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Blood purification during valve surgery for infective endocarditis in an adolescent
Theodor Tirilomis | Thoracic and Cardiovascular Surgery, University of Goettingen, Goettingen, Germany | Artificial Organs. 2021; 45:95–96
11/10/2021
New!PediatricsPeer Reviewed Published DataReduction in catecholaminesSafetyAortic SurgeryCardiac surgeryCase of the weekCase reportCPBEndocarditisInflammatory parametersIntra-Op
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Summary
CoW 45/2021 – This case reports on a 15-year old boy with history of bicuspid valve and mild aortic valve regurgitation, who had a recent history of abdominal pain, diarrhea, and vomiting.
Case presentation
With an increasing reduction in vigilance and the development of visual hallucinations, he was first admitted to a peripheral hospital, and then transferred to University of Goettingen
The clinical examination showed multiple skin emboli
Additionally, computed tomography scans and magnetic resonance imaging showed embolic infarctions in various organs including brain, kidneys, liver, and spleen
Examination of cerebrospinal fluid revealed clear liquid, but cell count and lactate were increased (50 cells per µL and 3.3 mmol/L, respectively)
The patient was admitted to the pediatric intensive care unit (PICU) and antibiotic therapy along with antiviral treatment was initiated
Transthoracic echocardiogram was initially assessed as unremarkable but in the course an increasing aortic insufficiency was seen
Therefore transesophageal echocardiography was performed which showed endocarditic vegetations of the aortic valve
Because of this finding and the increased risk of further embolic events, the patient underwent urgent cardiopulmonary bypass (CPB) assisted aortic valve surgery. During the operation, the diseased aortic valve was found to have two large endocarditic vegetations; one on the rudimental raphe between left-coronary and right-coronary leaflet and another one on ventricular side of noncoronary leaflet. The infected valve was excised and replaced
Additionally, a CytoSorb adsorber was installed into the CPB circuit due to the high risk of him developing septic shock postoperatively from the infective endocarditis, and also the possibility of an additional inflammatory reaction due to the operation itself
Treatment
One hemoadsorption treatment for the entire cardiopulmonary bypass time (102 mins),
CytoSorb was installed in the CPB circuit using a side arm coming from the venous cannula
CPB pump flow: 2.5 L/ min/m2
Measurements
Hemodynamics and vasopressor requirements (norepinephrine, epinephrine)
Free hemoglobin levels
Results
Treatment resulted in a hemodynamic stabilization as evidenced by constant and then increasing arterial blood pressure while vasopressor dosages decreased. Norepinephrine support was terminated 4 hours after surgery and epinephrine 24 hours later
Free hemoglobin level increased preoperatively from 16 to 28 mg/dL immediately after surgery and finally decreased 6 hours later to 15 mg/dL
Patient Follow-up
Microbial examination of valve tissue as well the blood cultures taken before surgery identified Staphylococcus aureus and the antibiotic treatment was adapted accordingly with flucloxacillin, rifampicin, and clindamycin
His postoperative PICU and hospital stay was uneventful
Conclusion
In this case of a pediatric patient undergoing valve surgery for endocarditis, the application of CytoSorb hemoadsorption treatment was associated with rapid and sustained hemodynamic stabilization
According to the authors this case shows that the prophylactic use of blood purification during CPB might have protective effects in the treatment of pediatric infective endocarditis
Nevertheless, further clinical studies are needed to assess optimal timing of treatment initiation.
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