Tricuspid valve endocarditis following central venous cannulation: The increasing problem of catheter related infection
A 45-year-old female with accidental flame burns of the chest and upper limbs (approximately 30%) was referred from another hospital with high fever and breathlessness requiring Ventilatory support. She was primarily treated there for superficial burns, during which time a right internal jugular vein catheter was inserted in the intensive care unit (ICU) for administration of drugs and volume. Five days after insertion of the CVC, the patient developed high fever and, over the next 7 days, breathing difficulty, this was interpreted as sepsis and supported by laboratory investigation and growth of methicillin-resistant Staphylococcus aureus (MRSA) in the blood sample. Appropriate antibiotics were administered and the patient showed no clinical improvement despite 3 weeks of antibiotic treatment. She persistently recorded high temperatures and was breathless even at rest. She was referred in this status to our hospital and was put on respirator for poor blood gas values. Further evaluation of sepsis with transthoracic echocardiogram showed large vegetation, measuring approximately 3 cm, on the anterior tricuspid leaflet (ATL) with no tricuspid regurgitation. Other cardiac valves were normal. Trans-oesophageal echocardiogram confirmed the findings []. The patient had to be ventilated for respiratory decompensation secondary to showering of the pulmonary circuit by tiny vegetations on the ATL and was taken for surgery immediately. Through a standard median sternotomy, the heart was placed on cardiopulmonary bypass and the tricuspid valve was approached through the right atrium after cardioplegic arrest. Large vegetation was seen occupying almost half of the anterior tricuspid leaflet [], and the vegetation seemed to travel down the chordal apparatus as well. Other leaflets of the tricuspid valve and the pulmonary valve were normal. Total vegetectomy was performed with curettage of the anterior tricuspid leaflet and the remaining defect in the ATL [] was repaired with a piece of native pericardium. Because the patient was culture positive for MRSA, a prosthetic ring was not placed and the patient weaned off cardiopulmonary bypass with minimal support. She was afebrile the next day of surgery and remained so till her discharge from the hospital. The vegetation grew MRSA.