Simultaneous Cardiac Surgery for Infective Endocarditis and Liver Transplantation in End-Stage Liver Disease

Abstract

Background

Concurrent infective endocarditis (IE) and end-stage liver disease present significant perioperative challenges due to overlapping clinical risks.

Case Summary

A 53-year-old man presented with decompensated cirrhosis and IE characterized by severe aortic regurgitation and vegetation extending into the aortomitral curtain. He underwent a complex, yet successful, simultaneous orthotopic liver transplantation and cardiac surgery, which included double valve replacement and reconstruction of the aortomitral curtain using a patch repair.

Discussion

Simultaneous cardiac and liver surgery is rarely performed because of overlapping risks of morbidity. This case illustrates the feasibility and potential benefit of a multidisciplinary, single-stage approach in select high-risk patients.

Take-Home Message

Concurrent orthotopic liver transplant surgery and double valve replacement with aorticmitral curtain patch reconstruction for IE can be feasible in very select cases, with successful outcomes hinging on close multidisciplinary collaborations.

Graphical Abstract

Managing patients with end-stage liver disease (ESLD) who also present with infective endocarditis (IE) requiring cardiac surgery presents a rare and formidable clinical challenge. These patients face heightened perioperative risks because of the combined burden of advanced hepatic dysfunction and active cardiac infection.¹ Cardiac surgery for IE, in this case, a double valve replacement and aortomitral curtain patch reconstruction, carries significant risk in patients with ESLD, including severe mediastinal bleeding, coagulopathies, vasoplegia, and profound immunosuppression. On the other hand, proceeding with liver transplantation in the setting of active endocarditis can precipitate decompensated heart failure, cardiogenic shock, and early graft failure due to inadequate hemodynamic support. These reciprocal risks render a staged surgical approach untenable, highlighting the critical need for a carefully coordinated, single-stage operative strategy. Despite the complexity, literature on the feasibility and outcomes of concurrent cardiac surgery using the double valve replacement with patch reconstruction of the aortomitral curtain and liver transplantation in this context is sparse. Herein, we present a novel case of a patient with ESLD and IE who successfully underwent combined orthotopic liver transplantation and complex cardiac surgery. To our knowledge, this represents the first reported case of its kind.

History of Presentation

The patient is a 53-year-old man who transferred to our facility for higher-level care from an out-of-country facility. He had presented to the outside facility with fever, abdominal pain, dark stool, dark urine, and lethargy. On examination, he was noted to be jaundiced, hypotensive, hypoxic, and with altered mentation. He was diagnosed with an upper gastrointestinal bleed, acute heart failure, and decompensated cirrhosis. He was admitted and treated with oxygen, intravenous fluids, blood products, and piperacillin-tazobactam. After being stabilized, he self-transferred to our facility for advanced care.

Past Medical History

The patient had a medical history of coronary artery disease and alcoholic liver cirrhosis complicated by esophageal varices and hepatic encephalopathy. He was taking atorvastatin, rifaximin, lactulose, furosemide, and spironolactone.

Investigations

Laboratory test results were significant for blood urea nitrogen 35 mg/dL, creatinine 1.31 mg/dL, total bilirubin 22.7 mg/dL, direct bilirubin 16.5 mg/dL, aspartate transaminase 56 U/L, alanine transaminase 29 U/L, alkaline phosphatase 251 U/L, albumin 1.9 g/dL, hemoglobin 8.4 g/dL, platelet count 42,000/μL, and international normalized ratio 1.8. The white blood cell count was within normal limits. He had a Model for End-Stage Liver Disease score of 33. A computed tomography head showed no significant intracranial abnormalities, and a computed tomography chest, abdomen, and pelvis demonstrated multifocal pneumonia, cirrhosis, splenomegaly, and a small volume of ascites.

Upper endoscopy revealed grade 1 esophageal varices and a Dieulafoy's lesion along the greater curvature below the gastroesophageal junction. For this, 2 clips were placed to achieve hemostasis. A transesophageal echocardiogram demonstrated an ejection fraction of 55% to 59%, severe aortic valve regurgitation with holodiastolic flow reversal in the descending aorta, a thickening/vegetation of the noncoronary cusp causing a flail leaflet and possible perforation, a large 1.2 × 1.3 cm mobile echodensity at the base of the anterior leaflet of the mitral valve and extending to the aortomitral curtain, and a 0.7 × 0.4 cm echodensity attached to the P2 scallop (Figures 1 and 2). Simultaneously, an ultrasound of the abdomen revealed calculus cholecystitis, concomitant choledocholithiasis, and ascending cholangitis.

Figure 1.

Transesophageal Echocardiogram Views Showing a Bicuspid Aortic Valve With Vegetation and Severe Regurgitation

Mid-esophageal transesophageal echocardiographic views of the aortic valve demonstrating a bicuspid morphology with fusion of the left and right coronary cusps. The noncoronary cusp shows leaflet thickening with vegetation, flail motion, and probable leaflet perforation, resulting in severe transvalvular aortic regurgitation.

Figure 2.

Transesophageal Echocardiogram Views Showing Vegetations on the Mitral Valve

Mid-esophageal transesophageal echocardiographic views demonstrating a 1.2 × 1.3 cm mobile echodensity at the base of the anterior mitral leaflet, contiguous with thickening over the aortomitral curtain. An additional 0.7 × 0.4 cm mobile echodensity is visualized attached to the P2 scallop of the posterior mitral leaflet, consistent with vegetations.

Management

Blood cultures were positive for Enterobacter cloacae and Klebsiella, likely from gut translocation due to liver failure. Antibiotics were escalated from piperacillin/tazobactam to meropenem. Despite treatment, the patient continued to decline clinically, developing coagulopathy, decompensated cirrhosis, and pulmonary edema from severe aortic and mitral regurgitation. Mechanical circulatory support was not feasible because of aortic insufficiency.

After several multidisciplinary meetings, including the transplant committee and family discussions, the patient was ultimately determined to be a candidate for combined cardiac surgery and an orthotopic liver transplant. He was listed for liver transplantation on hospital day 5, with a donor identified 4 days later. Given the severity of his valvular disease, liver transplantation was deemed unlikely to be tolerated before cardiac surgery. Intraoperative transthoracic echocardiography revealed an aortic root abscess and mitral valve endocarditis. After excising the native aortic valve via an aortotomy, a large abscess cavity was identified at the left and noncoronary annulus, extending into the aortomitral continuity, without fluid collection. On the basis of these findings, the surgical team proceeded with the reconstruction of the aortomitral continuity and left atrial dome, along with double valve replacement. A large, 6 × 2 cm bovine pericardial patch was sewn to the aortic valve annulus and aortomitral continuity. Bioprosthetic valves were preferred for both replacements because of anticoagulation concerns. Without liver transplantation, ongoing coagulopathy would have made mechanical valves risky because of the bleeding risks associated with the required anticoagulation. Even after transplant, the presence of esophageal varices and the potential for future abdominal surgeries posed significant anticoagulation challenges, further supporting the choice of bioprosthetics.

The postprocedure transesophageal echocardiogram demonstrated well-seated bioprosthetic valves, an intact bovine pericardial patch on the aortomitral curtain, a left ventricular ejection fraction of 45%, and mild-to-moderate right ventricular dysfunction. Because of coagulopathy, delayed sternal closure was planned. The donor liver was procured and transported on the TransMedics Organ Care System to minimize cold ischemic time. Once the cardiac surgery was completed and the patient stabilized, the liver transplant proceeded immediately. The out-of-circulation time for the donor liver was 15 hours and 18 minutes. The liver transplant was performed immediately after the cardiac surgery because of vasoplegia attributed to liver failure, which resolved upon liver reperfusion. On postoperative day 2, the patient underwent delayed sternal closure and exploratory laparotomy for wound washout and biliary reconstruction.

Follow-Up

The patient completed his course of antibiotics and was discharged stable on postoperative day 15, after a 28-day total hospitalization stay, on prophylactic medications, including trimethoprim/sulfamethoxazole, valganciclovir, nystatin, and tacrolimus, to a rehabilitation facility. A follow-up after 1 month showed progressive improvement in symptoms. He continued with cardiac rehabilitation and follow-ups with cardiology and the liver transplant team.

Discussion

Surgical intervention is required in approximately 40% to 50% of IE cases, often due to heart failure, uncontrolled infection, or risk of embolism.² In this case, a double valve replacement with patch reconstruction of the aortomitral curtain was performed. This is unlike the more extensive and higher-risk commando procedure, which entails en bloc removal of both the aortic and mitral valves, along with the complete excision of the aortomitral curtain.^3,4 In contrast, this patch and repair method emphasizes targeted reconstruction, preserving as much of the native structure as possible while maintaining structural integrity. This technique also minimizes surgical complexity, ischemic time, and postoperative morbidity.

IE in liver transplant recipients is associated with high mortality rates, reaching 43.5%.¹ For patients with liver disease and IE undergoing valvular surgery, hepatic impairment significantly increases postoperative morbidity and mortality. Cirrhotic patients are at an elevated risk for complications such as cardiogenic shock, acute kidney injury, thrombocytopenia, and in-hospital mortality due to coagulopathy, malnutrition, immune dysfunction, and multiorgan involvement.⁵ In addition, liver transplantation demands an adequate cardiac reserve to withstand its hemodynamic stress, making management of valvular disease in this population particularly complex.⁶

We faced a similar challenge while managing this patient. In such complex situations, combined cardiac surgery and liver transplantation have been shown to be beneficial for those ineligible for either procedure alone due to hepatic or cardiac dysfunction.⁷ This approach has demonstrated relatively lower mortality rates and acceptable early and midterm survival when performed in high-volume centers with multidisciplinary teams.⁸ Given the severity of this patient's valve disease from IE, valve replacement alone was insufficient, and a double valve replacement with aortomitral curtain reconstruction was the most appropriate option.

As of the end of 2023, approximately 54 case reports have described combined cardiac surgery and liver transplant, including standard valve replacement; however, none have involved patch reconstruction of the aortomitral curtain.⁹ The treatment for this patient was, therefore, highly individualized. Despite his medical complexity and high procedural risk, factors such as his relatively young age, high functionality, active lifestyle, and nearly 20 years of sobriety with active Alcoholics Anonymous participation supported favorable outcomes.

Therefore, a comprehensive multidisciplinary assessment is necessary to guide management in such complex cases, particularly when the patient exhibits positive prognostic indicators. Albeit the intricate nature of such a combined surgical procedure, careful planning of surgical timing and sequence, along with meticulous perioperative management, is essential to ensure procedural success and optimal patient outcomes.

Conclusions

This case highlights the double valve replacement with patch reconstruction of the aortomitral curtain as a safe and effective intervention for select complex patients with IE requiring valvular replacement and cardiac surgery, including those with ESLD who require a simultaneous liver transplant. Detailed discussions with the patient and their family regarding the associated risks are necessary before proceeding with the surgery. Further research is needed to better understand the outcomes and refine the management strategies for such patients.

Take-Home Messages

• •A double valve replacement with patch reconstruction of the aortomitral curtain is an effective treatment option for select complex patients with infective endocarditis and end-stage liver failure.
• •Early diagnosis and multidisciplinary collaborations are crucial in decision-making and ultimate operative success of these patients.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.