Long-term antibiotic therapy stabilized a 48-year-old woman with infective endocarditis, severe pulmonary arterial hypertension, and cerebrovascular complications who was ineligible for surgery.
Case Report (n=1)
Long-term antibiotic therapy can serve as a stabilizing alternative for patients with infective endocarditis who have prohibitive surgical risk due to severe pulmonary arterial hypertension and cerebrovascular complications.
Abstract Introduction Infective endocarditis (IE) carries high morbidity and mortality; management is especially challenging in patients with pulmonary arterial hypertension (PAH), where hemodynamic instability and cerebrovascular complications often preclude surgery. For surgery-indicated but not undergone surgery IE (SINUS-IE), long-term antibiotic therapy (LTAT) is a potential alternative. Case Presentation A 48-year-old woman with obesity, seizures, and severe Group 1 PAH presented with IE due to Staphylococcus aureus; blood and tunneled Hickman catheter-tip cultures ultimately grew methicillin-resistant S. aureus. PAH had been diagnosed after dyspnea with echocardiographic RV dilation/dysfunction and right-heart catheterization showing mPAP 61 mmHg, PCWP 8 mmHg, and PVR 19 WU. Her PAH therapy had been intensified to sildenafil 20 mg TID, macitentan 10 mg daily, IV treprostinil 50 ng/kg/min, and sotatercept, improving her REVEAL 2.0 score from intermediate to low. On presentation, she had fever, hypoxia, confusion, dehydration, and hypotension. Transthoracic echocardiography and cardiac CT (Figure 1) showed a 1.5 × 1.0 cm mitral vegetation; head CT and brain MRI revealed left subarachnoid hemorrhage and multiple bilateral infarcts. Modified Duke criteria confirmed definite IE (two major: typical positive blood cultures and echocardiographic vegetation; minor: fever and vascular phenomena). Discussion Surgery was contraindicated due to severe PAH with hemodynamic instability and recent SAH with multiple infarcts. Management followed SINUS-IE principles: removal of the infected central line, IV LTAT, and supportive care with continuation of IV prostacyclin, a PDE-5 inhibitor, and an endothelin-receptor antagonist; sotatercept was held for thrombocytopenia in critical illness. According to the 2022 comparative analysis of ACC/AHA and ESC guidelines 1, surgery remains the definitive therapy for left-sided IE when antibiotics alone are unlikely to cure or complication risk persists, but evidence is largely observational, timing after cerebrovascular events is consensus-based, and specific recommendations for LTAT in surgery-ineligible patients are lacking. Conclusion In severe PAH with recent cerebrovascular events, surgery may be prohibitive; LTAT within a multidisciplinary framework can stabilize selected SINUS-IE patients but does not address structural pathology, and the risk of recurrent embolic or infectious complications remain significant. This case underscores the need for data to define LTAT duration, monitoring, and adjuncts in high-risk, surgery-ineligible IE. References: 1. Wang A, Fosbøl EL. Current recommendations and uncertainties for surgical treatment of infective endocarditis: a comparison of American and European cardiovascular guidelines. Eur Heart J. 2022;43(17):1617-1625. doi:10.1093/eurheartj/ehab898 This abstract is funded by: None
Arikawa et al. (Fri,) conducted a case report in Infective endocarditis with severe pulmonary arterial hypertension and cerebrovascular complications (n=1). Long-term antibiotic therapy (LTAT) was evaluated. Long-term antibiotic therapy stabilized a 48-year-old woman with infective endocarditis, severe pulmonary arterial hypertension, and cerebrovascular complications who was ineligible for surgery.