Clinical background: 32 years old woman had a childhood anamnesis of unexplored heart murmur. Six weeks after giving birth to her first child under antibiotic prophylaxis she had a pain and a minimal oedema in her right leg after a long walk on the previous day.
Elevated levels of D-Dimer and CRP were found, although ultrasound examination did not show any sign of thrombosis. The medical professionals at the Intensive Care Unit decided that the reason of the elevated levels of D-Dimer and CRP were related to the peripartum status, and the leg pain and oedema is caused by the physical overuse.
Two weeks later the patient has got a severe hemiparesis on the left side. CT angiography was performed at the arrival of the patient to the Department of Neurology and showed occlusion of the right middle cerebral artery without any signs of ischemia. Besides these neurological symptoms the patient had fever (38.5 oC), tachycardia with rhythmic heart rate, a crescendo-decrescendo type systolic murmur of 2/6 grade and a proto-meso diastolic murmur of 2/6-3/6 grade.
Trans Thoracic Echocardiogarphy (TTE) at the Department of Cardiology showed roughly thickened bicuspid aortic valve. There was a 3.5 x 15 mm "kissing vegetation" attached to the septum, under the valve, in the left ventricular outflow tract, having a mobile part of 11 mm length, threatening with a high chance for new emboli. An aorta insufficiency of grade II-III was also found. Establishing the diagnosis of endocarditis with a life threatening mobile vegetation Trans Esophageal Echo was not performed to facilitate further treatment.
Questions of intervention:
1) Conservative treatment of the endocarditis and the stroke? (Higher risk for further thromboembolic events)
2) An urgent heart surgical operation? (Higher risk for intracranial bleeding)
The endocarditis itself represented about 17-fold increase for a second stroke, which was aggravated by the presence of large, mobile vegetation. On the other hand, the risk of bleeding was considered to be less than 10% in the absence of ischemia on the CT. Aortic valve replacement was performed with the excision of the infected, vegetation containing part of the septum. Clinical outcome: The patient woke up with an unchanged neurological and stabile cardiovascular status. The postoperative follow up is still going on.
Notes to editor
Submited by Sandor jr. Sipka (Debrecen /Hungary), Andrea Darago (Debrecen /Hungary), Lehel Palotas (Debrecen /Hungary), Tamas Szerafin (Debrecen /Hungary) and Laszlo Bigida (Debrecen /Hungary),