Recurrent Endocarditis Research Articles

Bilateral internal mammary artery T-grafts: Long-term survival and results of serial angiography

episode of endocarditis requiring surgery. During the second decade in-hospital mortality tended to be lower (6.9 vs 21%, p=0.057) and 5 years cumulative survival was higher (89 vs 64%, p=0.008). Age, reoperation for bleeding, and severe perioperative complication were independent predictors for mortality. Conclusions:Aortic prosthetic valve endocarditis is associated with a high early complication rate and a substantial early mortality. Patients that survive the immediate postoperative period have a satisfactory long term survival and the risk for recurrent endocarditis requiring surgery is low. The results have markedly improved during the last decade.

A Complicated Case of Triple Valve Infective Endocarditis in an IV Drug User with a Bicuspid Aortic Valve Requiring Three Separate Salvage Operations: A Case Report and Literature Review.

Infective endocarditis (IE) is an infection of the endocardium that involves valves and adjacent mural endocardium or a septal defect. Local complications include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses. If left untreated, IE is generally fatal. Diagnosing IE can be straightforward in patients with the typical oslerian manifestations such as bacteremia, evidence of active valvulitis, peripheral emboli, and immunologic vascular phenomena. In the acute course, however, the classic peripheral stigmata may be few or absent, particularly among intravenous drug abuse (IVDA) patients in whom IE is often due to a S. aureus infection of right-sided heart valves. We present a complicated case of a very aggressive native aortic valve MSSA (methicillin sensitive Staphylococcus aureus) IE in a young adult male with a past medical history of bicuspid aortic valve and IV drug abuse. His clinical course was complicated by aortic valve destruction and development of third-degree AV block, as well as an aorto-left atrial fistula requiring emergent operation for AV replacement and patch repair. The patient required two reoperations for recurrent endocarditis and its complications.

Surgical treatment of aortic prosthetic valve endocarditis: a twenty-year single centre experience

Background: Aortic prosthetic valve endocarditis remains a life-threatening disease despite progress in diagnostic methods, and in surgical and medical treatment. We report outcome after operations for aortic prosthetic valve endocarditis at our institution during the past twenty years. Methods: Eighty-seven operations in 84 patients between 1993 and 2013 were included in a retrospective study. An aortic homograft was used in 56 cases (64%), a mechanical prosthesis in 20 (23%) and a biological valve in 11 (13%). Early and late complications and mortality were compared between operations during the first and second decade. Predictors for mortality were identified with Cox regression. Mean follow-up was 5.5 years (range 0-20). Severe perioperative complication included dialysis, perioperative stroke, pacemaker implantation, myocardial infarction and tracheotomy. Results: Ten patients (11.5%) died in-hospital and severe perioperative complications occurred in 36 patients (41%). Overall cumulative survival at five and ten years was 80% and 65%, respectively. Three patients (3.4%) had a recurrent episode of endocarditis requiring surgery. During the second decade in-hospital mortality tended to be lower (6.9 vs 21%, p=0.057) and 5 years cumulative survival was higher (89 vs 64%, p=0.008). Age, reoperation for bleeding, and severe perioperative complication were independent predictors for mortality. Conclusions: Aortic prosthetic valve endocarditis is associated with a high early complication rate and a substantial early mortality. Patients that survive the immediate postoperative period have a satisfactory long term survival and the risk for recurrent endocarditis requiring surgery is low. The results have markedly improved during the last decade.

An Increased Incidence of Conduit Endocarditis in Patients Receiving Bovine Jugular Vein Grafts Compared to Cryopreserved Homograft for Right Ventricular Outflow Reconstruction

We compared the outcome of patients receiving bovine jugular vein grafts versus cryopreserved homografts for right ventricular outflow tract reconstruction. Between 2000 and 2012, 379 conduits (244 bovine jugular vein grafts, 135 homografts) were implanted in 298 patients (median age 50 months) with a median follow-up of 3.4 years. Freedom from reoperation at 1, 5, and 7 years was 96.3%, 79.3%, and 64.2% after bovine jugular vein graft and 94.6%, 75.7%, and 68.6% after homograft insertion (p = 0.086). There were 24 cases of endocarditis, 23 associated with bovine jugular vein grafts (9.4%) and 1 associated with a homograft (0.7%; p < 0.001) at median follow-up of 44 months (range, 15 days to 10 years) after conduit implantation. After endocarditis, 15 of 24 conduits were replaced. Three patients had recurrent endocarditis in the revised conduit. Multivariate logistic regression analysis showed age less than 3 years and endocarditis to be significant risk factors associated with conduit replacement. Age more than 3 years and bovine jugular vein grafts were significant risk factors for graft endocarditis. Patients more than 3 years of age at bovine jugular vein graft implantation had significantly lower freedom from reoperation (p = 0.01). Compared with homograft conduits, the use of bovine jugular vein grafts for right ventricular outflow tract reconstruction was associated with a significantly higher incidence of bacterial endocarditis and conduit deterioration in older children at our institution. That may influence decision making regarding conduit choice for right ventricular outflow tract reconstruction. Patients and practitioners should be aware of the late risks of bacterial endocarditis after bovine jugular vein graft implantation.

Surgical treatment of aortic paravalvular abscess by infective endocarditis

To summarize the clinical features, pathology and surgical treatment experiences in the patients with aortic paravalvular abscess by infective endocarditis. The study consisted of a retrospective analysis of 29 cases with aortic paravalvular abscess by infective endocarditis underwent surgical treatment between January 2001 and June 2013. Among the 29 patients, 22 were male and 7 were female, and the mean age was (37 ± 16) years (range from 11 to 63 years). The primary cardiac disease was congenital aortic valve malformation in 16 patients. There were 15 patients with a history of severe heart failure. Of 29 cases, 8 abscess cavities, 13 pseudoaneurysms and 6 fistulas were found, and complete aortoventricular discontinuity was present in 5 patients with serious infections. Of them, the abscess was above the annulus in 14 patients and below the annulus in 10 patients, and simultaneously involved the annulus above and below in 5 patients. 19 patients were culture positive either positive preoperative blood cultures or positive cultures of surgical specimens, including 9 patients with Staphylococcus infection. The paravalvular defect was repaired by patch in 19 cases, and by local closure in 10 cases. The valvular annulus was reconstructed simultaneously in 16 patients. Aortic valve replacement was performed in 26 patients, and Bentall procedure in 2 patients, including 23 with prosthetic mechanical valve and 5 with biological valve. Of the total 29 patients, 28 patients were recovered, and 1 patient was died of sepsis. During 3 months to 13 years postoperative follow-up (average 4.5 years), one was died of non-cardiac cause, and no patient had recurrent endocarditis and paravalvular leakage. Aortic paravalvular abscess by infective endocarditis is not uncommon, prone to heart failure. According to the different pathological manifestations, the appropriate surgical approach and strategy can achieve satisfactory outcomes.

Percutaneous valvuloplasty for severe bioprosthetic tricuspid valve stenosis in the setting of infective endocarditis

Bioprosthetic tricuspid valve stenosis as a sequela of infective endocarditis is extremely rare. We describe the case of a 29-year-old male patient with a history of intravenous drug use and two previous bioprosthetic tricuspid valve placements who presented with recurrent endocarditis and severe tricuspid stenosis. He was deemed extremely high risk for redo valve replacement surgery. Intracardiac ultrasound-guided balloon valvuloplasty was performed with good clinical outcome. We believe that interventional treatment of prosthetic valvular stenosis in the setting of endocarditis is a reasonable therapeutic choice when open surgical repair is associated with prohibitively high mortality. This can be performed either as destination therapy or as a bridge to valve replacement. The use of intracardiac ultrasound provided additive information to that obtained by transthoracic and transesophageal echocardiography.

Valvular repair or replacement for mitral endocarditis: 7-year cohort study

A few studies have compared mitral valve repair and replacement in the setting of infective endocarditis, with varying results. We compared the characteristics and outcomes of mitral repair and replacement in endocarditis patients. All patients undergoing mitral valve repair or replacement for active mitral endocarditis during 2005-2011 were included. Operative and follow-up mortality, composite morbidity, recurrent endocarditis, and redo operations were prespecified endpoints for analyses. There were 25 and 35 patients undergoing mitral valve repair and replacement, respectively. They were followed-up for 3.9 ± 2.5 years. Valve replacement patients were older (p = 0.029), had a higher prevalence of intracardiac abscess (p = 0.035), previous endocarditis (p = 0.036), atrial fibrillation (p = 0.001), worse renal function (p = 0.013), higher risk scores (p = 0.004-0.020), and longer operation times (p < 0.001). Repair and replacement had similar rates of operative mortality (4.0% vs. 8.6%, p = 0.634), composite morbidity (16.0% vs. 28.6%, p = 0.357), survival (p = 0.564), recurrent endocarditis (p = 0.081), and redo operations (p = 0.813). Independent predictors of operative mortality were preoperative inotropic or intraaortic balloon pump support. The independent predictor of mortality during follow-up was dialysis. Independent predictors of composite morbidity were intracardiac abscess and hypercholesterolemia. The independent predictor of recurrent endocarditis was previous endocarditis, and the independent predictor of redo operation was previous stroke. Mitral valve replacement candidates had more baseline risk factors and higher raw rates of postoperative mortality and morbidity, which did not reach statistical significance.

A Meta-analysis of MitraClip System versus Surgery for Treatment of Severe Mitral Regurgitation in High Surgical Risk Candidates

freedom from reoperation and recurrent endocarditis. Discussion: The comparison between early and late surgical intervention in our cohort did not show any statistical difference in neurological and mortality outcomes, although the power of this study has been limited by the small number of patients. The early group patients tend to have higher preoperative risk but there was no difference in outcome in terms of ICH or neurological function. This study also does not show a statistical excess for mortality and adverse events when early intervention is mooted for indications such as CHF, intracardiac abscess and Staph aureus endocarditis.

Surgical experience with infective endocarditis and aortic root abscess.

PurposeThis study was conducted to evaluate the surgical outcomes of active infective endocarditis with aortic root abscess formation.Materials and MethodsBetween February 1999 and June 2012, 49 patients underwent surgery for active endocarditis with aortic root abscess. The infected valve was native in 29 patients and prosthetic in 20 patients. The patients' mean age was 50±14 years, and 36 patients were male. Surgery was urgent/emergent in 15 patients (31%). The abscess involved the aortic annulus (11), left ventricular outflow tract (18), fibrous trigone (16), and mitral annulus (4). In all patients, wide debridement of abscess and aortic valve replacement with or without patch reconstruction of aortic root or annulus was performed.ResultsThere were 6 (12%) operative deaths. Causes of early mortality were sepsis (2) and multi-organ failure (4). On postoperative echocardiogram, there was significant improvement of left ventricular dimension (LVEDD, from 58.8±11.8 mm to 52.6±8.2 mm, p<0.001); however, LV ejection fraction was significantly decreased (from 61.4±12.0% to 49.8±16.5%, p<0.001). The mean follow-up duration was 68.7±40.4 months. There was no late death or recurrent endocarditis during follow up. New York Heart Association functional class significantly improved from 3.2±0.7 to 1.2±0.4 (p<0.001). Kaplan-Meier estimated survival at 10 years was 87.2%.ConclusionSurgical treatment for active endocarditis with aortic root abscess is still challenging, and was associated with high operative mortality. Nevertheless, long-term survival was excellent with good functional capacity after recovery from the early postoperative period.

Successful transfemoral Edwards Sapien aortic valve implantation in a patient with previous mitral valve replacement

Transcatheter aortic valve implantation (TAVI) is a new method for patients with severe aortic stenosis at high surgical risk, such as previous cardiac surgery. The presence of mechanical mitral prosthesis might complicate TAVI because of possible interference between the both prosthesis. Some reports have already demonstrated the feasibility of TAVI in such patients. We report our experience with TAVI in a patient with severe symptomatic aortic stenosis who has had two previous cardiac surgeries with two mitral valve replacement due to recurrent endocarditis. The Edwards Sapien (Edwards Lifesciences, Inc., Irvine, California) valve via transfemoral approach was successfully implanted. We observed no deformation or dysfunction of the both prosthesis. Balloon valvuloplasty prior to implantation helps to observe the mutual effect of the new aortic valve and preexistent mitral prosthesis. We conclude that TAVI can be safely and successfully performed in patients with mechanical mitral prosthesis carefully considering the altered anatomical conditions.

Recurrent infective endocarditis due to probable biofilm formation on cardiac stimulator probe

Background The global increase in antibiotic resistance and the high number of implant-associated infections have rendered antibiotics ineffective in certain cases. So it’s time for a new therapy. Bacteriophages are obligatory intracellular parasites of bacterial cells and bacteria can be infected by bacteriophages. They have specificity of infection, due to the presence of specific receptors on the bacterium surface.

A 43-Year-Old Man With Intravenous Drug Abuse and Recurrent Endocarditis

A 43-Year-Old Man With Intravenous Drug Abuse and Recurrent Endocarditis

Centrimag Right Ventricular Support After Tricuspid Valvectomy for Endocarditis

Recurrent endocarditis of a bioprosthetic tricuspid valve is a challenging condition, which sometimes requires complete valvectomy. We report a case in which a right ventricular assist device, a Thoratec Centrimag Blood Pump (Thoratec Corp., Pleasanton, CA), was successfully used for temporary hemodynamic support to protect the right ventricle until the new tricuspid bioprosthesis could be safely implanted.

Tricuspid Valve Infective Endocarditis In Drug Abusers: Clinical Features and Results of Surgical Treatment

The objective of this study was to evaluate the clinical features, diagnostic criteria and indications for surgery in patients – drug abusers with tricuspid valve infective endocarditis (TVIE), and outcome of surgical treatment in these patients. From December 1999 to August 2009 35 patients (drug addicts) with TVIE were operated in the department of acquired heart diseases of Cardiac and Vascular Surgery Center, Nizhny Novgorod. 25 males and 10 females aged from 15 to 51 years were included in this study. 3 patients were re-operated due to recurrence of endocarditis. Biological prosthetic valve "Bio-Lab" was used in all patients. Intravenous drug abuse was the cause of the disease in all patients. Acute onset with hectic fever, shivering, profuse sweating, intoxication and development of multi-organ failure were the main clinical features of the disease. Embolism of the peripheral branches of pulmonary artery by septic embolus or micro thrombi were common symptoms. Ultrasound investigation played an important role in diagnosis of TVIE. It was the only criteria for the verification of the diagnosis in patients with fever of unknown origin until the appearance of valve damages and cardiac murmurs. All 35 (100%) patients underwent tricuspid valve replacement (TVR). 3 (8.57%) patients underwent redo TVR because of prosthetic valve endocarditis due to persistent intravenous drug abuse after surgery. The hospital mortality rate was 0%. Acute debut of the disease may be the first clinical feature of tricuspid valve infec­tive endocarditis in drug abusers. Ultrasound investigation is important for early diagnosis and effective treatment. Surgical treatment is indicated in cases of ineffective antibiotic therapy and massive tricuspid valve damages. Tricuspid valve replacement by a biological prosthesis was the treatment of choice in these patients. The use of biological prosthetic valve had good clinical re­sults with low thrombogenic risk and high resistance to infection. Nepalese Heart Journal | Volume 7 | No.1 | November 2010 (special issue) | Page 29-34 DOI: http://dx.doi.org/10.3126/njh.v7i1.8499

Freestyle root replacement for complex destructive aortic valve endocarditis

In destructive aortic valve endocarditis with abscess formation in the root, homografts are used more often than xenografts. Because we had reliable perioperative results with Freestyle (Medtronic Inc, Minneapolis, Minn) xenograft root replacement in these complex patients, we analyzed the long-term outcome in this high-risk indication. Of 126 consecutive patients with aortic valve endocarditis treated by surgery from 1997 to 2012, 32 (25.4%) received a Freestyle aortic root replacement for severe, destructive valve endocarditis and were studied retrospectively with approval of the local ethical committee. Perioperative complications, recurrence of endocarditis, and long-term morbidity and mortality were analyzed. The follow-up period was 3 months to 11.5 years. Indication for surgery was native (n=9) and prosthetic valve endocarditis (n=23). In 18 patients, concomitant procedures were performed: coronary bypass (n=9), additional valve surgery (n=6), and ascending aortic surgery (n=7). Thirty-day mortality was 19.4% (n=6). There were no instances of technical failure requiring modification of the surgical strategy or reoperation for anastomotic bleeding. Actuarial survival at 5 and 10 years was 61.9% and 54.2%, respectively. Freedom from death, reoperation for prostheses dysfunction, and recurrence of endocarditis as the composite end point at 5 and 10 years was 56.3% and 53.1%, respectively. The Freestyle root was used successfully with no technical complications in all patients with most severe destructive aortic root endocarditis. In view of this complex patient population, short- and long-term results make this conduit a reliable choice for treatment of this condition.

Hematemesis in a Patient With Diabetic Ketoacidosis and Chronic HCV Infection

292 Question: A 55-year-old man with past medical history of poorly controlled diabetes mellitus, recurrent infective endocarditis (last episode 2 months ago), and chronic hepatitis C presented to the emergency department with 2 episodes of coffee ground emesis. He also complained of fatigue, polyuria and lightheadedness for 2 days before admission. He denied any abdominal pain, prior retching,melena, or hematochezia. He denied using any nonsteroidal anti-inflammatory drugs, smoking, and recent alcohol or illicit drug use. On admission he was afebrile, tachycardic at 116 bpm, with a blood pressure of 121/92 mmHg, was breathing 24 times a minute and saturating well on room air. On physical examination, his skin and oral mucosa were dry. He was alert and oriented, with lungs clear to auscultation, heart sounds normal, and abdomen soft, nondistended, and nontender. He had no stigmata of chronic liver disease. Laboratory examination revealed blood sugar of 331 g/dL, sodium of 127 mEq/L, potassium of 6.4 mEq/L, bicarbonate of 7 mEq/L, anion gap of 29, and pH of 7.023. His blood urea was 69 mg/dL and creatinine 2.6 mg/dL. His hemoglobin was 16.7 g/dL; white blood cell count and platelets were normal. He was treated for diabetic ketoacidosis with an insulin drip and his electrolytes were corrected as needed. Nasogastric lavage was done and was clear. He was started on pantoprazole drip and an upper gastrointestinal endoscopy was performed which revealed diffuse blackish discoloration of the mid and distal esophagus (Figure A), which abruptly ended at the gastroesophageal junction. There was also evidence of erosive gastritis and erosive duodenitis (Figure B) in the bulb and second portion of duodenum. What is the diagnosis? What is the appropriate management? Look on page 491 for the answer and see the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Use of a Valved-Conduit for Exclusion of the Infected Portion in the Prosthetic Pulmonary Valve Endocarditis

A 51-year-old male was admitted to the hospital with complaints of fever and hemoptysis. After evaluation of the fever focus, he was diagnosed with pulmonary valve infective endocarditis. Thus pulmonary valve replacement and antibiotics therapy were performed and discharged. He was brought to the emergency unit presenting with a high fever (>39℃) and general weakness 6 months after the initial operation. The echocardiography revealed prosthetic pulmonary valve endocarditis. Therefore, redo-pulmonary valve replacement using valved conduit was performed in the Rastelli fashion because of the risk of pulmonary arterial wall injury and recurrent endocarditis from the remnant inflammatory tissue. We report here on the successful surgical treatment of prosthetic pulmonary valve endocarditis with an alternative surgical method.

Heart transplantation in a patient with recurrent early extensive endocarditis

Active valvular endocarditis could be considered a contraindication to heart transplantation. Nevertheless, there have been some reports of success with this form of treatment, despite the characteristics of the infection and its aggressive nature. Here, we describe the case of a patient with acute bicuspid aortic valvular endocarditis caused by Staphylococcus aureus and with a periannular abscess. Cryopreserved aortic homograft replacement of the aortic root was initially carried out, in addition to debridement and reconstruction of the interventricular septum with a pericardial patch. Early recurrence occurred, however, with extensive tissue destruction, a periaortic abscess and involvement of multiple valves, associated with severe sepsis. In view of the failure of 'conventional' surgery, an emergency heart transplantation was decided on after discussing the case with the Spanish National Transplant Organization (ONT), because of the theoretical contraindication of transplantation in this case. Transplantation was finally carried out after a waiting period of 3 days, in emergency code conditions, and the postoperative course proved uneventful, with no reinfection during the follow-up period. The present case suggests that heart transplantation may be an alternative option in patients suffering aggressive endocarditis with extensive involvement of the heart structures.

The Ross procedure in endocarditis: a report of 28 cases

The Ross procedure has received increasing interest as an attractive alternative to a prosthetic aortic valve. Given its presumably greater resistance to infection, the pulmonary autograft is theoretically preferable for active endocarditis. The objective of this retrospective study was to present our experience in aortic valve endocarditis treated using the Ross procedure. Between May 1997 and February 2011, the Ross procedure was performed on 142 patients in our institution. Twenty-eight patients had aortic valve endocarditis at the time of operation. Fourteen patients had urgent or emergency procedures, and 13 had active disease at the time of surgery. Twelve patients were alcoholics and/or drug addicts. Eight patients had an abscess of the aortic annulus. Clinical follow-up was complete. Hospital mortality was 10.7%. Overall patient survival (± standard deviation) was 47 ± 13% at 10 years with no cardiac-related death during the mean follow-up of 6.4 ± 4.2 years. There were 3 cases of recurrent endocarditis including anterior mitral leaflets endocarditis and right-sided endocarditis to another germ in a drug addict. Four patients required further surgery, 2 on the pulmonary autograft; 18 of the 19 survivors were in New York Heart Association class I. At the final investigation, all patients had no or grade I autograft regurgitation. The mean pressure gradient across the homograft was 9 ± 7.5, 11 ± 9.5 and 15 ± 9.5 mmHg, respectively, for patients between 0-3, 4-9 and >9 years. Endocarditis can be treated with good results using the Ross procedure, with a very low rate of recurrence of endocarditis.

Outcomes of Surgical Therapy for Infective Endocarditis in a Pediatric Population: A 21-Year Review

Infective endocarditis is a rare disease in the pediatric population. We sought to define patient characteristics and outcomes of surgical therapy for endocarditis in children. We performed a retrospective review of all patients with infective endocarditis who received surgical therapy between January 1, 1990, and March 1. 2011. We were interested in their congenital heart defect, prior surgical procedures, and outcome of the operation. We identified 35 cases of endocarditis in 34 patients requiring surgical intervention. Mean age was 10.7 ± 8.8 years. There was a bimodal age distribution at presentation: 11 (31%) were younger than 1 year and 15 (43%) were 10 to 21 years. Of the 34 patients, 22 (63%) had no history of prior cardiac operation. The infective organism was identified in 30 (86%), with Staphylococcus aureus (n = 8) and Streptococcus viridans (n = 6) predominating. Valve replacement was performed in 22 patients and valve repair in 10. All patients received 6 weeks of postoperative intravenous antimicrobial therapy. Operative mortality was 15% (5 of 34). The 5 deaths occurred in infants who were a mean age of 2.5 months, and 3 of the 5 infants (60%) were premature. Of 4 patients with fungal infection, 3 patients died. The Ross operation was performed successfully in 5 patients with severe aortic valve disease. Reoperations (n = 10 [28%]) included valve replacement in 5 and conduit replacement in 3, all but 1 due to somatic growth resulting in functional stenosis. The outcome of surgical therapy for endocarditis in children was similar to that reported for adults, with an overall mortality of 15%. The Ross operation was very effective in patients with aortic valve endocarditis. There is a significant incidence of late reoperation for valve and conduit replacement due to somatic growth. Age younger than 1 year, prematurity, and fungal organisms appear to be risk factors for death. Patients surviving to discharge had good outcomes, with no episodes of recurrent endocarditis.