Transcatheter Aortic Valve Implantation for Severe Aortic Insufficiency Due to Infective Endocarditis in a Patient with Cirrhosis and Hepatocellular Cancer: A Novel Indication

Abstract

Infective endocarditis (IE) of the native aortic valve (AV) secondary to Streptococcus infantarius is subacute, a highly destructive pathology leading to aortic regurgitation (AR) and severe cardiac complications such as progressively deteriorating heart failure. In these cases, valvular correction with surgery may not be the optimal option because of multiple chronic illnesses and the use of medications. Although transcatheter AV implantation (TAVI) is a well-known, established alternative method to surgical replacement in patients with severe aortic stenosis, it can be a good alternative in patients with severe AR in whom valvular surgery is not an option due to comorbidities. Here, we presented a case of TAVI in a patient with cirrhosis, hepatocellular cancer, and symptomatic severe AR due to S. infantarius IE.

INTRODUCTION

Streptococcus infantarius is a Gram-positive cocci belonging to the Streptococcus bovis/Streptococcus equinus complex (SBSEC)[1] and responsible for highly destructive subacute infective endocarditis (IE) in patients with colonic neoplasm, gastrointestinal lesions, diabetes, cirrhosis, and/or other chronic liver pathologies.[1,2] Sometimes, the treatment of SBSEC-related IE will become very challenging due to patient-related factors (underlying cirrhosis, gastrointestinal neoplasms, renal failure, and thrombocytopenia) and the progressive, destructive nature of the disease itself.[1,2]

The transcatheter aortic valve implantation (TAVI) is a well-known, established alternative to surgical replacement in patients with severe aortic stenosis.[3] Although the role of TAVI in chronic aortic regurgitation (AR) is limited due to the distorted anatomy of the aortic root, it has been used in patients with symptomatic severe AR that were not suitable for surgical intervention due to poor surgical outcomes.[3,4] In such particular cases, TAVI can be a life-saving procedure. Here, we reported a case of the TAVI performed for symptomatic severe AR developed secondary to IE in a patient with underlying cirrhosis and hepatocellular cancer.

CASE PRESENTATION

A 62-year-old male patient had a history of more than 5-year HBV-related liver cirrhosis, thrombocytopenia (<80 × 103/µL for the last 5 years); recurrent and progressive, single-lesion hepatocellular carcinoma of the right lobe. In addition, the patient had a history of percutaneous coronary intervention with six drug-eluting stents approximately 5 months before the admission. He had a history of two transarterial chemoembolizations of the hepatic artery (TACE) in the last 4 years and ultrasound-guided microwave ablation of the hepatic lesion two years ago before the admission. In his previous hepatology visit, the patient was referred to the echocardiography laboratory to perform elective echocardiographic examination as a part of routine cardiac assessment before the third TACE of the hepatic lesion with doxorubicin administration.

An echocardiographic exam of the patient showed that the right cusp of the aortic valve (AV) was thickened with a suspected small mass appearing during systole on the aortic side, and a small mobile liner structure appearing in the left ventricle outflow tract (LVOT) during diastole with mild-moderate AR and left ventricle ejection fraction (LVEF) of 56%. Urgent transesophageal echocardiography (TEE) exam showed a 7.0 mm × 2.0 mm highly mobile mass attached to the ventricular side of the tri-leaflet valve prolapsing into LVOT with warty localized swellings at the coaptation edges of the 3 cusps causing moderate AR (VTI of 42 ml and effective orifice area by PISA of 0.22 cm²) [Table 1].

Table 1.

Echocardiographic examination findings of the patient before and after the transcatheter aortic valve implantation procedure

	TEE or TTE	LVEF (%)	AI severity	ERO by PISA (cm2)	RV by VTI (mL)	Mass size (mm)
Day 1 after the diagnosis	TEE	56	Moderate valvular	0.22	42	7×2
Day 7	TTE	54	Severe valvular	0.40	65	7×4
Day 19	TTE	48	Moderate valvular	0.42	76	4×3
Day 31	TTE	48	Severe valvular	0.43	76	4×4
Day 42	TTE	45	Severe valvular
Day 44	TEE	43	Severe valvular
TAVI was performed 48 days after the diagnosis of IE
Post-TAVI Day 0	TTE	44	Mild paravalvular
Post-TAVI 2nd month	TTE	49	No insufficiency
Post-TAVI 4th month	TTE	48	No insufficiency
Post-TAVI 6th month	TTE	52	Trace-mild insufficiency

AI: Aortic insuffiiciency, ERO: Effective regurgitant orifice area, LVEF: The left ventricular ejection fraction, PISA: Proximal isovelocity surface area, RV: Regurgitant volume, TAVI: Transcatheter aortic valve implantation, TEE: Transesophageal echocardiography, TTE: Transthoracic echocardiography, VTI: Velocity-time integral, IE: Infective endocarditis

The patient had a history of only a 2-month cough without any other cardiac complaint or previous dental procedure. The patient reported having only one reading of a self-resolved body temperature of 37.7°C 2 weeks before the admission.

Blood cultures were performed in two sets (two sets consisting of a pair of aerobic and anaerobic bottles) of bottles containing 10 mL of blood each. Both sets showed the growth of S. infantarius (susceptible to ceftriaxone, and relatively resistant to penicillin). Intravenous antibiotic treatment was started for IE of the native AV. The plan included applying 2 g of intravenous ceftriaxone per day for 6 weeks. Concomitantly, he received 80 mg gentamicin every 8 h for 4 days following 3 doses of 1500 mg daily vancomycin as per the recommendations from the infectious disease department (ID) team. Following the last dose of gentamicin, the patient became oliguric then anuric, creatinine value jumped from a baseline value of 82 µmol/L to 502 µmol/L within 10 days starting from the first dose of gentamicin in addition to the development of pulmonary congestion. The patient required regular hemodialysis for 2 weeks as three times a week. Then, creatinine levels decreased and became stable at the level of stage 3b chronic kidney disease (glomerular filtration rate of 38 ml/min as per Cockroft–Gault formula).

During a 5-week hospital stay at the first admission, LVEF dropped from 56% to 48% and aortic regurgitation severity progressed from moderate to severe [Table 1] without fever or new blood culture growth. The patient was discussed in multidisciplinary team (MDT) meetings with respect to cardiac surgery but cardiac surgery was not recommended due to high-risk features (EuroSCORE II: 30.85% in addition to cirrhosis and persistent thrombocytopenia below 60 × 10³/µL during the hospital stay). The patient was stabilized with the help of medical treatment and discharged at the end of the 5^th week of the intravenous ceftriaxone treatment. He was recommended to complete it in 6 weeks as an outpatient.

The patient was readmitted to the hospital 3 days after the discharge due to the recurrence of congestive heart failure symptoms and signs (orthopnea, moderate pretibial edema, and bilateral pleural effusions) without fever. The new set of blood cultures was negative for bacterial growth. The new echocardiographic exam showed severe AR with an LVEF of 45% [Figure 1a]. After re-evaluation of the case in the MDT meeting, the TAVI was recommended. After getting the consent of the patient, pre-TAVI TEE [Figure 1b] and computed tomographic examination of the aorta [Figure 2a and b] were performed. Through 14F left femoral artery access, EvolutTM PRO + Transcatheter AV 29 mm was inserted over Safari wire with pacemaker-controlled pacing at 120 beats/min under intravenous ceftriaxone treatment and 48 days after the diagnosis of IE [Figure 3].

Figure 1.

Transthoracic continuous wave Doppler measurement over the aortic valve (a); transesophageal image of the aortic valve indicating severe aortic insufficiency (b)

Figure 2.

Computed tomographic examination of the aorta (a) and sinus valsalva (b) before the procedure

Figure 3.

The image from the transcatheter aortic valve implantation

Post-TAVI echocardiographic examination showed an AV maximum pressure gradient (PG) of 14.86 mmHg, AV mean PG of 7.22 mmHg, AV area of 2.5 cm² by continuity equation, and mild paravalvular AR.

The patient did not develop any complications during the procedure. As per the recommendation of the ID team, intravenous ceftriaxone treatment was extended to 8 weeks in total empirically. The pre-TAVI congestive heart failure signs and symptoms of the patients were relieved and the patient was discharged safely 1 week after the TAVI procedure. At the follow-up, the patient was free of cardiac complaints without any congestion, and post-TAVI 6^th-month echocardiography showed improvement in LVEF with trace-mild aortic valvular insufficiency [Table 1].

DISCUSSION

Here, we reported a TAVI case in a patient with comorbidities who developed symptomatic progressive severe AR due to S. infantarius IE. Since the patient had high mortality risk for cardiac surgery with multiple active underlying conditions (cirrhosis, hepatocellular cancer, and thrombocytopenia), the TAVI was the only option for the patient. Thus, the TAVI was performed successfully and the patient was discharged safely without any heart failure findings.

S. infantarius IE usually causes to subacute destructive native valve disease, especially in patients prone to have chronic hepatobiliary disease. Similarly, our patient had liver cirrhosis with hepatocellular cancer for more than 5 years and he developed severe AR. The source of bacteriemia is generally not obvious in these patients. Our patient had also no history of fever or obvious infection before the admission. SBSEC bacteremia, especially S. bovis biotype I, is related to colonic neoplasms. Our patient did not have colonic neoplasm in our case as per the electively performed colonoscopic examination.

The members of the SBSEC are very commonly seen in the bowel flora, the detection rate in human feces ranges from 5% to over 60%.[2] The mechanisms causing to IE are not clear but frequent gastrointestinal interventions, underlying chronic hepatobiliary diseases, old age, the immunity level of the host, and diet type may have a role in the disease development.[2,5] In our case, the patient had long-lasting cirrhosis with persistent, recurrent hepatocellular cancer with a history of multiple TACE and ablation.

The complications of S. infantarius IE are usually subacute, and highly destructive with large vegetations that lead to heart failure and embolizations[6] and these patients more frequently require cardiac valve surgery. In our case, the patient had single-valve involvement with progressive AR and developed progressively deteriorating congestive heart failure at the follow-up. Our patient had an indication for valve surgery due to the development of progressive symptomatic severe AR. However, the cardiac surgery was not recommended due to the high mortality rate. Thus, TAVI was the only option for the patient. The aortic anatomy was suitable for TAVI due to the presence of short-duration AR with proper aortic dimensions. Once the patient was out of heart failure at maximal medical therapy and free of active IE (nonembolic, stable vegetation size, and negative blood culture without fever), the TAVI was carried out successfully. Although there is no clear recommendation for post-TAVI antibiotic prophylaxis, we decided to extend intravenous ceftriaxone for 2 weeks more.

The TAVI is not a straightforward recommendation of the current guidelines for the treatment of pure AR. However, there are some studies and registries used TAVI for the treatment of pure AR or failing bioprosthesis.[7] We used TAVI for a progressively deteriorating heart due to progressive AR.

In conclusion, TAVI has been used in severe aortic stenosis and its usage in pure AR is limited. However, proper indication can make it a life-saving procedure in patients with severe AR and multiple co-morbidities. Here, TAVI was used for failing heart due to progressive AR at the setting of S. infantarius IE.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest

Funding Statement

Nil.