suggests that patients with splenic infarcts secondary to bacterial endocarditis are at risk of delayed splenic rupture. However, there is no definitive guidelines on the indications for elective splenectomy once diagnosed. It is generally accepted that splenic infarcts that are asymptomatic small or centrally located do not require specific therapy. If the splenic infarcts progress to an abscess then splenectomy should be the indicated therapy due to the high risk of splenic rupture. In case of large and peripherally located splenic infarcts it is necessary to observe them with abdominal CT scans even if they are asymptomatic.
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Abstract
1. Case report
