Destructive acute infective endocarditis and purulent pericarditis

Abstract

Infective endocarditis shows varied clinical status. Some papers presented the cases with spread of infection to the pericardium [1, 2]. A 28-year-old female patient presented with high-grade fever and dyspnea for several weeks. She also suffered from diarrhea and was administered intravenous doripenem. However. her condition worsened and she was admitted to a local hospital. Vegetations were detected by two-dimensional transthoracic echocardiography (TTE) and she was diagnosed with infective pericarditis. Blood cultures grew methicillinresistant Staphylococcus aureus (MRSA). She was treated with vancomycin and gentamicin sulfate. Multiple cerebral infarctions occurred on the second hospital day. On the fourth hospital day, congestive heart failure became more serious and she required high-dose catecholamine intubation and assisted ventilation. She was transferred to our hospital for operation. On admission, she was very sick and in shock. Chest X-ray showed severe pulmonary congestion. Large and pendulated vegetations were detected in the posterior mitral leaflets (Fig. 1a, b). We detected the abscess and dissection of the posterior mitral annulus and left atrial wall (arrow) (Fig. 1a–d). Two-dimensional color Doppler demonstrated to-and-fro abnormal flow from the left ventricle toward the mitral periannular abscess (Fig. 1e, f). TTE also revealed a circumferential dense mobile pericardial effusion. We considered that to be the abscess of the posterior mitral annulus, which extended to the left atrial wall, causing dissection, and perforated into both the left ventricle and left atrium, creating the communication between them. The wall of the left atrium was dissected. We diagnosed destructive acute infective endocarditis, periannular abscess, and purulent pericarditis. She was in a potentially lethal condition, so an emergency surgery of the mitral valve and left atrial reconstruction was immediately performed. We had no time to perform transesophageal echocardiography. The operation was performed through a median sternotomy under a mild hypothermic cardiopulmonary bypass. Marked accumulation of purulent pericardial fluid and pus was found (Fig. 2). There was a large vegetation on the P2 scallop of the mitral valve. The left atrial wall near the P2 and P3 scallops was dissected. The dissected space showed an abscess. Mitral valve repair was performed. The P2 and P3 scallops were resected and reconstructed by using a glutaraldehydetreated autologous pericardium patch. The left atrium was reconstructed by horse pericardium. Annuloplasty was performed by using autologous pericardium. On postoperative day 45, we performed TTE. The patient’s left ventricular function was normal and mitral regurgitation was not detected. After 6 weeks of treatment with intravenous vancomycin administration, she was discharged on foot on postoperative day 49.