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The Patient with Endocarditis
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Endocarditis should be suspected whenever a patient presents with a new-onset heart murmur, positive blood cultures, fever, and splinter hemorrhages.1 Patients can present with endocarditis with negative blood cultures. Echocardiographic visualization of the vegetation is critical in identification of the valves affected and the hemodynamic consequence of the infection. Antibiotic therapy can be used when the lesions are without hemodynamic consequence; however, should patients develop hemodynamic compromise, surgery is indicated. Likewise, recurrent embolism from valvular vegetations or infected prosthetic valves may need to be addressed surgically.
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Case Questions
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A 33-year-old IV drug abuser presents for surgery. Video 8–5 reveals the presence of vegetation on which valve/s?
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An aortic valve vegetation is demonstrated.
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The patient is taken for surgery and the valve replaced. Following administration of protamine the patient's systemic blood pressure is 60/40 mm Hg, his PA pressure is 60/40 mm Hg. What is the most likely diagnosis?
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Patient is experiencing a protamine reaction. His right heart has dilated and his LV is underloaded.
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What are the treatment options at this time?
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The patient is treated with inotropic support and the RV becomes more contractile, systemic blood pressure is restored to 90/70 mm Hg, and PA pressure is now 45/20 mm Hg. The remaining protamine is administered slowly and his ACT is corrected.
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Had he not responded to inotropic therapy what other options are available to the anesthesia and surgery team?
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The patient can be reheparinized and placed on cardiopulmonary bypass. Inhaled NO therapy can be started to lower PA pressures and decrease RV afterload.