Post-cardiac Catheterization Infective Endocarditis with Flail Mitral Valve Leaflets: A Rare Case

Infectious endocarditis (IE) occurs after colonizing the cardiac endocardium by virulent microorganisms, usually bacteria. Infective endocarditis causes significant morbidity and mortality, even in this era of antibiotics. Here, we present a 52-year-old male patient with hypertension and ischemic heart disease who presented with shivering, fever, and confusion for two days, fourteen days after percutaneous coronary intervention (PCI). On further assessment, transesophageal echocardiography was done due to the patient’s fulfillment of 3 minor and 1 major of Duke's criteria. The transesophageal echocardiography observed a flail posterior mitral valve leaflet of 1.1x0.60cm vegetation and severe eccentric mitral regurgitation. Post-PCI infective endocarditis is a rare and missed diagnosis, so it should be a high suspension for those present with signs and symptoms compatible with infective endocarditis.


Introduction
Infective endocarditis (IE) is a rare and life-threatening infection of the endocardium (inner lining of the heart).In decreasing order, the most commonly affected valves are the mitral, aortic, combined mitral-and-aortic, tricuspid, and pulmonic valves (1).In the past 30 years, IE incidence and mortality have risen, especially in areas with higher socio-demographic index (SDI) regions (2).Staphylococcus aureus is the most frequent cause in high-income countries, accounting for up to 40% of cases due to epidemiological reasons (3).There has been a considerable change in the ISSN: 2958-2849 Somalia Turkiye Medical Journal (STMJ) Volume 02, No 04 epidemiology and clinical characteristics of IE during the past ten years.Post-surgical and interventional IE incidence increased significantly (4).The most frequent complication of endocarditis is ischemic stroke.About 20% with infective endocarditis develop ischemic stroke.
Patients with commitment cardiomyopathy have a higher risk of AIS (5,17).
We present a rare case of infective endocarditis with a flail mitral valve leaflet with post-cardiac catheterization.

Case presentation
A 52-year-old man with hypertension and ischemic heart disease complains of exertional chest pain, shortness of breath (SOB), and fatigue.The vitals were normal.Basic laboratory tests of complete blood count, thyroid, liver, and renal function tests were normal, while electrocardiography showed lateral ST depression of v6 and v7, otherwise normal sinus rhythm.
The patient was monitored at the coronary care unit for 24 hours before being discharged on day 2 with the following medications: aspirin 100mg, clopidogrel 75mg, atorvastatin 40mg, metoprolol 25mg BID, and ramipril 2.5mg twice a day.
Fourteen days later, the patient was taken back to the hospital because he had shivering, a fever, and was disorientated for two days.On systemic review, he was confused but otherwise normal, while he has S3 on auscultation of his cardiopulmonary.On abdominal examination, he had mild left upper quadrant pain.Basic laboratory test results were normal, except elevated white blood cell count (15.39x1000/mm3), neutrophil (13.On the third day of his readmission, the patient developed a decreased level of consciousness and right hemiparesis.Non-contrast brain MRI showed multiple cortical embolic infracts of the brain (Figure 2).
For further investigation of the source of infection, transthoracic echocardiography showed 1.1x0.60cmvegetation of the mitral valve with severe eccentric mitral regurgitation and a dilated left atrium (43mm).In addition, transesophageal echocardiography demonstrated a flail posterior mitral valve, 1.1x0.60cmvegetation, and severe mitral regurgitation (Figure 3).
While waiting for the blood culture, vancomycin and gentamycin were started as empirical therapy based on hospital policy.On day one of blood cultures and seven days later, the results were all

Discussion
A bacterial infection of the endocardium known as infectious endocarditis is usually brought on by colonization of streptococci or staphylococci.Fever (90%) and heart murmurs (81%) are the most common presenting symptoms of infectious endocarditis, followed by dyspnea (42.9%) (5).
The growing incidence of congenital heart disease, the need for frequent medical care for other co-morbidities, hemodialysis, immunosuppression, and the use of intravenous drugs are all current risk factors for endocarditis (6).After cardiac catheterization and percutaneous coronary artery angioplasty, septic complications are pretty rare (7).In a prospective study, only 0.4% of 960 patients who underwent cardiac catheterization generated positive blood cultures significantly correlated with cardiac catheterizations and percutaneous coronary interventions (8).In our case, although we have adapted the sterilization system of our hospital, he has no risk factor for anything other than cardiac catheterization.According to the infectious endocarditis guidelines, antibiotic prophylaxis is not recommended prior to performing cardiac catheterization, even in high-risk patients (9).Infective endocarditis has many complications, including renal and neurological complications, perivalvular abscess, metastatic infection, septic embolization, and mycotic aneurysms.Acute, sub-acute, or chronic mitral regurgitation can cause mitral leaflet Flail, a rare IE complication, and about 50% of these patients with acute MLF experience sudden onset dyspnea (10).This case presented with acute dyspnea due to a flail posterior mitral valve leaflet with septic embolization of the brain and spleen.
Although infective endocarditis (IE) is rare, it still has high morbidity and mortality.In 267 individuals with definite or possible IE, sepsis (n = 23, 46%), multi-organ failure (n = 8, 16%), heart failure (n = 4, 16%), and sudden death (n = 4) were the primary causes of mortality (11).Although transthoracic echocardiography is an excellent tool for diagnosing infective endocarditis, about 50% of clinical suspicion of endocarditis is high (12), but it still has a downside.Factors that may increase the downside of TTE include the absence of Staphylococcal bacteremia and fungemia, as well as cultures of negative etiologies (13).
According to the modified European Society of Cardiology Duke criteria, transesophageal echocardiography (TEE) performed better than CT for the detection of valvular IE-related lesions and similarly to CT for the detection of paravalvular IE-related lesions in patients with a confirmed diagnosis of left-side IE (14).Based on his Duke criteria, he had 3 minor and 1 major: echocardiography findings, fiver, glomerulonephritis, and embolic infarct of brain and spleen.
Diffusion-weighted MRI (DWI) should be done for all patients with infective endocarditis who develop neurological deficits.The DWI is more sensitive to detect acute ischemic stroke than CT and may show tiny infarcts in cortical, deep cerebral structures and the posterior fossa (15,16).In this case, DWI showed multiple diffusion restrictions in both cerebral hemispheres, consistent with acute infarct.
Early surgical treatment, especially in high-risk patients, decreases mortality in patients with insufficient antibiotics to eliminate bacterial infection.However, many types of vegetation observed on TEE may still be missed by modern harmonic TTE (15,17).

Conclusion
Early suspicion of infective endocarditis should be considered for patients with fever after PCI.Therefore, transthoracic echocardiography should be performed on all patients with suspected infective endocarditis, and most of these patients should also have a TEE assessment.

Figure 2 .
Figure 2. Brain MRI showed multiple cortical embolic infract of the brain (red arrow)