Valvular Endocarditis Research Articles

Pulmonary Manifestations of Staphylococcus aureus Septicemia

This study includes 140 episodes (138 cases) of Staphylococcus aureus septicemia, made up mostly of community-acquired, nonintravenous drug abuse (nonIVDA) cases. Unlike other series, injury wounds and skin or soft tissue infections were the most common sites of primary infection. In spite of a different patient population and lack of cases with tricuspid valvular endocarditis, the lungs were still the most common site of secondary infectious foci and most developed within two weeks of onset of the septicemia.

Mitral valve replacement for active valvular infective endocarditis in an infant

Mitral valve replacement for active valvular infective endocarditis in an infant

Transesophageal echocardiography in critically III patients

The feasibility, safety and clinical impact of transesophageal echocardiography were evaluated in 51 critically ill intensive care unit patients (28 men and 23 women; mean age 63 years) in whom transthoracic echocardiography was inadequate. At the time of transesophageal echocardiography, 30 patients (59%) were being mechanically ventilated. Transesophageal echocardiography was performed without significant complications in 49 patients (96%), and 2 patients with heart failure had worsening of hemodynamic and respiratory difficulties after insertion of the transesophageal probe. The most frequent indication, in 25 patients (49%), was unexplained hemodynamic instability. Other indications included evaluation of mitral regurgitation severity, prosthetic valvular dysfunction, endocarditis, aortic dissection and potential donor heart. In 30 patients (59%), transesophageal echocardiography identified cardiovascular problems that could not be clearly diagnosed by transthoracic echocardiography. In the remaining patients, transesophageal echocardiography permitted confident exclusion of suspected abnormalities because of its superior imaging qualities. Cardiac surgery was prompted by transesophageal echocardiographic findings in 12 patients (24%) and these findings were confirmed at operation in all. Therefore, transesophageal echocardiography can be safely performed and has a definite role in the diagnosis and expeditious management of critically ill cardiovascular patients.

Valvular tuberculous endocarditis: A case report and review of the literature

Tuberculous valvular endocarditis is exceptionally rare. It is usually manifest in the context of miliary tuberculosis, and in all but one case the diagnoses have been made at necropsy. Because of its rarity there is still uncertainty as to whether true tuberculous endocarditis exists as a clinical entity. This paper describes a case of miliary tuberculosis with aortic valvulitis that resolved on antituberculous therapy.

Septic Pulmonary Arteriovenous Fistula: An Unusual Conduit for Systemic Embolization in Right-Sided Valvular Endocarditis

Right-sided valvular (tricuspid, pulmonic) endocarditis is frequently complicated by septic pulmonary embolization. Systemic embolization may also rarely occur due to associated left-sided endocarditis or right-to-left shunting in patients with septal defects. This report documents the occurrence of systemic embolization causing a cerebrovascular accident in an intravenous drug abuser with recurrent tricuspid valve endocarditis due to an isolated peripheral septic pulmonary arteriovenous fistula. Noninvasive diagnosis of the fistula by cardiac auscultation, contrast echocardiography, and nuclear magnetic resonance imaging was confirmed by selective pulmonary angiography. Subselective balloon embolization of the pulmonary arteries feeding this fistula was accomplished.

Right-Sided Valvular Endocarditis Supported by an Unexpected Intracardiac Foreign Body

One case of tricuspid valve endocarditis due to a catheter fragment inside the right chambers of the heart is described. The symptoms were fever, cardiac failure, splenomegaly and relapsing pneumonia. Blood culture was positive, revealing Staphylococcus aureus. A two-dimensional echocardiogram demonstrated a large vegetation on the tricuspid valve. The percutaneous removal of the foreign body allowed complete recovery in a few weeks.

Approach to Advanced Aortic Root Infection

Among our first 11,620 cases of valvular replacement, we observed 285 cases of valvular endocarditis and 59 cases (20.7%) in which the importance of the infectious lesions of the aortic or mitral annulus required complex valvular repair. In 23 patients with aortic valvular endocarditis, the presence of an abcess of the aortic annulus required its closure with a patch resulting in one early and one late death and five reinterventions with one death. Twenty patients are alive and well, 1 to 9 years after operation. In 11 patients, the extent of annular abcesses required the insertion of a subcoronary valved conduit. After a maximum follow-up of 8 years there were two early deaths, two late deaths, one reoperation, and seven good results. Twelve patients had a supracoronary valved conduit resulting in four early deaths, one late death, and two reoperations; seven are alive and well, 2 to 6 years later. Three patients previously operated on had a left ventricular abdominal aorta valved conduit, two of them are alive and well up to 6 years later. Severe infectious lesions of the valvular rings (aortic root) can require complex repairs that can be lifesaving and provide excellent long-term results.

Traumatic Coronary Arteriovenous Fistula Communicating the Left Main Coronary Artery to Pulmonary Artery, Associated with Pulmonary Valvular Insufficiency and Endocarditis: Case Report

The authors present a case of a seventeen-year-old white male who suffered from a knife chest wound and secondarily developed a traumatic coronary arteriovenous fistula communicating the left main coronary artery to the pulmonary artery, associated with pulmonary valvular insufficiency and endocarditis.

Controlled release implants for cardiovascular disease

The systemic therapy of many cardiovascular diseases is often hampered by adverse drug effects. The present paper examines the use of controlled release implants as a means for optimizing drug concentrations at the affected site in the cardiovascular system, while using a relatively low systemic dose. Controlled release systems have been prepared by combining a drug of choice with either a non-degradable polymer, such as a silicone rubber, polyurethane, and ethylene vinylacetate, or a biodegradable compound such as poly(glycolic-lactic acid) or a high molecular weight polyanhydride. Controlled release matrices containing ethylenehydroxydiphosphonate (EHDP), when implanted next to a bioprosthetic heart valve leaflet, prevented pathologic calcification. Similarly, controlled release matrices containing lidocaine-HCl have been used experimentally as epicardial implants to convert ventricular tachycardia to normal sinus rhythm in dogs. A matrix system containing gentamicin has been used by others [35] to prevent experimental valvular endocarditis. Other workers have used a dexamethasone-releasing cardiac pacing lead in clinical studies, to prevent scar tissue formation, which leads to elevated electrical pacing threshold [15,16]. Future controlled release systems for cardiovascular use will very likely incorporate innovative design features including: a reservoir configuration to replenish or change drug therapy, modulatable drug release to vary drug dosing as desired, and closed-loop feedback to increase or decrease release rates in response to disease status.

A CASE REPORT OF “LIPOMATOUS HYPERTROPHY OF THE CARDIAC INTERATRIAL SEPTUM”, WITH A PROPOSAL FOR A NEW TERM “LIPOMATOUS HAMARTOMA OF THE CARDIAC ATRIAL SEPTUM”

An autopsy case of "lipomatous hypertrophy of the cardiac interatrial septum" (LHIS) combined with marked stenosis and calcification of the aortic and mitral valves due to fibrous valvular endocarditis, malignant lymphoma, and mucin-producing cancer of the pancreas is reported. LHIS and mucin-producing cancer of the pancreas were incidental findings at autopsy. Microscopically, the LHIS in this case consisted of proliferation of mature fat cells, brown fat cells and cardiac muscle cells. Since these three cell types are normal structural components of the interatrial septum, it was considered that the LHIS was a hamartomatous rather than hypertrophic lesion, of the cardiac atrial septum. Accordingly it was concluded that the term "lipomatous hamartoma of the cardiac atrial septum" was more appropriate for this lesion in the case presented here. As far as we know, this is the first reported case of LHIS in Japan.

Surgical Treatment of Ascending Aortic Pathology

Among the first 10,200 valvular replacements performed in our unit, 288 complex repairs of the ascending aorta were done for various aortic pathology. Aneurysms of the ascending aorta were the most frequent; 53 supracoronary artery aneurysms with aortic valvular insufficiency were treated by the separate replacement of the aortic valve and the supracoronary ascending aorta; 206 annulo-aortic ectasia had total and combined replacement of the ascending aorta and the aortic valve with a personal modification of the Bentall's technique using an 8-mm diameter Dacron graft to perform the reimplantation of the coronary arteries on the composite aortic grafts. The operative mortality for the first 100 patients was 4% and for the entire 206 patients, 6%. Late mortality during a follow-up period ranging from 18 months to 8 years was 11%. The actuarial survival rate at 8 years is 75%; 25 patients restudied by angiography demonstrated satisfactory results with neither stenosis nor aneurysm on the coronary graft but a recurrent or persisting chronic distal aortic dissection in four patients. In 26 cases of aortic valvular endocarditis, large abscesses of the aortic annulus involved the aortic root. In 11, the aortic repair consisted of the insertion of a subcoronary valved conduit (two early deaths, two late deaths, one reoperation, seven good results--maximum follow-up of eight years). Twelve patients had a supracoronary valved conduit with four early deaths, one late death, and two reoperations; seven are alive and well, two to six years later. Three patients previously operated had a left ventricular abdominal aorta valved conduit; two of them are alive and well up to six years later. In three patients with iterative aortic paravalvular leak (recurring three or four times), ablation of the aortic insufficiency was obtained by interposition of a composite valved graft in the ascending aorta.

Mechanism of death in Syrian hamsters gavaged potato sprout material.

Greened or sprouted potatoes contain increased concentrations of steroidal alkaloids that have caused intoxication and death in a wide variety of animal species, however, the cause of death in these animals has not been determined. Potato alkaloids can cause death when parenterally administered, and is attributed to the acetylcholinesterase inhibitory activity of solanine and chaconine. To determine the cause of death in animals ingesting potato sprout material, 40 Syrian hamsters were divided into 4 equal groups and gavaged once on day 0 either water, 300 mg of potato sprout material, 400 mg of potato sprout material, or 500 mg of potato sprout material. Tissues were examined grossly and microscopically at 72 hr post-gavaging and brain acetylcholinesterase activity of each hamster was measured. The 300-mg dose group had increased mean acetylcholinesterase activity compared with control hamster mean activity, and the 400-mg and 500-mg dose groups had 90% and 84% of the mean acetylcholinesterase activity of the control hamster mean activity. There was severe gastric and proximal small intestinal mucosal necrosis in those hamsters which died prior to euthanasia. Additionally, several hamsters had valvular endocarditis and infarcts. Death could not be attributed to the slight acetylcholinesterase inhibition in the 2 higher dose hamster groups and was related to the severe gastrointestinal necrosis which occurred in hamsters of these groups.

Tricuspid Valve Endocarditis due to Staphylococcus aureus: Correlation of Two-Dimensional Echocardiography with Clinical Outcome

We studied 53 episodes (51 patients) of tricuspid valvular endocarditis caused by Staphylococcus aureus in a predominantly addicted population and correlated two-dimensional echocardiographic findings with clinical outcome. Thirty-eight episodes with (vs 15 episodes without) tricuspid vegetations on the two-dimensional echocardiogram were significantly associated with (1) longer duration of fever on therapy (mean of 12.3 days vs 6.8 days, respectively; p less than 0.005); and (2) higher frequency of increased right ventricular end-diastolic (RVED) dimension (25 of 38 cases [66 percent] vs two of 15 cases [13 percent], respectively; p less than 0.01). Only patients with increased RVED dimension (5/25; 20 percent) required tricuspid valvular surgery for prolonged fever or progressive right-sided heart failure (p less than 0.05 vs patients with normal RVED dimension). Tricuspid vegetations greater than 1.0 cm identified a subset of patients at increased risk for developing clinical right-sided heart failure during the active or convalescent phase of endocarditis (p less than 0.02 vs patients with tricuspid vegetations less than 1.0 cm). An unexpectedly high prevalence of asymptomatic prolapse of the mitral valve was observed in this population (23 of 53 episodes; 43 percent). Detection of tricuspid vegetations in patients with endocarditis due to S aureus is not a primary indication for early surgery, but identifies patients more likely to exhibit short-term and long-term complications of their infection.

Surgical treatment of active valvular infective endocarditis.

A review is presented of 20 patients consecutively operated on for acute valvular endocarditis. The diagnosis was established from at least two of the criteria: (a) typical clinical features, (b) two blood cultures positive for the same causal microorganism, and (c) echocardiographic evidence of vegetations. In all cases there was histologic evidence of active infection in the surgical specimen. Only three of the 20 patients had no previous cardiac disease. The most common causal agent was Staphylococcus aureus. The indications for surgery were refractory cardiac failure or infection (18 and 2 cases, respectively). Aortic valve replacement was performed in 16 of the 20 cases, suggesting that aortic valvulopathy aggravates the course of infective endocarditis and increases the risk of heart failure. The overall mortality rate was 30%. All surviving patients were infection-free at postoperative bacteriologic follow-up. Surgery is considered to be the management of choice in active valvular, therapy-resistant bacterial endocarditis with or without cardiac failure.

A NEW CHLAMYDIA COFACTOR IN CHD

Previous reports have identified various species of Chlamydia as potential cardiovascular disease agents. Chlamydia has been linked to valvular heart disease, myocarditis, endocarditis, and arterial emboli. Recently, a new Chlamydia species -- TWAR -- has been identified …

Reconstruction of the left ventricle with autologous pericardium

Autologous pericardium was used to reconstruct different parts of the left ventricle in 25 desperately ill patients. Fourteen patients had intractable sepsis resulting from infective endocarditis and myocardial abscess and 10 patients had noninfectious disorders. Of the patients with infections, 12 had valvular endocarditis with periannular abscess and three had interventricular septal abscess. The noninfected patients had acute rupture of the ventricular wall after mitral valve replacement (one patient) heavily calcified or surgically absent mitral anulus (three patients), or rupture of the interventricular septum after acute myocardial infarction (six patients). The interventricular septum, the posterior wall of the left ventricle, and the periannular areas were reconstructed by suturing appropriately tailored pericardial patches directly to the endocardium. In patients who also required valve replacement, the prosthetic valve was partially or completely secured to the pericardial patch. There were three operative deaths. All three patients were in either septic or cardiogenic shock before operation and in none of them was the death related to the pericardial patch. All 22 survivors have been observed from 3 to 34 months, an average of 14 months. There has been no case of patch dehiscence, patch aneurysm, prosthetic valve dehiscence, or recurrent endocarditis. Autologous pericardium appears to be safe for reconstruction of the left ventricle. It is easy to handle and problems with suture line bleeding are practically nonexistent.

Chronic granulocytic leukaemia in a dog with associated bacterial endocarditis, thrombocytopenia and preretinal and retinal haemorrhages

ABSTRACTThe clinical, haematological and pathological features of a case of chronic granulocytic leukaemia (CGL) associated with valvular bacterial endocarditis are described in a nine‐year‐old male Springer Spaniel. The disease was characterized clinically by lethargy, weight loss, hepatosplenomegaly, anaemia and leucocytosis. Severe thrombocytopenia resulted in preretinal and retinal haemorrhages. A diagnosis of CGL was based on the finding of a hypercellular bone marrow with increased M: E ratio and morphologically abnormal myeloid precursors. The dog terminally became leucopenic and bacteraemic. Necropsy revealed invasion of liver, spleen and bone marrow with a pleiomorphic population of myeloid blast cells, consistent with transition to a blast cell crisis.

Doppler Echocardiographic Detection of a Ruptured Acquired Aneurysm of the Sinus of Valsalva: Clinical-Morphologic Correlations

Two-dimensional, pulsed Doppler echocardiographic and pathologic features of an unusual form of ruptured aneurysm of the sinus of Valsalva are presented. The presence of an aneurysm of the left sinus of Valsalva protruding into the left atrium complicating acute aortic valvular endocarditis was detected by two-dimensional echocardiography. Rupture of the aneurysm of the sinus of Valsalva into the left atrial cavity was suggested by pulsed Doppler echocardiography. The size and location of the site of the rupture precluded recognition by two-dimensional echocardiography or contrast angiography. This report illustrates the unique value of pulsed Doppler echocardiography to define the location and direction of intracardiac flow patterns in evaluating patients with an aneurysm of the sinus of Valsalva and suspected rupture.

Acute aortic occlusion from aspergillosis in a healthy patient with survival

Valvular endocarditis caused by Aspergillus is a lethal disease. Only two survivors, both with infections of prosthetic valves, have been reported in the world literature. This report describes a patient with an Aspergillus valvular endocarditis on a native valve with embolization to the right axillary, left iliac, and left popliteal arteries and the distal aorta. Diagnosis was made from a thromboembolectomy specimen. Treatment consisted of removal of the peripheral arterial emboli, mitral valve replacement, and prolonged intravenous infusion of high-dose amphotericin B. The patient presently has the longest survival period of any patient with an Aspergillus infection on a native heart valve. The importance of early diagnosis and aggressive operative management by the vascular surgeon needed to properly treat these patients is emphasized.

Influence of vegetation size on clinical outcome of right-sided infective endocarditis

Endocarditis involving right-sided valvular structures is largely a disease of intravenous drug abusers. The majority of these patients respond to antibiotic therapy with clearing of their bacteremia and preservation of their hemodynamic status. This study evaluated the prognostic value of echocardiographically determined vegetation size in 23 episodes of right-sided valvular endocarditis in 21 patients. Right-sided vegetations were visualized in 19 of 23 episodes (83 percent). Of these, a vegetation of 1.0 cm or greater was found in 11. No patient with an echocardiographically determined vegetation size of less than 1.0 cm required surgery, whereas four of 11 (36 percent) of those episodes in which the vegetation size was 1.0 cm or greater required surgery for persistent pyrexia (p <0.05). In all patients requiring surgery, a bioprosthetic tricuspid valve was placed at the time of initial surgery and in no patient did early reinfection occur. This study reconfirms the benign prognosis of right-sided valvular endocarditis. Further, although vegetations of less than 1.0 cm identify those patients who will respond to medical therapy, echocardiographically documented vegetations of 1.0 cm or greater are associated with a significantly lower response rate to appropriate medical therapy. The association of fever that persists for more than three weeks in the absence of another source of infection with an echocardiographically demonstrable right-sided vegetation of 1 cm or more identifies those patients who will require surgical intervention. Finally, tricuspid valve replacement can be performed at the time of initial surgery without undue concern for early reinfection or valve dysfunction.