Fungal endocarditis: what is the best time for surgery? The role of a heart team

ABSTRACT

Fungal endocarditis is an uncommon affliction with high mortality rate; it represents 2% of infectious endocarditis cases with a mortality rate of about 50% and many times diagnosed post-mortem.¹² It most frequently affects an adult's aortic or mitral valves. Standardized treatment requires antifungal therapy associated with surgical treatment.³ If there is an uncontrolled fungal infection, an early valvular replacement is recommended (<7 days). Patients that have received only medical treatment have a 100% mortality rate.² 78-year-old male, diabetic, with a previous bioprosthetic aortic valve replacement due to severe aortic stenosis, attended the emergency department with fever for the past two months, initially once a week and recently twice daily, associated with nonspecific unwellness and chills. He brought transthoracic echocardiogram that suggested prosthetic valve endocarditis. The patient was hospitalized. Blood cultures were taken and a transesophageal echocardiogram done, which showed typical vegetation annexed to the prosthetic's aortic ring (7x7mm) with mobile component projecting out of the left ventricle and restricting the opening of the prosthetic valve in this region, causing an increase of its gradients. A multi-sensitive Candida parapsilosis was shown in the blood cultures and then Anidulafungin 200mg/day was initiated for an estimated 42-day treatment.The case was discussed with Heart Team because of the high surgical risk and the early need of valve replacement. Initial course of action had us schedule surgery for the seventh day of the antifungal treatment. Patient maintained daily fever and blood cultures were collected every 72h showing increase in Candida parapsilosis in all samples and surgery was sped up.The patient was submitted to a bioprosthetic aortic valve replacement with amplification of the ring due to the presence of abscess evidenced in mid-surgery. The patient was admitted in critical condition to the ICU, hemodynamically unstable in use of ascending vasoactive drugs, in vasoplegic shock with refractory septic component. The patient remained refractory to instituted measures evolving to death 24h after surgery. Fungal endocarditis is a rare but extremely serious condition, and a multidisciplinary approach is extremely important. Discussing a case of reoperation with high surgical risk with all those responsible for the care is the role of Heart Team and was essential to decide the best time for the surgery.