How Much Attention Should Be Paid to Urinary Tract Infection in a Patient with Congenital Heart Disease?

Case Report

Austin J Cardiovasc Dis Atherosclerosis. 2023; 10(2): 1058.

How Much Attention Should Be Paid to Urinary Tract Infection in a Patient with Congenital Heart Disease?

Dragana D Radoicic¹; Stefan Veljkovic¹; Jovana Lakcevic¹; Ivan Ilic1,2; Slobodan Tomic¹; Aleksandra Nikolic1,2

¹Institute for Cardiovascular Disease’ Dedinje’ Belgrade, School of Medicine, Serbia

²Faculty of Medicine, University of Belgrade, Belgrade, Serbia

*Corresponding author: Dragana D.Radoicic Institut for Cardiovascular Disease Dedinje, Heroja Milana Tepica 1, Belgrade, Serbia. Tel: +381 63 38 37 38 Email: dragana.kastratovic@yahoo.com

Received: November 06, 2023 Accepted: December 06, 2023 Published: December 13, 2023

Abstract

Background: Tetralogy of Fallot (TOF) is the most common cyanotic Congenital Heart Disease (CHD). As therapy becomes increasingly effective, the number of adults with CHD is growing. There are many surgical options to resolve the pulmonary stenosis as a part of TOF, and Pulmonary Valve (PV) replacement with biological prosthesis is one of the solutions. We reported a case of prosthetic valve endocarditis in a patient with TOF.

The Case Report: A patient with weeklong fever, cough, and suspicion of infective endocarditis previously admitted to a local hospital was transferred to Cardiovascular Institute the next day. The pulmonary valve replacement was performed three years previous to his admission to the hospital as well as a complete surgical correction of TOF 22 years before that. Transthoracic Echocardiography (TTE) revealed a large vegetation 27x32mm attached to the leaflet with significantly increased embolic potential and a very high transvalvular gradient across the valve (66/37mmHg). These findings have been confirmed by Trans Esophageal Echocardiography (TEE). Empirical antibiotic therapy was administered. Blood cultures and urine samples, that were taken at the patient’s admission to the Institute, received as negative after two days. However, 4 weeks later, the control TEE examination has shown that the large vegetation was persisted with high embolic risk and clear signs of valve dysfunction. Although this patient already had two midline sternotomy, the Heart team had to decide whether to perform another open-heart surgery with pulmonary valve replacement. Intraoperative findings showed thrombus with vegetation on prosthesis and leaflets, both destroyed by endocarditis. These were sent to microbiological and antibiotic sensitivity analysis and afterward, the valve was replaced with biological prosthesis SJM Supra Epic 27. Cultures of the vegetation identified Staphylococcus epidermitis. Six weeks of antibiotic treatment was applied after the surgical procedure. The patient has been followed up for a year without complications.

Keywords: Congenital heart disease; Pulmonary valve; Infective endocarditis; Staphylococcus epidermitis; Urinary infection

Introduction

Congenital Heart Diseases (CHD) are the most common types of birth defects; with the incidence of 10/1000 live births [1]. The number of adults with some form of CHD is rapidly growing as therapy becomes increasingly effective. It is estimated that 90% of patients with CHD reach adulthood [2]. Tetralogy of Fallot (TOF) as an often cyanotic heart disease can be treated with several different surgical procedures. Treatment of pulmonary stenosis as a part of TOF depends on the stenosis level and localization. Common treatments are valve commissurotomy with a trans-annular patch, pulmonary valve replacement, and conduit. Prosthetic valve dysfunction is frequently a long-term complication after pulmonary valve replacement (age between 15-20 is average) [5]. Patients with CHD are more susceptible to a higher incidence of endocarditis (11 per 100000 persons/year) than the general population therefore it is considered to be the most prevalent underlying condition in patients with Infective Endocarditis (IE) [6]. Inappropriate treatment of urinary infection as a risk factor for IE is associated with serious dysfunction of a prosthetic valve on a pulmonary position and may require open-heart surgery with valve replacement.

The Case Report

A 29 years old male patient with a history of valve replacement caused by TOF was admitted to our tertiary clinic, complaining about weeklong fever, cough, and headache. His vitals parameters revealed very high body temperature (40,6°C) and laboratory findings showed the elevation of WBC 14,6x10³ with 82% polymorphs, anemia with hemoglobin and hematocrit of 11g/dl and 29% respectively. C reactive protein has been proven to be elevated 100,8mg/dl, while procalcitonin had negative value (<0,15ng/ml).

The patient’s anamnesis included surgical correction of TOF at the age of four with resection of the infundibulum and ventricular septal defect patch as well as commissurotomy of the bicuspid pulmonary valve. Owing to inappropriate results, the surgical repair with a transannular patch including the reconstruction of the main pulmonary artery was necessary for the patient. In 2016 the patient underwent bio prosthetic pulmonary valve replacement and reconstruction of truncus pulmonalis.

On a physical exam, he had a regular heart rhythm, with normal first sound and fixed split-second sound, without heart murmur. Electrocardiogram showed a sinus rhythm with an advanced right bundle branch block, a 150 QRS axis and his blood pressure level was normal. Chest CT showed pleural effusion right with compressive atelectasis of the lower part of the right lung.