Acute Mesenteric Ischemia Prior to Emergency Cardiac Surgery for Infective Endocarditis: Can We Design a Strategy to Improve Outcomes?

Infective endocarditis (IE) can be complicated by systemic embolization. Unfortunately, in some situations, it requires radical and urgent therapeutic approaches. Herein, we describe a case of IE complicated by acute mesenteric ischemia (AMI) due to septic embolism prior to emergent cardiac surgery. A previously healthy 38-year-old woman was admitted to our emergency department with a diagnosis of mitral valve IE. She presented with tachycardia and was tachypneic. In addition, a systolic murmur in the mitral area and Janeway lesions were documented. Transthoracic and transesophageal echocardiography confirmed large mobile vegetations on the mitral valve and the presence of mitral regurgitation. A thoracic computed tomography scan showed splenic and bilateral renal infarctions. Emergency mitral valve replacement was scheduled. Prior to surgery, AMI developed because of occlusion of the superior mesenteric artery (SMA). Endovascular treatment was performed with percutaneous aspiration, thrombectomy, and in situ fibrinolysis, yielding satisfactory results. Ten hours later, she underwent cardiac surgery. AMI developed postoperatively due to re-occlusion of the SMA, requiring an open laparotomy with mesenteric revascularization and extensive resection of the necrotic bowel. The patient died 18 days after hospitalization. In the IE setting, AMI is a very rare, potentially life-threatening complication. This case highlights the importance of recognizing this complication and designing a better therapeutic strategy to reduce the associated mortality rate.