| Abstract|| |
We describe a very rare case of human brucella multivalvular endocarditis. Patient presented in a state of cardiogenic shock with low urine output and a history of breathlessness. Patient was diagnosed to have brucellosis 2 months back by blood cultures and agglutination tests and was receiving doxycycline and rifampicin therapy. Echocardiography showed severe aortic regurgitation, moderate mitral regurgitation, severe left ventricular dysfunction and a mobile vegetation attached to the aortic valve. Patient was scheduled for emergency surgery; while preparing for surgery hemodynamic monitoring, non-invasive ventilation and inotropic supports were started. During surgery, the aortic valve was found perforated and the aortomitral continuity was disrupted. Aortic valve replacement and mitral valve repair were performed. Hemofiltration was used during cardiopulmonary bypass. Weaning from bypass was achieved with the help of inodilators, dual chamber pacing and intra-aortic balloon pump.
Keywords: Aortic valve replacement; Brucellosis; Cardiogenic shock; Levosimendan
|How to cite this article:|
Kandasamy A, Ramalingam SK, Reddy BD, Krupananda H. Anesthetic and hemodynamic management of a rare case of Brucella multivalvular endocarditis in cardiogenic shock undergoing emergency aortic valve replacement and mitral valve repair. Ann Card Anaesth 2013;16:286-8
|How to cite this URL:|
Kandasamy A, Ramalingam SK, Reddy BD, Krupananda H. Anesthetic and hemodynamic management of a rare case of Brucella multivalvular endocarditis in cardiogenic shock undergoing emergency aortic valve replacement and mitral valve repair. Ann Card Anaesth [serial online] 2013 [cited 2020 Jan 21];16:286-8. Available from: http://www.annals.in/text.asp?2013/16/4/286/119182
| Introduction|| |
Brucella endocarditis is a rare (less than 2%) complication of brucellosis.  In Brucella endocarditis, patient is at a high-risk of embolization due to the tendency for progressive ulceration; therefore, timing of surgery is a cause for concern. Emergency surgery is indicated when infection becomes uncontrollable and when there is a chance of developing congestive heart failure.  However, anesthetic and hemodynamic management of such a patient is highly challenging.
| Case Report|| |
A 45-year-old farm worker from Middle East presented in a state of cardiogenic shock, low urine output and with a history of sudden breathlessness and intermittent fever for 4 months. He had a positive history of consuming raw milk. He was diagnosed to have brucellosis 2 months back by positive blood cultures and slide agglutination test and was treated with doxycycline and rifampicin. On examination, patient was tachypneic, blood pressure (BP) was 70/40 mmHg, peripheries were cold and on auscultation a grade 4/6 early diastolic murmur was heard in aortic area. Transthoracic echocardiography examination revealed severe aortic regurgitation (AR), moderate mitral regurgitation, severe pulmonary hypertension and severe left ventricular (LV) dysfunction. In addition, a 14 mm × 10 mm mass was found attached to the inferior aspect of the left coronary cusp with its base extending to the interventricular septum [Figure 1]. In view of persistent hypotension, invasive hemodynamic monitoring was established. Pulmonary artery pressure (PAP) was about 60% of the arterial blood pressure (ABP) and mixed venous oximetry (MvO 2 ) was 31%. Non-invasive ventilation and inotropic therapy with levosimendan, noradrenaline and adrenaline were started to stabilize the hemodynamics. The pre-induction heart rate (HR) was 108/min. The ABP and PAP and pulmonary capillary wedge pressure (PCWP) were 78/26, 54/24 and 20 mmHg, respectively. After pre-oxygenation, anesthesia was induced with fentanyl (5 μg/kg), midazolam (0.04 mg/kg) and ketamine 1 mg/kg; vecuronium 0.1 mg/kg was administered to facilitate endotracheal intubation. Anesthesia was maintained with infusions of fentanyl (2 μg/kg/h) and midazolam (0.02 mg/kg/h) along with 0.4-0.6% sevoflurane. Immediate post-induction fall in ABP (68/28 mmHg) was managed using trendelenburg position and by increasing inotropic support. Midline sternotomy was done and standard cardiopulmonary bypass (CPB) was initiated after heparinization. Retrograde cardioplegia was administered for myocardial protection. Aortic valve showed vegetations involving the left coronary cusp. There was disruption of the anterior mitral leaflet from the aortomitral junction. Aortic valve was excised completely; the anterior mitral leaflet was reattached to restore aortomitral continuity and the aortic mechanical valve (Medtronic ATS-size 20 mm) was sutured in the aortic position. Ultrafiltration was performed on CPB. Furosemide (20 mg), magnesium (4 g) and methyl prednisolone (500 mg) were administered on bypass. Levosimendan, adrenaline, noradrenaline and nitroglycerine infusions were started during rewarming. Atrioventricular sequential pacing was started at a rate of 100/min. Intra-aortic balloon pumping (IABP) was initiated in view of difficult weaning from CPB. Patient was separated from bypass at the second attempt after IABP; the various parameters at separation were - HR 100/min, augmented pressure 108 mmHg, mean arterial pressure 72 mmHg, PCWP 13 mmHg and MvO 2 39%. Patient was ventilated for 21 h, inotropic support and IABP was continued for 43 h and gradually weaned. By third post-operative day, the PA pressures regressed to lesser than 30% of ABP and MvO 2 improved to 61%. The aortic valve tissue culture was positive for brucella. Subsequent follow-up at 1 year after surgery showed an improvement in ejection fraction to 43% with normally functioning valves and negative titers for brucella.
|Figure 1: Parasternal long axis view showing aortic valve vegetation during transthoracic echocardiography|
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| Discussion|| |
The interest in brucellosis has been increasing because of the growing international tourism and the potential use of brucella as a biological weapon. , Endocarditis is the most serious complication of brucellosis, which accounts for about 5% mortality among human brucellosis.  The aortic valve is preferentially involved and mitral valve involvement is very rare.  The patient underwent urgent aortic valve replacement and mitral valve repair for control of the infectious process and cardiac failure. It is worth stressing that our patient had been treated with antibiotic therapy for 2 months, which did not prevent the negative evolution and eventually, the need for surgery, apparently, the antibiotics do not easily reach the inner layers of the cardiac vegetations.
Medical therapy may be used to stabilize the patient en route to surgery in selected cases; however, surgery should not be delayed in favor of efforts at medical management.  The LV in this situation is not able to adequately compensate for the regurgitant volume and excessive backward blood flow impairs forward stroke volume. Compensatory tachycardia may preserve cardiac output initially, but eventually hypotension, organ failure and cardiogenic shock develop. IABP is contraindicated in the presence of AR because balloon inflation during diastole is detrimental to LV hemodynamics.  Anesthetizing such a patient is challenging. Maintenance of tachycardia and avoidance of myocardial depression are anesthetic goals in this condition. Using a combination of titrated doses of fentanyl, midazolam and ketamine for anesthetic induction can offset the HR reducing effects of fentanyl and vecuronium and the vasodilating effect of midazolam. Maximizing forward cardiac output with the correct balance of afterload reduction and preload augmentation is possible with the use of PA catheter. Ultrafiltration was performed on CPB to remove the excess fluid and attenuate the inflammatory response. Reliable placement of a retrograde coronary sinus cannula for delivery of cardioplegia is essential for myocardial protection.
| Conclusion|| |
Conservative management of this patient in cardiogenic shock (in a setting where IABP is contraindicated) would not have stabilized this patient. This case report highlights the fact that emergency surgery along with strategies to maximize the hemodynamics using a combination of invasive monitoring, cardiac-stable anesthetic regimen, inotropic and mechanical support can result in good outcomes.
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