Abstract 14509: A Rare Case of Cardiac Tamponade as an Initial Presentation of Native Aortic Valve Infective Endocarditis

Background: Pericardial involvement is a rare presentation of infectious endocarditis (IE). We present a case of septic cardiac tamponade, paravalvular abscess and fibrinous pericarditis secondary to native aortic valve (AV) IE. Presentation: A 50-year-old gentleman with a history of IV drug use presented with fever, dyspnea and pleuritic chest pain for one week. He was febrile, tachycardic and hypotensive on presentation. Examination revealed a new onset early diastolic murmur. Workup: EKG showed mild diffuse ST segment elevations and PR segment depressions suggestive of pericarditis. Blood cultures grew Serratia marcescens in 6 out of 6 bottles and IV cefepime was initiated. TTE revealed large effusion with right atrium and right ventricle diastolic collapse consistent with tamponade physiology (fig. A, B). A vegetation was seen on the right coronary cusp of AV along with aortic insufficiency and aortic root abscess. TEE confirmed the above findings (fig. C-F) Management: An emergency cardiac surgery was performed for acute aortic regurgitation and cardiac tamponade. Intraoperative findings revealed 600mL of purulent effusion. A large vegetative mass near left-to-right commissure covering an abscess cavity that extended into the aortic wall that destroyed the annulus and extended into the ventricular muscle. AV replacement with 21mm Inspiris pericardial AV and pericardial patching was done. Epicardial tissue as well as AV leaflet cultures revealed moderate to heavy growth of S. marcescens . He was discharged on cefepime for a total duration of 6 weeks. Follow up TTE revealed normal peak and mean transaortic gradients. Conclusion: Cardiac tamponade is a rare but life-threatening complication of IE. Pericardial involvement should prompt us further work up to exclude intra-cardiac abscess which carries poor prognosis due to high complication rates. Hence, early multidisciplinary team response is of paramount importance to reduce in-hospital mortality.