HACEK ENDOCARDITIS: A COMPLEX CASE OF HAEMOPHILUS ENDOCARDITIS AND COMBINED HEART-LIVER TRANSPLANTATION

SESSION TITLE: Chest Infections Case Report Posters 34 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Infective endocarditis (IE) has high mortality rates despite advancements in management. HACEK bacteria can cause IE, typically progressing insidiously in individuals with heart conditions or prosthetic valves (1). This report discusses a 57-year-old male with a complex cardiac history and end-stage liver disease who developed Haemophilus endocarditis with complications that eventually required combined heart-liver transplantation. CASE PRESENTATION: A 57-year-old male with a past medical history of coronary artery disease, aortic stenosis, cirrhosis, and hepatocellular cancer presented with fevers, rigors, fatigue, and shortness of breath. He was diagnosed with Haemophilus bacteremia and culture-negative endocarditis due to Haemophilus influenzae, for which he was treated with ceftriaxone. He returned a month later with similar symptoms. A transthoracic echocardiogram revealed an enlarged left ventricular chamber size with myocardial thinning and perivalvular aortic insufficiency. Due to the risk of bleeding, the patient's transesophageal echocardiogram (TEE) was delayed, and he was followed up with repeat blood cultures. Three months later, he presented with recurrent ascites, acute decompensated heart failure, and newly diagnosed portal vein thrombosis. A TEE was then conducted, which showed a periaortic abscess and pseudoaneurysm with communication from the aorta to the LV outflow tract. The patient was deemed unsuitable for surgical intervention and was referred to Mayo Clinic Florida's high-risk multiorgan selection committee for combined heart-liver transplant evaluation. Since no other options were available, the patient was listed, and four months after his initial endocarditis diagnosis, the patient was successfully transplanted. Following the transplant, the patient initially presented cardiogenic shock and vasoplegia but was managed with angiotensin II, epinephrine, dobutamine, norepinephrine, vasopressin, inhaled nitric oxide, and Cyanokit. The patient remained on CRRT for fluid removal and was eventually discharged on postoperative day 26. DISCUSSION: Infected aortic aneurysms are a complication of IE and are severe conditions with high morbidity and mortality. Treatment typically involves antibiotics, surgical debridement, and aortic repair (2). However, a challenging case arose due to the patient's comorbid esophageal varices, delaying the identification and management of a periaortic abscess and pseudoaneurysm via TEE. Despite chronic antibiotic therapy, the patient was found to have an extensive abscess and pseudoaneurysm, rendering surgical aortic repair unsuitable. A combined heart and liver transplantation was a life-saving option. CONCLUSIONS: HACEK endocarditis may have an insidious course but can lead to severe complications like periaortic abscesses and aneurysms, particularly in patients with complex cardiac comorbidities. Early identification is crucial to prevent complications and improve outcomes. To the best of our knowledge, this is the first reported case of a combined heart and liver transplant in a patient with HACEK endocarditis, highlighting the importance of considering novel treatment approaches in complex cases to optimize patient outcomes. REFERENCE #1: (1) Khaledi, M., Sameni, F., Afkhami, H., Hemmati, J., Asareh Zadegan Dezfuli, A., Sanae, M. J., & Validi, M. (2022). Infective endocarditis by HACEK: a review. Journal of cardiothoracic surgery, 17(1), 185. https://doi.org/10.1186/s13019-022-01932-5 REFERENCE #2: (2) Reddy DJ, Shepard AD, Evans JR, Wright DJ, Smith RF, Ernst CB. Management of Infected Aortoiliac Aneurysms. Arch Surg. 1991;126(7):873–879. doi:10.1001/archsurg.1991.01410310083012 DISCLOSURES: No relevant relationships by Lisa Brumble No relevant relationships by Kristopher Croome No disclosure on file for Rohan Goswami No relevant relationships by Sean Kiley No relevant relationships by Pablo Moreno Franco No relevant relationships by Parag Patel Data Safety Monitoring Board relationship with Talaris Therapeutics Please note: 2020-2023 Added 04/01/2023 by Si Pham, source=Web Response, value=Consulting Share holder relationship with GanD, Inc. Please note: 2019--Present Added 04/01/2023 by Si Pham, source=Web Response, value=Share holder Advisory Committee Member relationship with Noveome Biotherapeutics Please note: 2018-present Added 04/01/2023 by Si Pham, source=Web Response, value=Share holder Share holder relationship with Adolore Biotherapeutics Please note: 2022-present Added 04/01/2023 by Si Pham, source=Web Response, value=Share holder No relevant relationships by Jorge Sinclair De Frías No relevant relationships by Trisha Singh No relevant relationships by Liu Yang