Right-sided Endocarditis Research Articles

The Preoperative Evaluation in Patients with Endocarditis: Is Cardiac Catheterization Necessary?

We retrospectively compared clinical assessment and cardiac catheterization to subsequent surgical findings with regard to specific valvular involvement, hemodynamic status, and presence of myocardial abscess in patients recommended for cardiac surgery for endocarditis. Of 105 consecutive patients with endocarditis, 19 met one or more of the following criteria suggesting the need for early surgery: congestive heart failure; systemic emboli; persistent infections or new conduction abnormalities. Of these 19 patients, seven had prosthetic cardiac valves. Clinical assessment was highly sensitive (95 percent) and specific (89 percent) for specific valvular involvement and was also highly sensitive and specific in evaluating myocardial abscess and congestive heart failure; however, clinical assessment could not identify the source of infection in one patient with multiple prosthetic valves, did not define the specific valve in one patient with right-sided endocarditis, and overestimated the severity of mitral regurgitation in one patient who had normal pressures and flows at catheterization. Catheterization incorrectly predicted multivalvular involvement in four patients. At catheterization, only one patient experienced evidence of clinical deterioration, and this was probably not related to the procedure. We conclude that although clinical assessment is correct in most patients, it may on occasion lead to an erroneous conclusion. Catheterization and angiograms are of value in the preoperative evaluation of patients with endocarditis, particularly in cases where the clinical assessment is ambiguous or uncertain. The procedures can be performed at low risk, and the information obtained may substantially influence management in some cases.

Right-Sided Endocarditis Complicating Peritoneovenous Shunting for Ascites

We describe two patients with alcoholic cirrhosis in whom staphylococcal right-sided endocarditis developed after insertion of a peritoneovenous shunt (PVS). Massive pulmonary embolism caused early death in one patient. In the other patient, staphylococcal septicemia was cured after shunt removal and antibiotic treatment; recurrent endocarditis due to Corynebacterium xerosis ultimately caused the patient's death. No clinical manifestation of tricuspid valve dysfunction was noted in either patient, and right-sided endocarditis was recognized only at autopsy. The protracted contact of the tip of the venous line of PVS with the atrial wall is likely to be a major factor in the development of right-sided endocarditis in these patients.

Right-sided endocarditis complicating peritoneovenous shunting for ascites

Right-sided endocarditis complicating peritoneovenous shunting for ascites

Current problems in the treatment of infective endocarditis due to Pseudomonas aeruginosa.

Mortality from pseudomonas infective endocarditis remains high despite optimal use of available antibacterial agents. Infection of the tricuspid valve is subacute, but involvement of the mitral or aortic valve precipitates more serious disease. Most valvular infections are due to a single pseudomonad immunotype, but 20% of cases are mixed infections. Antimicrobial susceptibility tests and tests of synergy by beta-lactam and aminoglycoside antibiotics in combination were performed on 30 isolates of Pseudomonas aeruginosa. Azlocillin was the most effective beta-lactam in combination with an aminoglycoside; MKO 787 was least effective. Among the aminoglycosides tested, netilmicin was the most effective. Medical treatment combined with valvulectomy (without valve replacement) is now standard treatment for refractory right-sided endocarditis at this medical center. A high dose of aminoglycoside in combination with a beta-lactam has proved efficacious. For left-sided infection, immediate valve replacement accompanied by a six-week course of the high dose-combined drug regimen is recommended. Newer beta-lactam antibiotics, such as piperacillin, may be limited in usefulness due to beta-lactamase inactivation.

Therapy of experimental Pseudomonas endocarditis with high-dose amikacin and ticarcillin.

Right-sided infective endocarditis due to Pseudomonas aeruginosa was induced in 130 rabbits. Animals received either: (1) no therapy (controls); (2) standard-dose amikacin (AMK) (15 mg/kg/day) plus ticarcillin (300 mg/kg/day), or (3) high-dose AMK (20 or 25 mg/kg/day) plus ticarcillin, for 20 days. Animals in each treatment group were evaluated at 10 days after therapy for bacteriologic relapse. Both standard- and high-dose AMK regimens significantly decreased mortality and Pseudomonas aeruginosa vegetation titers versus controls (p less than 0.01, p less than 0.05, respectively). Despite significantly higher serum AMK levels at 25 mg/kg/day, there was no significant difference in mean vegetation titers, percent of vegetations sterilized, or posttherapy bacteriologic relapse in the three treatment groups. AMK at 20 or 25 mg/kg/day (but not at 15 mg/kg/day) significantly reduced the incidence of pulmonary infarction versus untreated controls (p less than 0.01).

Combination Antimicrobial Therapy forStaphylococcus aureusEndocarditis in Patients Addicted to Parenteral Drugs and in Nonaddicts

Single (nafcillin for 6 weeks) and combined (nafcillin for 6 weeks plus gentamicin for 2 weeks) drug regimens were compared in two separate multicenter prospective randomized trials. Forty-eight parenteral drug addicts and 30 nonaddicts with clinically and bacteriologically documented Staphylococcus aureus endocarditis were studied. In the addicts, combined therapy effected a more rapid mean clinical response (defervescence and normalization of leukocyte count) and a reduced duration of bacteremia in patients with right-sided endocarditis. In the nonaddicts, combined therapy effected more rapid clearance of bacteremia, but was associated with a higher incidence of azotemia. The addition of gentamicin did not alter morbidity or mortality in either group.

Effect of nitrogen mustard on natural history of right-sided streptococcal endocarditis in rabbits: role for cellular host defenses.

Cellular host defenses are considered to be ineffective in bacterial endocarditis; the microorganisms in infected vegetations are protected from phagocytic cells by dense layers of fibrin. To test this hypothesis, nitrogen mustard-induced agranulocytosis and leukopenia were produced in rabbits with right-sided streptococcal endocarditis. The spontaneous sterilization of tricuspid infection observed in the control animals was not present in the granulocytopenic, leukopenic animals. Since the bacterium Streptococcus intermedius is not sensitive to the complement-mediated bactericidal effect of serum and since the animals were not bacteremic during the time of agranulocytosis, an inhibitory effect of the drug on local cellular host defense mechanisms is postulated. We suggest that the spontaneous sterilization of infective endocarditis in the right side of the heart in rabbits is mediated by cellular host defenses.

Four-valve polymicrobial endocarditis caused by pseudomonas aeruginosa and serratia marcescens

This report describes what is believed to be the first case of mixed Pseudomonas and Serratia endocarditis, of probable nosocomial etiology, with involvement of all four heart valves in a 56 year old nonaddicted patient. Although both organisms were recovered in culture, infection and tissue invasion were documented by light and electron microscopy. The clinical course in this patient differed from more typical patterns of Pseudomonas or Serratia endocarditis that have been observed as complications of narcotic addiction or compromised cardiac status. Our patient had the rare occurrence of endocarditis with two organisms and four-valve involvement. Clinically, however, this presented as a right-sided endocarditis and behaved as though only a single organism were present.

Tricuspid valvulectomy without prosthetic replacement: Ten years of clinical experience

Sixty-one patients who underwent tricuspid valvulectomy without prosthetic replacement since September of 1970 are reported. In all of the patients the operation was indicated because of intractable infective endocarditis. Fifty-two patients (85%) were addicted to intravenous drugs and nine (15%) were not. The endocarditis was due to bacteria in 56 patients (92%) and fungi (Candida albicans) in three patients (5%). In two patients no microorganisms were reported. Among the 56 cases of bacterial endocarditis, 37 were due to gram-negative microorganisms (66%) and 19 to gram-positive bacteria (34%). In 41 patients (67%) the diagnosis of right-sided endocarditis was made on the basis of clinical manifestations alone (pleuropulmonary problems). Seventeen patients underwent cardiac catheterization, but in only three (5%) was this diagnostic procedure helpful. In 12 patients (20%) the echocardiogram was diagnostic. In this series of 61 patients there were six hospital deaths. Four patients (6%) died during the first 30 postoperative days; two (4%) died 44 and 60 days after the tricuspid valvulectomy without prosthetic replacement. There were five (8%) late deaths, three of which were not related to the operation. The other two were due to a recurrent endocarditis. Eleven patients underwent subsequent insertion of a prosthetic tricuspid valve. The results in the long-term follow-up of these 11 patients, when compared to those 50 patients who did not have a tricuspid valve insertion, show no differences. Because of this experience, we conclude that tricuspid valvulectomy without prosthetic replacement is the method of choice in the treatment of patients with right-sided, intractable infective endocarditis. Prosthetic valve insertion, at a second operation, should be indicated only when medical treatment has failed to control the hemodynamic alterations and when there is reasonable evidence that the drug addiction has been controlled.

Surgical treatment of constrictive fibrous endocarditis

Between 1971 and 1980, 20 patients with fibrous endocarditis were treated by resection of ventricular endocardium and replacement of the atrioventricular valve. There were 13 male and seven female patients whose ages ranged between 12 and 58 years. Thirteen were white and the remaining seven were black Africans. Nine presented a right-sided form, five a left-sided one, and six presented involvement of both ventricles. The role of hypereosinophilia is discussed in the etiology of the disease. The operation was performed according to the techniques we had developed in our first operative case-excision of the atrioventricular valve. Complete resection of the endocardium, and valvular replacement. There were three operative deaths. Complete atrioventricular dissociation was observed in seven of our patients. particularly in those with right-sided endocarditis. At late follow-up, we have not observed any case of recurrence of the disease. On the basis of our experience and the results previously published in the literature, we believe that endocardiectomy is the best current treatment of this disease.

Evaluation of ceforanide as treatment for staphylococcal and streptococcal endocarditis.

Ceforanide administered parenterally twice daily was used as the sole agent to treat 17 patients with right-sided endocarditis due to Staphylococcus aureus or nonenterococcal streptococci. Fifteen patients were cured of their original infection. Two patients were withdrawn from the study. One patient was transferred to another hospital 4 days after ceforanide therapy was initiated, and the other was changed to a different antibiotic regimen when his viridans streptococcus proved tolerant to ceforanide. The intramuscular form of ceforanide was well tolerated. It was stopped in two patients after week 3 of therapy because of adverse effects, possibly related to the study drug. These findings resolved with discontinuation of the ceforanide, and no additional antimicrobial therapy was necessary. Two patients who continued to abuse drugs intravenously during the study developed bacteremia with new organisms and required additional antimicrobial therapy. Ceforanide proved to be a useful agent in the treatment of right-sided endocarditis due to susceptible S. aureus and nonenterococcal streptococci.

A case of right-sided bacterial endocarditis

A case of right-sided bacterial endocarditis

Disseminated petriellidium boydii and pacemaker endocarditis

Clinical and morphologic findings are described in a 62 year old woman with "mixed connective tissue disease" who received corticosteroid therapy, and in whom disseminated and fatal Petriellidium boydii infection with right-sided endocarditis developed. The patient was a gardener. The organism is ubiquitous in soil in many part of the United States; therefore, it is likely that the infection was introduced by this means. Endocarditis due to P. boydii has not been reported previously. In the patient described, massive vegetations nearly obliterated the tricuspid valve orifice, encasing a pacemaker catheter which had been inserted eight years earlier. Although never previously isolated from blood cultures, P. boydii was isolated from 11 consecutive blood cultures. P. boydii is a true fungus and has only recently been appreciated as an opportunistic pathogen in a compromised host.

Two-dimensional echocardiographic findings in right-sided infective endocarditis.

M-mode and two-dimensional echocardiograms were recorded in 12 narcotic addicts who had right-sided infective endocarditis. The two-dimensional echocardiogram showed vegetations in 10 patients (nine tricuspid and one pulmonic), while the M-mode echocardiogram was positive in six (five tricuspid and one pulmonic). The use of multiple transducer positions resulted in better visualization of the valves and appeared to be an important reason for the large number of positive two-dimensional echocardiograms. Echocardiographic findings were also available after completion of antibiotic therapy in seven of 10 patients. Of these seven patients, the vegetation appeared unchanged in three, diminished in size in three and was no longer visualized in one. No patient required valve replacement. Two-dimensional echocardiography using a wide-angle sector scanner appears to offer distinct advantages over the standard M-mode technique in evaluating patients with right-sided infective endocarditis.

The relationship of central venous and pulmonary artery catheter position to acute right-sided endocarditis in severe thermal injury.

Autopsies of 1,105 burned patients completed from January 1951 through March 1977 were reviewed at the United States Army Institute of Surgical Research to investigate the relationship between central venous and pulmonary artery cannula use and the incidence of endocarditis. The incidence of endocarditis increased from 3.4 to 9.4% after 1969 when cardiac injury attributed to central venous cannula use was first noticed at autopsy. Since 1969, right heart nonbacterial and bacterial endocarditis has dramatically increased and the right heart has become the prevalent site of the cardiac lesions. Review of premortem chest roentgenograms from 14 recent autopsy cases with right heart endocardial injury confirmed that central venous catheter tips were placed in the vicinity of the right atrium or right ventricle in 86% of the cases. Pathogenetically, the majority of the infected right heart lesions are probably the result of cannula-induced injury, with subsequent thrombosis and later bacterial colonization during episodes of bacteremia which are common in burned patients.

Right-sided infective endocarditis: An echocardiographic study

Echocardiographic observations are described in 10 patients with right-sided bacterial endocarditis. Six of the nine patients with tricuspid regurgitation had shaggy echoes on the tricuspid valve, which were confirmed to be vegetations on autopsy in two patients. In six patients, right ventricular dilatation was present, and paradoxic septal motion was seen in four. In one of the patients with pulmonic valve endocarditis, the pulmonic valve and right ventricular outflow tract revealed the shaggy echoes in diastole, along with systolic fluttering of the pulmonic valve, right ventricular dilatation and paradoxic septal motion. When the findings are supplemented to the clinical picture, echocardiography is found to be a useful noninvasive adjunct in the diagnosis of acute vegetative bacterial endocarditis involving the right side of the heart, especially if other clinical features, e.g., fever, leukocytosis and positive blood cultures are absent.

Circulating Immune Complexes in Experimental Streptococcal Endocarditis: A Monitor of Therapeutic Efficacy

An important problem in the management of infective endocarditis has been the delineation of laboratory procedures that are sensitive, reliable indicators of therapeutic efficacy. Because circulating, complement-containing immune complexes of the IgG type (CICs) have been demonstrated in most humans with infective endocarditis, serum CIC levels during the natural course of the infection and in response to penicillin therapy were studied in 42 rabbits with right-sided endocarditis due to Streptococcus salivarius. A significant rise in the level of CICs in both 21 control rabbits and 21 treated rabbits was observed after induction but before treatment of infective endocarditis (P less than 0.01). In the 17 successfully treated rabbits, CIC levels fell sharply during the first week of therapy and remained at preinduction levels thereafter (P less than 0.005). In contrast, CIC values did not change significantly either in control animals or in the four treated animals with refractory endocarditis, although in the latter animals, serum bactericidal titers remained less than or equal to 1:32. These findings suggest that serial measurements of CIC levels during antimicrobial therapy of infective endocarditis may aid in monitoring therapeutic efficacy.

Endocarditis with the indwelling balloon-tipped pulmonary artery catheter in burn patients.

The postmortem finding of acute right-sided bacterial endocarditis in a burn patient monitored with an indwelling pulmonary artery (Swan-Ganz) catheter for 14 days prompted a review of burn autopsies in which the catheter had been used. Autopsies of six consecutive burn patients monitored with a pulmonary artery catheter and who then died showed septic or aseptic endocarditis. In two of the six patients, right-sided staphylococcal endocarditis was the anatomic cause of death. In the remaining four, the lesions were aseptic thrombotic vegetations involving primarily the right atrium, tricuspid valve, right ventricle, and pulmonic valve. Several factors in the severely burned patient would favor endocarditis where a foreign object impacts on the heart valves. These include intermittent bacteremia, hypercoagulability, hyperdynamic cardiovascular function, and the use of antibiotics resulting in resistant strains. While an indwelling pulmonary artery catheter can provide useful monitoring information, it is sometimes responsible for serious complications in burned or septic patients.

Culture-negative Endocarditis

Etiologic factors in culture-negative endocarditis--better referred to as "apparent" culture-negative endocarditis--include (1) previous antibiotic therapy, (2) fastidious, slow-growing bacteria, (3) nonbacterial organisms, (4) right-sided endocarditis, and (5) noninfective endocarditis. Patients with apparent culture-negative endocarditis are more likely to have had prior antimicrobial therapy and to experience major emboli than are patients with endocarditis whose blood cultures are positive within 48 hours. The literature suggests that survival of patients with apparent culture-negative endocarditis is 92% if fever responds to therapy within 1 week but only 50% if they are still febrile after 1 week of therapy. Guidelines for diagnosis and therapy are outlined.

Septic pulmonary embolization

Septic pulmonary embolization occurs when an infected thrombus lodges in the pulmonary arterial tree. Pulmonary abscess, empyema, bronchopleural fistula, shock and death may follow. During the preantibiotic era, septic pulmonary embolization was a dread complication of septic thrombophlebitis occurring in the pelvis and after infections of the head and neck. More recently, the multiplicity of long term indwelling catheters has changed the epidemiologic aspect of this disease, pointing toward iatrogenic causes in many instances. The drug addict, however, remains the person at greatest risk of having septic pulmonary embolization develop. A clinical evaluation seeking drug abuse and related stigmata is extremely helpful in suggesting the proper cause, establishing the presence of right-sided endocarditis and directing appropriate therapy. Staphylococcus aureus is the most common offending organism in all patient populations except for the patient with thermal injury in which gram-negative organisms predominate. Early diagnosis and proper therapy, which includes high doses of parenteral antibiotics and control of the inciting septic focus in all instances, are prerequisites for a favorable outcome.