A 69-year-old hemodialysis patient with a pacemaker developed Enterococcus faecalis native pulmonic valve endocarditis and died from multiorgan failure despite aggressive surgical and medical therapy.
Case Report (n=1)
This case highlights the high mortality and rapid hemodynamic deterioration associated with Enterococcus faecalis native pulmonic valve endocarditis in dialysis-dependent patients with cardiac devices, despite aggressive surgical and medical management.
Abstract Background Native pulmonic valve endocarditis (PVE) is an exceptionally rare entity, representing 2% of all cases of infective endocarditis (IE). Its rarity is attributed to the low-pressure right-sided circulation and relative resistance of the pulmonic valve to endothelial injury. Diagnosis is often delayed because of nonspecific symptoms and limited echocardiographic visualization. Enterococcus faecalis is an uncommon but increasingly recognized pathogen in IE, particularly in elderly, immunocompromised, or dialysis-dependent patients and those with indwelling cardiac devices. Case Presentation A 69-year-old man with a history of coronary artery disease status post CABG ×1 (LIMA-LAD, 2014), dual-chamber pacemaker placement, atrial fibrillation on apixaban, chronic diastolic heart failure, hypertension, hyperlipidemia, and end-stage renal disease recently started on hemodialysis presented with generalized weakness and anemia (Hgb 6.9 g/dL). He denied overt bleeding. Imaging showed a right middle lobe infiltrate, and he was empirically treated for pneumonia. Blood cultures grew E. faecalis in two bottles. Transthoracic echocardiography revealed a 16-mm vegetation on the pulmonic valve with flail leaflet, torrential regurgitation, and LVEF 35-40%. There was no vegetation on the pacemaker leads, but the tricuspid valve demonstrated echodensities concerning for early involvement.The patient was started on renally adjusted intravenous ampicillin and ceftriaxone. Infectious disease, electrophysiology, and cardiothoracic surgery teams were involved. Despite absence of device infection, complete extraction of pacemaker hardware was performed per guideline-directed management, and a temporary pacing system was placed. He subsequently underwent redo sternotomy and pulmonic valve replacement using a 27-mm Inspiris Resilia bioprosthetic valve. Postoperatively, he developed severe right-sided failure and refractory septic and cardiogenic shock, requiring continuous renal replacement therapy, multiple vasopressors, and Impella RP Flex mechanical support. Echocardiography showed progressive right ventricular dysfunction (EF 30-35%). His course was further complicated by lactic acidosis, ischemic hepatitis, and bowel ischemia, culminating in multiorgan failure and death despite maximal supportive measures. Conclusion This case illustrates the diagnostic and therapeutic complexity of native pulmonic valve endocarditis in the setting of hemodialysis and cardiac implantable electronic devices. E. faecalis infection in such patients carries a high risk of rapid hemodynamic deterioration and mortality, even with early surgical intervention and optimal antimicrobial therapy. Clinicians should maintain a high index of suspicion for right-sided IE in dialysis-dependent patients presenting with unexplained Enterococcus bacteremia. Early multidisciplinary involvement and aggressive management remain critical, though prognosis is guarded once septic and cardiogenic shock ensue. This abstract is funded by: none
Biscuitwala et al. (Fri,) conducted a case report in Native pulmonic valve endocarditis (n=1). Intravenous ampicillin and ceftriaxone, pacemaker extraction, and pulmonic valve replacement was evaluated. A 69-year-old hemodialysis patient with a pacemaker developed Enterococcus faecalis native pulmonic valve endocarditis and died from multiorgan failure despite aggressive surgical and medical therapy.
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