Lactococcus endocarditis after Bentall procedure presenting with intracranial hemorrhage

Abstract

Background: Endocarditis is more common in patients with cardiac prostheses. A Bentall procedure entails surgical replacement of the aortic valve, aortic root, and ascending aorta with re-implantation of coronary arteries into the graft.

Case: 65-year-old male with history of atrial fibrillation on rivaroxaban, bicuspid aortic valve, and ascending aortic aneurysm with a history of a Bentall procedure two years prior, presented with headache and dysarthria for one day. National Institutes of Health Stroke Scale was 3 and CT head showed 2.7 cm left frontal hematoma with extension into the subarachnoid space. Andexanet alfa was given for rivaroxaban reversal followed by cerebral angiogram which showed 5 mm intracranial inferior MCA aneurysm and embolization and coil placement was done. Blood cultures grew Lactococcus garvieae and transesophageal echocardiogram revealed aortic valve thickening and vegetation on the non-coronary cusp. He was subsequently treated with six weeks of IV ceftriaxone and Gentamycin.

Conclusion: With increasing use of bioprosthetic valves, the possibility of infective endocarditis with uncommon pathogens should be kept in mind. Lactococcus commonly affects native valves, however it can affect bioprosthetic valves and can present with mycotic aneurysms.

Keywords: Bentall procedure; Endocarditis; Intracranial Hemorrhage; Lactococcus.

Fig. 1

CT Head showing left frontal hematoma with extension into subarachnoid space.

Fig. 2

CT angiogram showing Inferior middle cerebral artery aneurysm. MCA = Middle Cerebral Artery.

Fig. 3

Midesophageal short axis view showing aortic valve with vegetation on non-coronary cusp and thickening of right coronary cusp.

Fig. 4

Midesophageal long axis view showing aortic valve with vegetation on non-coronary cusp and thickening of right coronary cusp.