Triple-valve replacement for Rhizobium radiobacter endocarditis with septic shock in an adult with ventricular septal defect. A case report

Andrei George Iosifescu; Ioana Marinică; Alexandru Popescu; Alina Teodora Timișescu; Elena-Laura Antohi; Vlad Anton Iliescu

doi:10.1016/j.ijscr.2022.107401

Triple-valve replacement for Rhizobium radiobacter endocarditis with septic shock in an adult with ventricular septal defect. A case report

Int J Surg Case Rep. 2022 Aug:97:107401. doi: 10.1016/j.ijscr.2022.107401. Epub 2022 Jul 13.

Authors

Andrei George Iosifescu¹, Ioana Marinică², Alexandru Popescu³, Alina Teodora Timișescu⁴, Elena-Laura Antohi⁵, Vlad Anton Iliescu⁶

Affiliations

¹ Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Cardiac Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania. Electronic address: iosifescuag@yahoo.com.
² Department of Anesthesia and Intensive Care, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania.
³ Department of Cardiac Surgery, Emergency Hospital for Children Maria Sklodowska Curie, Bucharest, Romania.
⁴ Department of Cardiac Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania.
⁵ Department of Cardiology, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania.
⁶ Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Cardiac Surgery, C.C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, Romania.

Abstract

Introduction and importance: Triple-valve replacement in active infective endocarditis has rarely been reported. This paper is the first report of a triple-valve replacement performed in endocarditis with septic shock and the first presentation of multivalvular endocarditis due to Rhizobium radiobacter.

Case presentation: A 26-year-old patient with a neglected ventricular septal defect referred to us in septic shock, with multiple organ failure, severe biventricular dysfunction, and pulmonary hypertension, due to Rhizobium radiobacter infective endocarditis affecting the aortic, tricuspid and pulmonary valves. Initially, he was deemed unfit for surgery. However, after clinical stabilization, triple-valve replacement, aortic annular abscess repair, membranous septum aneurysm resection, and ventricular septal defect patch closure were performed. The postoperative evolution was good; both ventricles showed functional recovery after six months.

Clinical discussion: Although surgery provides the best chances of survival in endocarditis with septic shock, reportedly, most cases are considered inoperable. Clinical stabilization under intensive care using specific therapies to manage septic shock, myocardial dysfunction, and pulmonary hypertension was crucial for surgery success. Custodiol® cardioplegia, and replacement of the right-sided valves using a beating-heart technique were used to reduce the myocardial ischemic time.

Conclusion: Rhizobium radiobacter, an opportunistic gram-negative bacterium, potentially may cause multiple valve endocarditis. Patients with endocarditis and septic shock initially considered inoperable can still benefit from surgery after tenacious intensive care (cytokine hemoadsorption and levosimendan are helpful in this process). In complex multivalvular procedures, a beating heart technique to replace the right-sided valves should be considered to minimize the duration of myocardial ischemia.

Keywords: Case report; Infective endocarditis; Rhizobium radiobacter; Septic shock; Triple-valve replacement; Ventricular septal defect.