Case report:
A 72-year-old male patient was referred to our hospital for one-month history of high-grade fever. The patient had multiple comorbidities including: end-stage kidney disease on haemodialysis in the last six months through a dialysis catheter, diabetes mellitus, and chronic obstructive pulmonary disease. He also had coronary artery disease (CAD) with a stent implantation in the right coronary artery (RCA) seven years before presentation, that was complicated with a hemopericardium and evacuated by a pericardial window. In addition, he had a complete atrio-ventricular block with a dual chamber pacemaker implantation. Physical examination revealed a holosystolic murmur at the left lower sternal border and severe bilateral lower limb oedema. Laboratory workup revealed leukocytosis (wbc 12700 c/ul). Blood cultures were obtained. Trans-thoracic echocardiography showed decreased left ventricular ejection fraction (35%), severely decreased right ventricular function, grade 4/4 tricuspid regurgitation, 15-mm mobile vegetation in the right atrium (RA), and a large saccular aneurysm on the RCA. CT angiography revealed a 58 x 47 mm collection crossed by the RCA that has a thrombosed wall of 9 mm thickness (figure 1). Coronary angiography showed triple vessel CAD with extravasation of the contrast material through the RCA (video 1). He was prepared for surgery and had to be started on low dose norepinephrine due to hypotension. Under cardio-pulmonary bypass and after aortic cross-clamping, the false aneurysm was opened, pus came out; samples were sent to culture. Fibrin membranes and old clots were entirely removed (video 2). The RCA was completely avulsed; it was suture ligated (figure 2.A). The whole pouch was washed using povidone iodine, normal saline, and oxygen peroxide. The lateral wall of the RA seemed ruptured with creation of a fistula. A right atriotomy was performed. The fistula was found and debrided (figure 2.B). It was closed using a pericardial patch. De Vega technique was used for tricuspid valve annuloplasty, then CABG was done using saphenous vein grafts to the left anterior descending and the obtuse marginal arteries. Weaning of the bypass needed high doses of vasopressors. The patient was transferred to the cardiac surgery unit in a frail hemodynamic condition; three hours later, he developed severe sepsis resistant to maximal medical therapy, and unfortunately passed away.
The preoperative blood cultures grew MRSA. The intraoperative purulent secretions grew the same pathogen.