Infective endocarditis on the aortic valve in a young patient with liver cirhossis – therapeutic challenge

Introduction: Patients with liver cirrhosis are prone to develop bacterial infections due to the blood sta-sis, portosistemic collateral circulation and immuno-suppression. They have an increased risk of developing bacterial endocarditis, evolving towards sepsis and multiple organ dysfunction syndrome (MODS). Due to the presence of severe hepatic dysfunction and the very high surgical risk, cardiac surgery is often not under-taken. This kind of patients have a very high mortality rate, especially those in stages B and C of liver cirrhosis. Methods: We present the case of a 35 year old man, known with hepatic cirrhosis Child C stage, admitted for dyspnea at rest and fever for about 4 days. Clini-cal examination: BP=90/30 mmHG, HR=80 bpm, SpO2=92%, holodiastolic murmur in the aortic area. ECG: sinus rhythm, 80/min, left anterior superior fas-cicular block. Blood analysis: leucocitosis=41740/mm3, anemic syndrome, presepsin 1188 pg/ml, INR=2.45, hemocultures positive with group C beta hemolytic Streptococcus – Streptococcus zooepidemicus. Echocar-diography reveals severe aortic regurgitation, a mass on the right coronary cusp of the aortic valve suggestive for vegetation, LVEF=65%, no pericardial liquid.
Results: The clinical and paraclinical findings support the diagnosis of bacterial endocarditis on the aortic val-ve. The cardiovascular surgeon recommends conserva-tory treatment given the very high surgical risk of the patient. We initiated intravenous antibiotic treatment as recommended by the infectionist doctor, inotropic support, diuretics, repeated blood transfusions, hepa-tic protectors. Initially the patient status improved, he-modiamically stable, with the improvement of the in-flammatory and anemic profile, without fever. After 14 days of hospitalization is worsening, with no response to readjustment of the therapeutic regimen, with repea-ted episodes of superior digestive hemorrhage, MSOD and death.
Conclusions: The management of this case in difficult considering the severity of both diseases: bacterial en-docarditis with severe aortic regurgitation associated with advanced liver cirrhosis. The lack of specific re-commendations in the guidelines for these kind of frail patients makes the therapeutical approach very diffi-cult. The prognosis in these cases in unfavorable despi-te any therapeutic resource.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
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CODE: 379
CME Credits: 10 (Romanian College of Physicians)