A 69-year-old man was admitted in our hospital due to fever, chill, orthopnea and paroxysmal nocturnal dyspnea. In physical examination, respiratory sounds were reduced in both his lower half of lung fields.\nHe had undergone a major cardiac surgery including CABG, MVR, aortic valve replacement (AVR) and ascending aorta replacement due to severe coronary artery disease, significant valvular heart disease (rheumatic) and aneurysmally dilated ascending aorta, 75 days prior to his recent admission.\nAn electrocardiogram revealed atrial fibrillation rhythm, normal axis and non-specific ST-T changes in inferior and lateral leads (). The posteroanterior view of the chest radiography showed massive bilateral pleural effusion. Transthoracic echocardiography followed by TEE showed normal LV size with preserved systolic function, bioprosthetic MV with acceptable hemodynamic and mobility and no paravalvular regurgitation. Bioprosthetic AV had acceptable hemodynamic and mobility without paravalvular regurgitation. There was normal functioning ascending aorta Dacron tube graft without leakage from proximal and distal part of prosthesis.\nThe LA was enlarged and dissection was found on the posterior wall. Two homogenous particles (1.18 × 0.4 cm and 0.9 × 0.58 cm) were attached to the dissecting flaps which were highly suggestive for vegetations and IE (, , and , , , and ).\nLaboratory tests showed severe coagulopathy, high levels of fibrin degradation products, leukocytosis (white blood cells count: 26700/cm3, predominantly poly morphonucleated), severe anemia, thrombocytopenia, elevated liver enzymes and serum creatinine levels. These data were suggestive for DIC. The blood culture revealed enterococci septicemia.\nHis general condition deteriorated rapidly. He suffered from tonic-clonic seizures, diminished consciousness, widespread mucosal bleeding and oliguria. Bilateral chest tubes were inserted for massive pleural effusion. The patient was treated with intravenous vancomycin, cefepim, gentamycin and oral rifampin. He received infusion of fresh frozen plasma, packed cells, valproic acid, diazepam and phenytoin.\nBased on his poor general condition, cardiac surgery was not performed and finally he expired from multi organ failure. Autopsy findings were consistent with clinical, laboratory and echocardiographic findings.
A 55-year-old man presented with rheumatic heart disease, severe mitral regurgitation, moderate pulmonary arterial hypertension, and good biventricular function. He was scheduled for mitral valve replacement (MVR). After applying standard monitors and preoxygenation, general anesthesia was induced with 2 mg of midazolam, 50 mg of propofol, 200 μg of fentanyl, 60 mg of lidocaine, and 8 mg of vecuronium. Anesthesia was maintained with oxygen: Air, 1% isoflurane, and intermittent doses of fentanyl. The trachea was intubated with an 8.5-mm single-lumen tracheal tube. A right femoral arterial catheter was placed for continuous blood pressure monitoring.\nMVR with 29 mm St. Jude mechanical prosthetic valve with posterior mitral leaflet preservation was performed through transseptal approach on conventional cardiopulmonary bypass (CPB) and cold blood cardioplegia. The patient was weaned off CPB with the optimal inotropic support of 5 μg/kg/min of dopamine and 5 μg/kg/min dobutamine. But, the pressures were on borderline around 80/38 mmHg, and right ventricle appears to be distending with poor myocardial contractions. So, we decided to put transesophageal echocardiography (TEE) probe to see for any abnormality. To our surprise, we saw a circular hypoechoic mass in the left atrial (LA) free wall encroaching onto the mitral valve []. This finding was discussed with the surgeon, who decided to re-explore the LA. LA atriotomy was reopened, the mitral valve appeared to be well seated, and there was no evidence of dissection. Only the LA free wall appeared to have subendocardial blood collection. There were no continuities between the cavity and the LA, left ventricle, posterior pericardial space. Marsupialization of the cavity is done and opened it to the LA cavity [].\nThe patient was then weaned from CPB for the 2nd time with inotropic support of 0.375 μg/kg/min of milrinone, 5 μg/kg/min of dopamine, 5 μg/kg/min dobutamine, and 0.05 μg/kg/min of nor epinephrine. The post-bypass TEE examination showed that LA dissection (LAd) wall appeared to be incised in the middle and drained out the blood.\nThe patient's postoperative course was complicated by intermittent periods of desaturation which required bi-level airway pressure ventilation with which he showed improvement in oxygenation. The patient was discharged from the hospital 15 days after surgery.