Aortic Valve Endocarditis Research Articles

Aortic valve endocarditis with root abscess causing superior vena cava obstruction: a case report

BackgroundTo our knowledge, we report the first case of endocarditis with root abscess causing compressive superior vena cava (SVC) obstruction.Case summaryAn 84-year-old gentleman with previous tissue aortic valve replacement presented with fevers and systemic upset. Blood cultures grew Streptococcus anginosus and transoesophageal echocardiogram identified prosthetic valve vegetations with an associated root abscess. Antibiotics were commenced and referral made for surgical consideration. Several days into treatment the patient developed clinical signs of SVC obstruction and computed tomography demonstrated an enlarging root abscess with SVC compression. The patient was discussed with local cardiothoracic centres, but surgery was not an option primarily due to abscess size and vascular involvement. Priority moved from active to palliative treatment given no improvement with antibiotics, unsuitability for surgery, and patient discomfort. Within several weeks, symptoms/signs of SVC obstruction actually improved, likely due to collateral venous circulation formation and the patient was discharged home with palliative care input.DiscussionThere are previous reports of SVC obstruction related to infected SVC thrombus, indwelling intravascular devices, and para-aortic abscess, but none related to infective endocarditis. Streptococcus anginosus endocarditis is rare but often associated with abscess formation, and male gender, increasing age, and previous surgery are recognized risk factors.

3D echocardiography allows rapid and accurate surgical planning in complex aortic root abscess cases

SummaryDespite 3D echocardiography (3DE) acquiring significantly greater data than standard 2D echocardiography (2DE), it is underutilised in assessing cardiac anatomy and physiology. A key advantage is the ability of a single 3DE acquisition to be post-processed to generate volume-rendered 3D models and an unlimited number of multiplanar reconstruction (MPR) images. We describe the case of a highly anxious patient with life-threatening complex aortic valve endocarditis and aortic root abscess, refusing transesophageal echocardiography (TOE) under general anaesthesia with tachycardia, breathlessness and acute kidney injury precluding accurate or safe gated (computed tomography) CT, who was comprehensively assessed with a rapid 3D-TOE under sedation. This led to timely surgery and an excellent outcome for the patient.

Infective aortic valve endocarditis with root abscess formation: a mitral sparing root-Commando operation

Infective aortic valve endocarditis with root abscess formation: a mitral sparing root-Commando operation

Incidence and Surgical Outcomes of Patients With Native and Prosthetic Aortic Valve Endocarditis

The aim of this study was to retrospectively evaluate the incidence and surgical outcomes of patients with native infective endocarditis (IE) and prosthetic aortic valve endocarditis (PVE) over the past decade at a single institution. Between January 2005 and December 2015, 289 patients (mean age, 63.3 ± 14.2 years) suffering from native IE (n= 186) and PVE (n= 103) of the aortic valve underwent surgical procedures. Perioperative data were acquired retrospectively for statistical analysis. During the study period the mean incidence of endocarditis increased from 22.0 ± 4.2 (2005-2009) to 29.8 ± 10.1 (2010-2015) cases per year. In-hospital mortality was significantly increased in PVE (22.3%) versus IE (9.1%) patients (P < .001). In elective cases in-hospital mortality between the 2 groups was comparable (2.2% vs 4.6%; P= .288). Multivariate analysis identified urgent surgery (odds ratio [OR], 6.461; 95% CI, 1.941-21.509; P= .002), mitral regurgitation II (OR, 4.230; 95% CI, 1.249-14.331; P= .021), previous homograft operation (OR, 66.096; 95% CI, 2.369-1844.272; P= .0.14), and left ventricular ejection fraction < 40% (OR, 8.267; 95% CI, 1.931-35.388; P= .004) as independent risk factors for in-hospital mortality, whereas pathogen identification by preoperative blood cultures (OR, .228; 95% CI, 0.063-0.817; P= .023) was found to be independently protective. Surgery for native IE and PVE of the aortic valve may be performed with satisfactorily results at experienced cardiac surgical centers. In comparison PVE patients suffer from a more than twice as high in-hospital mortality, more postoperative complications, and inferior long-term survival. However preoperative identification of causative pathogens in IE and PVE allows for improved in-hospital survival.

Aortic valve endocarditis by a rare infectious agent in a patient with a rare congenital mitral valve abnormality.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

Native aortic valve endocarditis with Morganella morganii in a patient with multiple myeloma and valvular amyloidosis: a case report

BackgroundPatients with multiple myeloma (MM) are known to be immune incompetent and experience higher incidences of infectious diseases. However, infective endocarditis (IE) is rarely observed in patients with MM and Morganella morganii (M. morganii) has rarely been associated with IE.Case presentationA 72-year-old female receiving 4th line treatment for MM presented with fever and concomitant confusion. Urinary culture revealed growth of Escherichia coli, wherefore broadspectrum penicillin and high-dose corticosteroids were initiated. However, blood cultures showed growth of M. morganii. Fluoroquinolone was added due to penicillin-resistance of the Morganella species. Two days after admission, the patient acutely deteriorated with hemodynamic instability. Gentamicin and high dose corticosteroids were added. Echocardiography showed marked aortic valve vegetation with severe aortic valve regurgitation, leading to the diagnosis of bacterial endocarditis of the native aortic valve. Shortly after diagnosis, the patient died. At autopsy, vegetation with gram-negative rods in the native aortic valve was observed, confirming the diagnosis of M. morganii-endocarditis. Additional staining for amyloid confirmed advanced light-chain (AL) amyloidosis with extensive amyloid depositions of the aortic valve and valvular damage as complications of her MM.ConclusionsOur case suggests that IE with M. morganii was facilitated by the combination of the cardiac amyloidosis with valvular impairment and the profound immune deficiency caused by the several chemo-immunomodulatory treatment lines and the MM itself. This case further illustrates that awareness for rare opportunistic infections in an era with growing potential of combined chemoimmunotherapy is warranted.

Outcomes After Left Ventricular Outflow Tract Reconstruction With a Tube Graft for Annular Erosion

Aortic annular erosion is a serious complication of aortic valve endocarditis or previous aortic valve replacement. This study examined the outcomes of a technique for left ventricular outflow tract reconstruction using a polyester tube graft, followed by translocation of the aortic valve and coronary arteries. A total of 23 patients with extensive annular erosion resulting from endocarditis or previous aortic valve replacement with or without pseudoaneurysm formation, or occurring after excision of the native valve, underwent suture of a polyester tube graft in the left ventricular outflow tract below the annulus, replacement of the aortic valve and proximal ascending aorta with a composite graft, and reimplantation of the coronary arteries with the use of interposition polyester grafts. The mean age of the patients was 50 years, and 57% were men. There were no hospital deaths. The mean duration of follow-up was 6.5 years and extended to 16 years. Actuarial survival at 1, 5, and 10 years was 86.7%, 82.2%, and 62.6%, respectively. Two patients required reoperation for a graft-graft pseudoaneurysm and for degeneration of a porcine bioprosthesis. Echocardiograms obtained at a mean of 75 months postoperatively in 15 of the 23 patients demonstrated normal left ventricular outflow tract dimensions and velocities and a mean effective valve orifice area of 1.07 cm2/m2. All coronary artery grafts were patent on angiography a mean of 40 months postoperatively in 13 patients. Extended experience with this technique confirms its safety and effectiveness for patients withextensive destruction of the aortic annulus. It represents a suitable alternative to other currently used techniques.

Aortic valve endocarditis complicated by proximal false aneurysm.

Aortic valve endocarditis remains a life-threatening condition, especially in cases of periannular complications. Aorto-ventricular discontinuity associated with proximal false aneurysm represents a severe picture caused by extensive tissue disruption and is usually associated with prosthetic valve infection. Complex surgical repair is required in these cases and continues to be associated with high mortality and morbidity rates. We retrieved information for 32 patients undergoing operation for infective aortic valve/prosthetic valve endocarditis complicated by pseudoaneurysm arising from aorto-ventricular discontinuity. Patients were relatively young, mostly male and most of them had a prior cardiac operation. Aortic root replacement with valve graft conduit was performed in all cases; it was associated with other procedures in seven patients: CABG (n=2), MV surgery (n=3), MV surgery + CABG (n=1) and pulmonary valve replacement (n=1). We reported and analysed patient outcomes at early and mid-term follow-up. Pre-discharge mortality was 22% (n=7). The postoperative course was complicated in 24 (75%) cases. Eighteen patients (56%) sustained low cardiac output resulting in multiple organ failure syndrome and death in five cases. One patient (3%) experienced a major neurologic deficit with a permanent cerebral stroke. Acute kidney injury complicated the course in 12 cases (37%), continuous renal replacement therapy was necessary in four patients (12%). Overall survival and freedom from endocarditis and reoperation at 5-year was 59% and 89%, respectively. Patients with complicated aortic valve endocarditis presented generally in a poor preoperative state. Surgical treatment poses a non-negligible risk of postoperative mortality and morbidity but provides an acceptable survival rate and a satisfactory recovery at mid-term.

The "UFO" procedure.

The term "UFO" is not a medical term, but helps emphasize the extremely high degree of complexity of a surgical repair that is akin to someone observing an unidentified flying object. It involves replacement of the mitral and aortic valves with reconstruction of the intervalvular fibrous body (IVFB). Specific pathologies that render this operation necessary usually involve the IVFB, which is located between the aortic and mitral valves and constitutes a major portion of the fibrous skeleton of the heart. Patients that most often require such an operation are those with extensive aortic and mitral valve endocarditis with perivalvular extension into the IVFB. Other infrequent situations such as severe aortic and mitral annular calcification involving the IVFB, double valve replacement in patients with extremely small aortic and mitral annuli or double valve reoperations in which no IVFB is available following excision of both valves, necessitating the UFO procedure. The basic surgical principle has been first described as early as 1980. Depending on the extent of excised tissue due to the underlying disease, modifications and additional complex repair techniques have to be adopted. It is of utmost importance to have adequate visibility and exposure. There are certain important structures, which are at a risk of either injury or neglect, that can result in development of life-threatening complications during this operation, which a surgeon should be aware of. A step by step description of the "UFO" procedure can help guide the surgeon to perform this operation safely and efficiently. Although clinical complications are high, they are often related to the underlying disease and not specifically to the procedure itself, if performed perfectly.

Surgical options in infective valve endocarditis with neurological complications.

Surgery is a common treatment option for patients with infective endocarditis. We present a large cohort of surgically managed patients with infective endocarditis and evaluate the long-term mortality of those with and without neurological complications. We performed a retrospective review of patients surgically managed for infective endocarditis between 1994 and 2017. Demographic and outcome data were collected using a hospital database. Time-to-event analysis was performed with Kaplan-Meier curve and compared statistically with log-rank testing. At the time of admission, 680 (27.7%) patients with infective endocarditis showed neurological complications. The mean age was 62.6±14.0 years and 70% were male. Two thousand two hundred and sixty-one (92%) patients had left-sided valve endocarditis. Isolated aortic valve endocarditis was present in 59% of patients and 35% of patients had isolated infective endocarditis of the mitral valve. Mean logistic EuroSCORE was 21.2±21.6. Microbiologic cultures were positive in 1,939 patients (79%). The most common bacteria were Staphylococcus aureus (26%). In-hospital mortality in the group of patients with Staphylococcus aureus was significantly higher than in the group infected with other pathogens (18.2% vs. 13.4%, P=0.004). Patients with vegetations ≥1 cm had significantly more systemic embolization (P<0.001). 44% of patients had septic embolization with the most common site being the spleen, followed by the brain. Patients presenting with neurological complications had significantly higher in-hospital and long-term mortality (P<0.0001). Infective endocarditis patients with neurological complications have a significantly higher risk of mortality than patients without neurological complications. Surgery is an effective treatment in patients presenting with infective endocarditis, and may be undertaken in patients with neurological complications to prevent poorer prognosis.

190. Clinical Presentation of Streptococcus gallolyticus Infections

BackgroundThere are multiple publications on the association of Streptococcus gallolyticus (SG) with malignancies of the colon. SG has been also found in association with hepatocellular carcinoma, biliary tract infections, meningitis, endocarditis, urinary and other infections. In a preliminary analysis of SG and other streptococcal infections, we find that any of the GI flora may gain access to the bloodstream when there is a breach of the mucosa due to inflammation or malignant invasion. In our study, the majority of SG infections were polymicrobial and lower urinary tract infections were the most common presentation. Only 2 out of 45 had gastrointestinal malignancies both with polymicrobial blood culture results.MethodsWe evaluated 45 cases of SG seen in our health network hospitals for the past 15 months. The charts of all SG isolates were reviewed for age, sex, clinical presentation, laboratory data and susceptibilities.ResultsThere were 34 female and 11 male patients.The majority were elderly with only 5 patients below age 50, Thirty patients presented with urinary infections, 28 lower and 2 upper tract. All except 4 urinary infections were in females. Sixteen urinary infections were polymicrobial and 14 monomicrobial. Two upper tract urinary infections were monomicrobial.There were 8 bloodstream infections, 4 polymicrobial and 4 monomicrobial. Three gall bladder infections were polymicrobial and one monomicrobial. Two liver abscesses yielded polymicrobial flora. Only 4 patients had cancer 1. Metastatic pancreatic cancer 2. Carcinoma of the ampulla of Vater 3. Advanced prostate cancer 4. Anal cancer. Only 1 and 2 had positive blood cultures, both polymicrobial.The other 2 had polymicrobial lower tract urinary infections. One patient had aortic prosthetic valve endocarditis. All SG isolates tested were susceptible to penicillin, ceftriaxone and vancomycin.ConclusionThe most common presentation was urinary. There was a higher number of females due to a large number of urinary infections.The majority of infections were polymicrobial including all 4 cancer patients. Two bacteremias were associated with gastrointestinal malignancies but none with the colon. SG isolates were susceptible to penicillin, ceftriaxone and vancomycin.Disclosures All authors: No reported disclosures.

146. Infective Endocarditis in South Korea: a 12-year Single-Center Experience of 419 Patients

BackgroundInfective endocarditis (IE) is a potentially lethal disease that has undergone constant changes in epidemiology and pathogen. Treatment of IE has become more complex with today’s myriad healthcare-associated factors as well as regional differences in causative organisms. Therefore, it is necessary to investigate the overall trends, microbiological features, clinical characteristics and outcomes of IE in South Korea.MethodsWe performed a retrospective cohort study of patients with the diagnosis of probable or definite IE according to the modified Duke Criteria admitted to a tertiary care center in South Korea between November 2005 and August 2017. Poisson log-linear regression was used to estimate time trends of IE incidence rate and mortality rate. Risk factors for in-hospital mortality were evaluated by multivariate logistic regression analysis including an interaction term.ResultsThere were 419 IE patients (275 male vs. 144 female) during the study period. The median age of the patients was 56 years. The annual incidence rate of IE of our institution was significantly increased. (RR 1.05; 95% CI, 1.02–1.08; P = 0.006) The mortality rate showed trends toward down, but not statistically significant (P = 0.875). IE was related to a prosthetic valve in 15.0% and 21.7% patients developed IE during hospitalization. The mitral valve was the most commonly affected valve (61.3%). Causative microorganisms were identified in 309 patients (73.7%) and included streptococci (34.6%), followed by Staphylococcus aureus (15.8%) and enterococci (7.9%). The in-hospital mortality rate was 14.6%. Logistic regression analysis found aortic valve endocarditis (OR 3.18; P = 0.001), IE caused by staphylococcus aureus (OR 2.32; P = 0.026), a presence of central nervous system embolic complication (OR 1.98; P = 0.031), a high SOFA score (OR 1.22; P = 0.023) and a high Charlson’s comorbidity index (OR 1.11; P = 0.019) as predictors of in-hospital mortality. On the other hand, surgical intervention for IE was found to be a protective factor against mortality. (OR 0.25, P < 0.001)ConclusionAlthough IE has been increasing, the mortality rate has not yet reduced significantly. Studies on causative organisms of IE and risk factors for mortality are warranted in improving prognosis. Disclosures All authors: No reported disclosures.

The use of allogenic and autologous tissue to treat aortic valve endocarditis.

The surgical treatment of aortic valve endocarditis (AVE) is generally performed using conventional mechanical or biological xenograft prosthesis, with limited use of aortic homograft (Ao-Homo) or pulmonary autograft (PA). Clinical evidence has demonstrated a clear contradiction between the proven benefits of Ao-Homo and PA in the context of infection and the very limited use of allogenic or autologous tissue in everyday clinical practice. This review aims to summarize the most recent and relevant literature in order to foster the scientific debate on the use of the use of allogenic and autologous tissue to treat AVE. The decisional process of the Heart Team should also include the preferences of the patient, his/her family, the general cardiologist or primary care physician. The use of allogenic or autologous valve substitute is beneficial if there is a high risk of recurrence of infection, avoiding extensive adhesiolysis and debridement of synthetic material. In any case, those procedures should be performed by highly trained centers to optimize outcomes.

Use of the Medtronic Freestyle for aortic valve infection: A retrospective propensity score matched analysis.

Aortic valve and prosthetic valve endocarditis present a challenging subgroup of patients at high risk. We analyzed our experience using the Medtronic Freestyle in full root technique for the treatment of these cases over 18-year time period. We investigated the endocarditis subgroup from our cohort of 971 patients and compared results against other valve types with propensity score matching implementing nearest neighbor method. T-test, χ2 test, logistic regression, and Cox regression were performed. Fifty-four patients from the Freestyle group (FS) were matched against 54 patients from a cohort of 376 aortic valve/root endocarditis patients treated by other valve types (non-FS). Hospital mortality was 9/54 (16.7%) in the FS vs 13/54 (24.1%) in the non-FS group (P = .33). Variables age (P = .003) and renal impairment (P = .026) had an impact on mortality according to Cox regression analysis for early results. Variables with significant risk for long-term mortality included postoperative renal impairment (P = .0001) and multiorgan failure (P = .0001). Recurrent infection was low (1.8% for FS and 3.7% for non-FS group), and freedom from reoperation was 97.2%. Use of the Medtronic Freestyle was no significant risk factor for long-term mortality. The Freestyle stentless xenograft is a viable alternative for treatment of valve/root and prosthetic endocarditis. In our experience, it showed good postoperative performance with low rate of reinfection while having an acceptable operative risk-profile for this high-risk cohort.

Prosthetic valve endocarditis: A challenging complication of prosthetic valves.

This study aims to evaluate the surgical outcomes of prosthetic valve endocarditis. A total of 21 patients (6 males, 15 females; mean age 58.9±12.6 years; range, 33 to 79 years) who were surgically treated for prosthetic valve endocarditis between January 2013 and January 2018 were retrospectively analyzed. Surgical indications included persistent fever for more than seven days after antibiotherapy, congestive heart failure refractory to medical treatment, vegetations larger than 1 cm on echocardiography, the presence of fungal endocarditis, severe valvular leak and valvular dysfunction, and staphylococcal prosthetic valve endocarditis. Five patients had previous aortic valve replacement and three of the aortic prostheses were re-replaced. Two patients had coexisting native mitral valve endocarditis and double valve replacement was done. Thirteen patients had previous mitral valve replacement and 12 of the mitral prostheses were re-replaced. One patient had coexisting native aortic valve endocarditis and double valve re-replacement was done. Three patients had previous aortic valve replacement + mitral valve replacement. Mitral valve endocarditis was diagnosed in two patients and these patients had only mitral valve re-replacement. The other patient had double valve endocarditis, and double valve replacement was done. The mean time from the first operation to the development of endocarditis was 7.3±5.7 years. Of five lost patients, two died from multiple organ failure, one from low cardiac output, one from pneumonia, and one from respiratory failure. Radical resection of the infected tissues is critical to achieve favorable surgical outcomes. Single valve replacement of the infected valve may be preferred in patients having previous double valve replacement. Mechanical valves or bioprostheses can be used for re-replacement procedures.

A Comparison of Erysipelothrix rhusiopathiae Bacteremia With and Without Endocarditis in Frequent Fish Handlers

Abstract A facultatively anaerobic gram-positive bacillus, Erysipelothrix rhusiopathiae is widely present in the environment and also as a commensal and pathogenic organism associated with livestock, birds, and fish. Invasive infections in humans are rare, classically affect patients with exposures to animal products, and frequently progress to include endocarditis. Here we present our successful experience of treating 2 patients with E. rhusiopathiae bacteremia, both frequently exposed to fish. One patient presented in new-onset heart failure after a protracted illness and was found to have subacute aortic and mitral valve endocarditis successfully treated with surgical valve replacement and prolonged intravenous penicillin therapy. The other patient had acute uncomplicated bacteremia responsive to ceftriaxone followed by step-down treatment with oral penicillin, the first published report using such regimen. Our experience highlights the spectrum of clinical disease seen in E. rhusiopathiae bacteremia and offers new perspectives to optimize treatment for these patients.

Acquired Infectious Defect in the Atrioventricular Septum: A Complication of Aortic Valve Endocarditis

The abstract not available.

Surgical Outcome of Infective Aortic Valve Endocarditis Involving Valve Annulus. Comparison between Native Valve Endocarditis and Prosthetic Valve Endocarditis

Surgical Outcome of Infective Aortic Valve Endocarditis Involving Valve Annulus. Comparison between Native Valve Endocarditis and Prosthetic Valve Endocarditis

Uso de homoinjertos en la endocarditis sobre válvula aórtica nativa

Introduction and objectivesThe type of prosthesis used in infective endocarditis surgery of the native aortic valve depends largely on the age of the patient and the preferences of the surgeon. There is little information on the use of allografts in these patients. MethodsA total of 20 cases of infective endocarditis of the native aortic valve were treated in our centre from 1997 to 2017, using allograft implants. ResultsThe mean age of patients was 60 ± 12 years, the negative blood culture rate was 20%, and the main causal agent was enterococci (30%). Patients underwent urgent surgery in 70% of the cases, with an ischaemia time of 112 ± 32min, and 9 patients (45%) died during the active phase. Re-intervention, major bleeding or re-infection were infrequent, and 3 patients died during follow-up. ConclusionsPatients with infective endocarditis on the native valve in whom an allograft homograft is implanted, frequently have to undergo urgent surgery, have prolonged ischaemia times and their short and long-term prognosis is unfavourable.

Complete unroofing of the intramural coronary artery for anomalous aortic origin of a coronary artery: The role of commissural resuspension?

ObjectivesAlthough surgical repair of an anomalous aortic origin of the coronary artery has low operative mortality, longer-term risk of ischemia and aortic regurgitation remains concerning. We routinely perform aortic commissure resuspension after unroofing and sought to evaluate the outcomes with regard to aortic valve competence, symptoms, and signs of ischemia with this approach. MethodsTwenty-six consecutive patients who received the unroofing procedure for anomalous aortic origin of the coronary artery (10 left; 16 right) between 2004 and 2016 were reviewed. In addition to complete unroofing of the intramural coronary, patients early in the cohort (n = 9) received unroofing only, and aortic commissural resuspension was performed routinely in the subsequent patients (n = 17). Outcomes between commissural resuspension versus no commissural resuspension were compared. The occurrence of mild and greater aortic regurgitation was assessed using a time-to-event analysis after varying lengths of time. Commissural resuspension was considered as the predictor, and the groups were compared using a log-rank test. ResultsThere was no operative mortality. One patient in the no commissural resuspension group died 10 years later of prosthetic aortic valve endocarditis (aortic valve replacement 7 years after unroofing). The follow-up duration was 6.9 years (4.9-9.1) and 3.7 years (2.1-4.3) in the no commissural resuspension and commissural resuspension groups, respectively (P = .001). Available postoperative exercise stress test data (n = 14) revealed that 50% had an endurance level at the 25th percentile or greater for age. After a median follow-up of 1.9 years (3 months to 10.6 years), no patient in the commissural resuspension group had aortic regurgitation, whereas 6 of 9 patients (67%) in the no commissural resuspension group had stable but mild or greater aortic regurgitation. Time-to-event analysis with the primary event of occurrence of mild or greater aortic regurgitation showed significantly higher freedom from the occurrence of aortic regurgitation in the commissural resuspension group (P = .035). ConclusionsSurgical repair of an anomalous aortic origin of the coronary artery can be performed with excellent early and midterm outcomes. Routine commissural resuspension of the aortic valve may lead to a lower rate of aortic valve regurgitation without increasing the risk of ischemia.