Acute aortic valve regurgitation (AAR) is a life?threatening condition characterized by abrupt incompetence of the aortic valve during diastole, leading to rapid volume overload of the left ventricle, elevated left ventricular end?diastolic pressure, reduced forward output, and often resulting in pulmonary edema and cardiogenic shock. AAR has multiple etiologies including infective endocarditis, aortic dissection, blunt chest trauma, suture dehiscence, or complications of invasive procedures. Among these, infective endocarditis is one of the more common and severe causes and frequently necessitates urgent or emergent surgical aortic valve replacement.

Patients with AAR due to endocarditis often deteriorate rapidly. Clinical and echocardiographic markers such as high heart rate (e.g., ≥94 bpm), low diastolic blood pressure, features like premature closure of the mitral valve, and diastolic mitral regurgitation are predictive of decompensation, including pulmonary edema and severe hemodynamic instability. [4] In one large cohort, about half of patients presenting with AAR had severe heart failure (New York Heart Association functional class III–IV), and many required emergency surgery; in?hospital mortality was high in those with advanced functional class. [5].

Surgical treatment is indicated when valve dysfunction results in acute heart failure, persistent pulmonary edema, or cardiogenic shock, especially when medical therapy is insufficient. Delay in surgical management in these settings is associated with significantly worse outcomes. [6] Additionally, while acute pulmonary complications (pulmonary edema) may improve after surgery, delayed lung recovery or prolonged ventilatory support in the postoperative period contribute substantially to morbidity. Case reports illustrate that urgent aortic valve replacement in infective endocarditis with severe regurgitation can lead to marked relief of symptoms and resolution of pulmonary edema; however, the magnitude and speed of lung recovery vary [7].

Herein, we present a case of acute severe aortic valve regurgitation secondary to native valve infective endocarditis, complicated by cardiogenic shock and acute pulmonary edema, which required urgent aortic valve replacement. The case also demonstrates significant postoperative delay in pulmonary recovery, and we highlight intraoperative and perioperative measures that may improve outcomes in such critically ill patients.

Acute Aortic valve regurgitation is a clinical condition that can occur due to many causes like endocarditis, aortic dissection, blunt trauma etc. of which Endocarditis is more often and require early surgical Aortic valve replacement. Herein, we present a case of acute severe aortic valve regurgitation secondary to aortic valve endocarditis leading to cardiogenic shock and pulmonary edema that required urgent aortic valve replacement. Delayed Lung recovery in the post-operative period adds significantly to the morbidity. This case highlights the intra operative measures for the better outcomes in such cases.

51-year-old male farmer, works in animal husbandry, with no comorbidities, presented to Emergency with complaints of fever for 6 days, breathlessness and cough with pink frothy sputum for 3 days and chest discomfort for 1 day. On admission to ER, his had BP of 120/43mmHg, PR 98/min regular, high-volume pulse, on Inj. Noradrenaline 0.07mcg/kg/min, inj. Furosemide 1mg/hr, respiratory rate of 33/min saturating 92% with BIPAP (12/6) with 2lit/min oxygen supplementation. On examination, he had generalized bilateral crepitations with early diastolic murmur at aortic area.

Echo revealed perforation of size 0.7 x 0. 3cm in Non coronary cusp of aortic valve with severe regurgitation as per 2020 ACC/AHA and 2021 ESC guidelines: ERO: 0.8 cm2; AR Reg Vol: 98 ml and early root involvement adjoining aorto-mitral curtain, RVSP 69mmHg with moderate Tricuspid regurgitation.

Figure 1: RVSP 69mmhg with Moderate Tricuspid Regurgitation.

Baseline blood investigations showed haemoglobin of 10.5 gm%, elevated WBC counts at 18,120/cu.mm and rest of the parameters being with in normal limits. Blood, urine, sputum was sent for culture and sensitivity and was started on Inj. Ceftriaxone 2g BD and Inj Daptomycin 700mg OD.

He was continued on NIV, Inj. Noradrenaline, Inj furosemide infusion. Fever settled 3 days after the admission. CAG showed normal coronaries. Blood, urine, sputum sent for cultures were negative. He was taken up for AVR. Class I indication as per 2020 ACC/AHA and 2021 ESC guidelines.

Intra operatively, Cardio pulmonary bypass was initiated with Aorta and RA- 2 stage cannulation. Blood cardioplegia was used.

Findings: - Two vegetations on 1 cm each over the LCC and small abscess cavity under the LCC-NCC junction extending below the LCC. Valve excised. Root abscess cavity is washed with Inj. Gentamycin. Aortic valve was replaced with SJM regent flexcuff mechanical heart valve using 15 (3 non pledgeted and 12 pledgeted) 2-0 ethibond everting horizontal mattress sutures sealing the abscess cavity. Aortotomy closed with 5-0 prolene in 2 layers.

Intra operatively, Packed RBC and FFP were used in priming fluid and pulsatile flows were given using centrifugal pump. Cell saver and ultra-filter were used. Aortic cross clamp time was 72 minutes and total cardio pulomonary bypass time was 103 minutes. Patient was shifted to ICU without inotrope/vasopressors.

Aortic valve tissue was sent for histopathology, gram staining, fungal staining, AFB staining, culture and sensitivity, AFB culture, fungal culture, RID with Bactifast and fungifast. Swab from root abscess was sent for culture and sensitivity.

On receiving to icu, baseline ABG showed pO2 of 117mm Hg with 100% fiO2. He was put on PEEP of 8 cm of water overnight. His oxygenation has gradually improved and was extubated to NIV on POD 1. He was started on Inj. Furosemide infusion on pod 1.

Spirometry exercises and chest physiotherapy started post extubation. Drains were removed on pod 1. He was mobilised on pod 2 and was shifted to ward on pod 3 with 2 lit/min oxygen. Oxygen supplementation was tapered and stopped on POD 4.

Post op Echo showed AV MPG of 8 mmHg and AVPPG of 15 mmHG with no para valvar leak. And was discharged on pod 5.RID with bactifast in valve tissue detected Streptococcus agalactia. Inj Ceftriaxone 2g iv OD is being continued for 6 weeks.

 Figure 2: AV MPG of 8 Mmhg and AVPPG of 15 Mmhg with No Para Valvar Leak.

1. “Age and other peri-operative risk factors for poet operative systemic inflammatory response syndrome after cardiac surgery” by JM Dieleman.

Systemic inflammatory response syndrome post cardiac surgery has significant impact on the patient recovery as it causes end organ injury. SIRS worsens the morbidity and mortality risk in the peri operative period. Various peri operative features namely age, gender, BMI, smoking, diabetes mellitus, hypertension, renal dysfunction, peripheral vascular disease, lung disease, CCF, recent MI, valve surgeries, cardio pulmonary bypass, prolonged CPB time, infections, blood transfusions can lead to SIRS.

2. Efforts should be made to effectively reduce the risk of SIRS.

Modified Ultrafiltration Reduces Morbidity After Adult Cardiac Operations-

A Prospective, Randomized Clinical Trial

Giovanni Battista Luciani, MD; Tiziano Menon, CP; Barbara Vecchi, MD; Stefano Auriemma, MD; Alessandro Mazzucco, MD

Ultra filtration during Cardio pulmonary bypass reduces the risk of end organ injury reducing the morbidity and mortality post operatively.

3. Pulsatile Perfusion during Cardiopulmonary Bypass: A Literature Review Aileen Tan MBBS;*, Caroline Newey MSc† and Florian Falter MD, FRCA, FFICM, PhD*.

Measures to control SIRS peri operatively make a great impact on the recovery of the patient especially in cases of emergency/urgent cardiac surgeries involving cardio pulmonary bypass.

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4. Chasapi A, Kamatamu A, Mbonye MB, Bajomo O, William J, Primus C, et al. ‘Clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to infective endocarditis. 2021; 38: 590-595.
5. Claudia CM, Casabé JH, Favaloro RR, Raffaelli H, Dulbecco E, Abud J, et al. Cortes et al. Acute aortic regurgitation due to infective endocarditis. 2017; 77: 373-381.
6. Bernard D, Tornos P. Surgery for infective endocarditis: Who and When. 2010; 121.
7. Hou C, Wang WC, Chen H, Zhang YY, Wang WM. Infective bicuspid aortic valve endocarditis causing acute severe regurgitation and heart failure: A case report. 2021; 19: 1221-1227.