Case report:
A 72-year-old male patient was referred to our hospital for one-month
history of high-grade fever. The patient had multiple comorbidities
including: end-stage kidney disease on haemodialysis in the last six
months through a dialysis catheter, diabetes mellitus, and chronic
obstructive pulmonary disease. He also had coronary artery disease (CAD)
with a stent implantation in the right coronary artery (RCA) seven years
before presentation, that was complicated with a hemopericardium and
evacuated by a pericardial window. In addition, he had a complete
atrio-ventricular block with a dual chamber pacemaker implantation.
Physical examination revealed a holosystolic murmur at the left lower
sternal border and severe bilateral lower limb oedema. Laboratory workup
revealed leukocytosis (wbc 12700 c/ul). Blood cultures were obtained.
Trans-thoracic echocardiography showed decreased left ventricular
ejection fraction (35%), severely decreased right ventricular function,
grade 4/4 tricuspid regurgitation, 15-mm mobile vegetation in the right
atrium (RA), and a large saccular aneurysm on the RCA. CT angiography
revealed a 58 x 47 mm collection crossed by the RCA that has a
thrombosed wall of 9 mm thickness (figure 1). Coronary angiography
showed triple vessel CAD with extravasation of the contrast material
through the RCA (video 1). He was prepared for surgery and had to be
started on low dose norepinephrine due to hypotension. Under
cardio-pulmonary bypass and after aortic cross-clamping, the false
aneurysm was opened, pus came out; samples were sent to culture. Fibrin
membranes and old clots were entirely removed (video 2). The RCA was
completely avulsed; it was suture ligated (figure 2.A). The whole pouch
was washed using povidone iodine, normal saline, and oxygen peroxide.
The lateral wall of the RA seemed ruptured with creation of a fistula. A
right atriotomy was performed. The fistula was found and debrided
(figure 2.B). It was closed using a pericardial patch. De Vega technique
was used for tricuspid valve annuloplasty, then CABG was done using
saphenous vein grafts to the left anterior descending and the obtuse
marginal arteries. Weaning of the bypass needed high doses of
vasopressors. The patient was transferred to the cardiac surgery unit in
a frail hemodynamic condition; three hours later, he developed severe
sepsis resistant to maximal medical therapy, and unfortunately passed
away.
The preoperative blood cultures grew MRSA. The intraoperative purulent
secretions grew the same pathogen.