Hepatic Duct Perforation Following Mitral Valve Replacement for Infectious Endocarditis: A Case Report

Hepatic duct perforation (HDP) is a rare and life-threatening condition in adults, typically caused by direct injury or increases in intraductal pressure. The risk of HDP following cardiac surgery is poorly documented, although predisposing factors, such as bilirubin overload and ischemia from cardiopulmonary bypass, share common pathophysiological mechanisms with postoperative cholecystitis. We report the case of an 80-year-old woman who underwent mitral valve replacement for infectious endocarditis. Preoperatively, she was asymptomatic with mild common hepatic duct dilatation but no stones or ascites. However, her condition was also complicated by anemia and sepsis-induced disseminated intravascular coagulation. The cardiac surgery involved 153 minutes of extracorporeal circulation and required massive transfusion. On postoperative day (POD) four, she developed respiratory failure requiring re-intubation. A subsequent computed tomography and abdominal paracentesis confirmed HDP. Given her hemodynamic instability and prohibitive surgical risk, percutaneous drainage was performed. Although the acute biliary peritonitis initially improved, she developed persistent low-grade inflammation. On POD 61, she suffered from pancytopenia and reactivation of both varicella-zoster virus and cytomegalovirus, ultimately leading to multiple organ failure and death on POD 84. HDP can be a critical postoperative complication of cardiac surgery, potentially triggered by bypass-induced hypoperfusion and systemic stress. Despite successful percutaneous drainage, the persistent inflammatory state may induce secondary immunodeficiency and fatal opportunistic viral reactivation. This case highlights the inherent limitations of conservative management and the difficulty of deciding on definitive surgical intervention in critically ill postoperative patients.