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.