Case Report
A 28-year-old gravida 2 para 1001 female with prior uncomplicated full-term pregnancy delivered via cesarean section, active intravenous drug use (IVDU) disorder, and limited prenatal care presented at 26-weeks of gestation with fever, pleuritic chest pain, right knee pain, and dyspnea. She used cocaine and heroin the day prior and was without obstetric complaints. Fetal status was reassuring and appropriate for gestational age. Transabdominal ultrasound demonstrated an active fetus, normal amniotic fluid volume, and expected estimated fetal weight.
She was found to have Methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia. Initial transthoracic echocardiogram (TTE) demonstrated a 3.5cm mobile mass in the right ventricle (RV) attached to the interventricular septum and subvalvular apparatus, and trace tricuspid regurgitation (TR). Computed tomography with angiography (CTA) of the chest demonstrated multifocal cavitating pneumonia. Additionally, aspirated right knee fluid was consistent with septic arthritis.
Oxacillin, heparin infusion, and methadone were initiated with plan to undergo cesarean delivery at 34-weeks of gestation followed by interval TVR after completion of a 6-week course of oxacillin. After 5 days of treatment, repeat TTE showed enlargement of RV mass to 4.9cm and severe worsening of TR (Figure 1) . Repeat arthrocentesis grew S. aureus , suggesting either left heart involvement or right-to-left shunting. Transesophageal echocardiogram (TEE) (Figure 2 ) identified no left-sided involvement, severe TR, and a large patent foramen ovale (PFO). After 12 days, the patient developed a purpuric rash of her lower extremities, deemed as a drug-related vasculitis from oxacillin. Thus, oxacillin was replaced with IV vancomycin, resulting in gradual resolution of the rash.
Due to the urgent need for cardiac intervention, multidisciplinary consensus was to proceed with cesarean section followed by interval TVR and PFO closure. The patient received antenatal corticosteroids for fetal lung maturity. Anticoagulation was held prior to delivery. She underwent repeat cesarean delivery via classical hysterotomy at 28 weeks 6 days gestation under general anesthesia. Femoral arterial and venous access was obtained to allow for emergent availability of venoarterial extracorporeal life support (ECLS). Cardiothoracic surgery, cardiac anesthesia, obstetric anesthesia, perfusionists, and neonatology teams were present for the surgery. Fetal status remained reassuring throughout. A viable female infant was delivered weighing 1230g, with Apgar scores 3, 5, and 8 at one, five, and ten minutes, respectively. The neonate was intubated at 4 minutes of life and admitted directly to the newborn intensive care unit in stable condition.
On post-delivery day 5, patient underwent TVR via median sternotomy and right atriotomy on cardiopulmonary bypass (CPB) and heart arrest A large, friable flesh-colored mass was attached to the interventricular septum and entangled throughout the anterior and posterior subvalvular apparatuses (Figure 3 ), necessitating careful excision along with removal of the anterior and posterior leaflets. The septal leaflet was free from involvement and subsequently preserved to minimize risk of injury to the atrioventricular conduction system. A 33mm Epic bioprosthetic valve was inserted. The PFO was closed primarily. Bipolar epicardial pacing wires were placed on both ventricles and right atrium. Intra-operative TEE demonstrated good biventricular function with no residual mass or interatrial shunt. Despite sparing of the septal leaflet, her post-operative course was notable for high-grade second-degree atrioventricular conduction block requiring pacemaker generator placement. She recovered well from her procedures and was discharged home in excellent condition. The neonate was extubated on day of life 10 and recovered well.