Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2000  |  Volume : 11  |  Issue : 2  |  Page : 205--207

Aortic Valve Replacement for Infective Endocarditis in a Renal Transplant Recipient


Sayda Masmoudi, Imed Frikha, Walid Trigui, Abdelhamid Karoui, Moncef Daoud, Youssef Sahnoun 
 Service de Chirurgie Cardio-vasculaire, Hopital Habib Bourguiba, SFAX, Tunisia

Correspondence Address:
Sayda Masmoudi
Service de Chirurgie Cardio-vasculaire, Hospital Habib Bourguiba, Route L’Ain Km 05, 3029 – SFAX
Tunisia

Abstract

Renal transplant recipients are more prone to developing infections. We report a 37-year old renal transplant recipient who developed infective endocarditis of the aortic valve, heart failure and renal allograft dysfunction. He underwent aortic valve replacement which was followed by improvement in cardiac as well as allograft function.



How to cite this article:
Masmoudi S, Frikha I, Trigui W, Karoui A, Daoud M, Sahnoun Y. Aortic Valve Replacement for Infective Endocarditis in a Renal Transplant Recipient.Saudi J Kidney Dis Transpl 2000;11:205-207


How to cite this URL:
Masmoudi S, Frikha I, Trigui W, Karoui A, Daoud M, Sahnoun Y. Aortic Valve Replacement for Infective Endocarditis in a Renal Transplant Recipient. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2022 Dec 8 ];11:205-207
Available from: https://www.sjkdt.org/text.asp?2000/11/2/205/36680


Full Text

 Introduction



An increasing number of renal transplants are being performed world-wide. Conse­quently, cardiac surgery in these individuals has become an important issue since it may have an impact on graft and patient survival. We present herewith, a renal transplant recipient who underwent aortic valve replacement for infective endocarditis.

 Case Report



A 37-year old man underwent a living donor renal transplantation in December 1996. He had stable graft function and was on triple immunosuppression with cyclos­porine 150 mg, azathioprine 100 mg and prednisone 30 mg daily. His native kidney disease was unknown and he was not a known diabetic.

The patient presented months after renal transplantation with fever and a newly appeared diastolic murmur over the precor­dium. Echocardiogram showed moderate aortic regurgitation and vegetations were seen over the aortic valve. Repeated blood cultures were negative. The patient was managed with teicoplanin and ofloxacin for six weeks with which he improved sympto­matically and the vegetations disappeared.

Eleven months later, the patient presented again with fever associated with chest pain and dyspnea. He was in New York Heart Association (NYHA) functional class III. Precordial auscultation revealed reappearance of the diastolic murmur. An x-ray chest showed cardiomegaly with pulmonary congestion and electrocardiogram showed left ventricular hypertrophy. Two-dimen­sional echocardiogram revealed floating vegetations attached to the aortic valve [Figure 1] and significant aortic regur­gitation [Figure 2]. There was associated graft dysfunction with the serum creatinine rising from 200 µmol/L to 920 µmol/L. Blood cultures done repeatedly were negative and response to antibiotics was not satisfactory. In view of his overall general condition, the patient was subjected to aortic valve replacement surgery. A mechanical valve (Saint Jude) was used and the patient was weaned off cardiopulmonary bypass easily.

The post-operative course was uneventful and smooth. The serum creatinine level improved to 280 µmol/L within a few days of surgery. Aortic valve histology revealed evidence of infective endocarditis. He was discharged in NYHA class I-II and when last seen, nine months after cardiac surgery, he was well with a normally functioning renal allograft.

 Discussion



Renal transplant recipients are vulnerable to development of infectious diseases in view of the immunosuppressive medications used. These infections are often caused by highly virulent organisms. Infective endocarditis is one such infection which can arise on diseased, as well as previously healthy valves, and has a special affinity towards the aortic valve. [1] The causative organisms are different in organ transplant recipients as compared to the general population. Thus, more than 50% of infective endocarditis in transplant recipients are caused by aspergillus fumigatus and staphylococcus aureus and only 4% are due to streptococcus viridans [2] .

In our patient, no organism could be isolated despite repeated cultures of blood samples. The possibility of the causative organisms being staphylococcus aureus was high because the patient had a functioning arterio-venous fistula and a puncture at this site could have possibly triggered off a staphylococcus aureus bacteremia. In view of negative blood cultures and applying the diagnostic criteria laid down by Durack et al, [3] a diagnosis of infective endocarditis was very likely but not confirmed initially. However, histology of the affected valves confirmed the diagnosis in our patient.

Infective endocarditis of the aortic valve causes destruction of the valve resulting in aortic regurgitation, reduction of cardiac output, allograft hypoperfusion and dys­function. Thus, energetic treatment in the form of valve replacement becomes mandatory. Although the exact timing of surgery remains undecided, most workers recommend performing surgery early, once diagnosis is confirmed. [4],[5] This ensures better results and smoother post-operative course. Advances in anesthetic techniques have made this approach feasible. The surgical technique in transplant recipients is similar to what is used in the general population. Meticulous excision of infected tissues is a must. [6] The intra- and post­operative risk in transplant recipients is only slightly increased when compared to patients with normal renal function. The principal post-operative complications are bleeding and infection and the overall mortality related to surgery is 8-10%. [7]

In conclusion, we report a renal transplant recipient who developed infective endocar­ditis and allograft dysfunction. He under­went aortic valve replacement following which the allograft function improved. Energetic approach is indicated in organ transplant recipients while managing infective endocarditis.

References

1Baglin BD. Les complications cardiaques observees sous hemodialyse periodique. Coeur 1974;5:723.
2Paterson DL, Dominguez EA, Chang FY, Syndman DR, Singh N. Infective endo­carditis in solid organ transplant recipients. Clin Infect Dis 1998;3:689-94.
3Durack DT, Lukes AS, Bright DK, et al. New criteria for diagnosis of infective endocarditis: utilization of specific echo­cardiographic findings. Am J Med 1994; 96:200-9.
4Prager RL, Maples MD, Hammon JW JR, Friesinger GC, Bender HW Jr. Early operative intervention in aortic bacterial endocarditis. Ann Thorac Surg 1981;32: 347-50.
5Wilson WR, Danielson GK, Giuliani ER, et al. Valve replacement in patients with active infective endocarditis. Circulation 1978;58:585-8.
6Young JB, Welton DE, Raizner AE, et al. Surgery in active infective endocarditis. Circulation 1979;60:77-81.
7Dresler C, Uthoff K, Wahlers T, et al. Open heart operations after renal trans-plantation. Ann Thorac Surg 1997;63(1): 143-6.