Surgical left ventricular repair using a right ventricular homograft successfully treated a ruptured LV apex pseudoaneurysm in a 37-year-old male with congenital heart disease and MSSA bacteremia.
Case Report (n=1)
This case highlights the critical importance of early echocardiographic evaluation and rapid interdisciplinary surgical intervention in patients with congenital heart defects and substance abuse presenting with thoracic infection and MSSA bacteremia.
Abstract Introduction Left ventricular (LV) pseudoaneurysm rupture is a rare but catastrophic complication typically associated with myocardial infarction, cardiac surgery, or infection. We present a case of ruptured LV apex pseudoaneurysm in a young adult with congenital heart disease and Methicillin-Susceptible Staphylococcus Aureus (MSSA) bacteremia. Case Report A 37-year-old male with a history of repaired Atrial Septal Defect (ASD) /Ventricular Septal Defect (VSD), situs inversus with levocardia, and substance use presented with worsening shortness of breath and pleuritic chest pain. He had recently received antibiotics for presumed pneumonia and had prior positive blood cultures. On admission, he was afebrile, tachycardic, and normotensive. Chest X-ray showed bilateral infiltrates. Empiric cefepime, vancomycin, and azithromycin were initiated. Blood cultures on day 1 grew pan-sensitive MSSA, prompting de-escalation to cefazolin. A limited transthoracic echocardiogram raised concern for mitral valve vegetation and a transesophageal echocardiography (TEE) was planned. On hospital day 5, he developed crushing chest pain and hypotension. CT chest revealed a ruptured left ventricular (LV) apex pseudoaneurysm with left-sided hemothorax. Cardiothoracic surgery and critical care teams were emergently involved. Chest tube placement was deferred due to concern for self-tamponade. He was transferred to the intensive care unit for close hemodynamic monitoring. He subsequently developed hemorrhagic shock requiring intubation and pressors. A femoral cordis was placed in anticipation of blood transfusion for resuscitation. CT surgery recommended transfer to a tertiary center specializing in congenital cardiac repair. There, he underwent TEE, left thoracotomy with hemothorax evacuation, and LV repair using a right ventricular homograft, later complicated by homograft stenosis. His ICU course was complicated by mixed shock and acute kidney injury. He improved with supportive care, was extubated on hospital day 14, and discharged on intravenous cefazolin to complete a 6-week course. Discussion This case highlights the importance of early echocardiographic evaluation in all patients presenting with thoracic infection in the setting of known substance abuse and congenital heart defects. Additionally the presence of MSSA bacteremia should heighten the provider to thoroughly investigate for endocarditis with or without known risk factors such as previous cardiac surgery or recreational drug use. Rapid critical care consultation and intervention is imperative when cardiac complications are suspected.Early involvement of cardiothoracic surgery should also be considered for a comprehensive interdisciplinary approach to management. This abstract is funded by: N/A
Gill et al. (Fri,) conducted a case report in Ruptured left ventricular pseudoaneurysm and MSSA bacteremia in congenital heart disease (n=1). Left ventricular repair using a right ventricular homograft and intravenous antibiotics was evaluated. Surgical left ventricular repair using a right ventricular homograft successfully treated a ruptured LV apex pseudoaneurysm in a 37-year-old male with congenital heart disease and MSSA bacteremia.