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• W4387268520 abstract "SESSION TITLE: Cardiovascular Disease Case Report Posters 16 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 02:10 pm - 02:55 pm INTRODUCTION: The prevalence of IV drug use (IVDU)-associated infective endocarditis (IE) is steadily rising (1-3). Despite this, there is a paucity of data on the management of right-sided IE, particularly in the population of people who inject drugs (2). The management of IE in this population is complex due to high morbidity and mortality in addition to challenging psychosocial factors (3). While antimicrobial therapy is the mainstay of management, surgical intervention is often considered (1, 2). Indications for surgery include persistent bacteremia, size greater than 20 mm, right heart failure, microorganisms difficult to eradicate, recurrent pulmonary emboli, and abscess formation (2). Despite surgical criteria, the application of surgery is heterogenous in clinical practice (1). We present a case of complete recovery from pulmonary septic embolism with medical management in a patient with IVDU-associated IE from a large tricuspid valve (TV) vegetation meeting surgical criteria. CASE PRESENTATION: A 27-year-old male with polysubstance use disorder was admitted for acute hypoxic respiratory failure and cardiac arrest. He presented with shortness of breath, emesis, and pink frothy sputum. On arrival he was febrile, hypotensive, and hypoxic. He was ill-appearing and in acute distress with diaphoresis, tachycardia, rhonchi, and respiratory failure requiring intubation. Workup was notable for septic shock due to multifocal pneumonia and cardiogenic shock from cardiac arrest and hemodynamically significant culture negative TV IE. Echocardiogram (TTE) showed biventricular failure, a two-centimeter TV vegetation, and a right atrial mass. He was medically managed and cardiac surgery was deferred, despite vegetation size, due to critical illness and history of IVDU. His course was complicated by respiratory decline with maximal oxygen support while intubated due to embolization of the large vegetation. He was managed with medical therapy and gradually improved. He was weaned from the ventilator and ultimately achieved a complete recovery. DISCUSSION: A large proportion of IVDU-associated IE patients require valvular intervention (1). Outcomes in this population are mixed. Overall survival for first repair is high, however, there is a high rate of recurrence and mortality in patients with untreated substance use disorder (1,3). Furthermore, the reoperation rate is high and associated with worse post-operative outcomes (1). The most common complications include valvular insufficiency, abscess formation, and pulmonary septic embolism (2) with higher mortality in cases of vegetation size greater than 20 mm (3). Despite this, evidence suggests a lower comparative mortality for IVDU-associated IE, due to right-sided disease, young age, and lack of comorbid illness (3). This suggests that avoidance of valvular replacement may ultimately portend a more favorable outcome, even despite complications of pulmonary septic embolism as demonstrated in this case. CONCLUSIONS: The management of IVDU-associated IE is complex, in large part due to co-morbid substance use disorder and high rate of relapse and recurrence. Therefore, there is a trend in clinical practice to avoid valve replacement in this population (2). This case demonstrates that though pulmonary septic embolization is a feared complication of TV IE and often necessitates surgery, it may be well tolerated in young patients without underlying pulmonary disease and burdensome medical comorbidities. REFERENCE #1: Baddour LM, Weimer MB, Wurcel AG, et al. Management of infective endocarditis in people who inject drugs: A scientific statement from the american heart association. Circulation. 2022;146(14):e187-e201. Accessed Mar 22, 2023. doi: 10.1161/CIR.0000000000001090. REFERENCE #2: Shmueli H, Thomas F, Flint N, Setia G, Janjic A, Siegel RJ. Right-sided infective endocarditis 2020: Challenges and updates in diagnosis and treatment. J Am Heart Assoc. 2020;9(15):e017293. Accessed Mar 22, 2023. doi: 10.1161/JAHA.120.017293. REFERENCE #3: Yucel E, Bearnot B, Paras ML, et al. Diagnosis and management of infective endocarditis in people who inject drugs: JACC state-of-the-art review. J Am Coll Cardiol. 2022;79(20):2037-2057. Accessed Mar 22, 2023. doi: 10.1016/j.jacc.2022.03.349. DISCLOSURES: No relevant relationships by Alan Gandler No relevant relationships by Cara Pietrolungo" @default.
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• W4387268520 date "2023-10-01" @default.
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• W4387268520 title "NOW YOU SEE IT, NOW YOU DON'T: A CASE OF WELL-TOLERATED LARGE SEPTIC PULMONARY EMBOLISM IN TRICUSPID VALVE ENDOCARDITIS" @default.
• W4387268520 doi "https://doi.org/10.1016/j.chest.2023.07.481" @default.
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