Unusual cause of myocardial infarction and congestive heart failure in a patient with prosthetic valve endocarditis

In a patient with staphylococcus lugdunensis prosthetic aortic valve endocarditis and coronary septic embolism accompanied by antero‐lateral myocardial infarction, embolic material was successfully aspirated from the bifurcation of the left anterior descending coronary artery and the first diagonal branch. A good angiographic result was documented six months thereafter when the patient presented with a second complication, pulsatile compression of the left main coronary artery by an abscess cavity originating between the aortic and mitral annulus, leading to congestive heart failure. The patient underwent successful surgical replacement of the aortic valve prosthesis with concomitant patch reconstruction of the annulus as well as tricuspid annuloplasty. © 2013 Wiley Periodicals, Inc.     

Allograft aortic root replacement for aortic valve endocarditis with aortopulmonary fistula

Acute infective endocarditis affecting the aortic root and valve associated with development of a fistulous communication between the aorta and pulmonary artery was presented in a young Turkish girl. Emergency surgery was required. Operation consisted initially of closure of the defect on the main pulmonary artery with a pericardial patch. This was followed by allograft aortic root replacement.     

Tetralogy of fallot with diminutive pulmonary arteries: Preoperative pulmonary valve dilation and transcatheter rehabilitation of pulmonary arteries

Objectives. The study sought to determine the results of a novel transcatheter management approach in tetralogy of Fallot with diminutive pulmonary arteries.

Background. Tetralogy of Fallot with diminutive pulmonary arteries and severe pulmonary stenosis is rare and resembles tetralogy of Fallot with pulmonary stresia: There is a high incidence of aortopulmonary collateral channels, arborization abnormalities, stenoses and need for multiple operations. Because a combined catheter-surgery approach facilitates repair in these patients, such an approach may benefit those with diminative pulmonary arteries and pulmonary stenosis.

Methods. Clinical, catheterization and surgical data were studied retrospectively for 10 such patients undergoing preoperative pulmonary valve balloon dilation, among other transcatheter interventions, from January 1989 to January 1995.

Results. Initially, the Nakata index ranged from 20 to 98 mm²/m² (mean 67 ± 28 mm²/m²). The pulmonary valve was first balloon dilated (mean balloon/annulus 1.5 ± 0.3), and the mean initial valve annulus Z score (−40 ± 1) increased to −3.3 ± 1.1 (p < 0.01). Other interventions included branch pulmonary artery balloon dilation (7 patients, 23 vessels) and coil embolization of aortopulmonary collateral channels (8 patients, 31 collateral channels). At preoperative follow-up catheterization, the mean pulmonary annulus Z score was −3.1 ± 0.7, and the aorta index increased to 143 ± 84 mm²/m² (p < 0.03). All patients underwent complete surgical repair successfully. At a mean follow-up period of 2.6 ± 2 years, right ventricular pressure was < 70% systemic in all patients and <50% systemic in seven.

Conclusions. In patients with tetralogy of Fallot, severe pulmonary stenosis and diminutive pulmonary arteries, initial pulmonary valve balloon dilation increases the annulus Z score and anterograde pulmonary blood flow and facilitates simultaneous coiling of sertopulmonary collateral channels and access for branch pulmonary artery dilation, all of which results in pulmonary artery growth, simpligying surgical management.     

Pulmonary and aortic valve endocarditis in an adult patient with silent patent ductus arteriosus

Pulmonary and aortic valve endocarditis are uncommon especially in an adult patient with patent ductus arteriosus. A 27-year-old woman diagnosed with pulmonary and aortic valve endocarditis underwent surgical treatment. Here, we report our clinical and surgical experience in treating a case of double valve endocarditis with clinically silent patent ductus arteriosus.     

Prenatal diagnosis of fetal absent pulmonary valve syndrome by two‐ and three‐dimensional echocardiography

Absent pulmonary valve syndrome (APVS) is a rare congenital cardiac anomaly characterized by hypoplastic or even absent pulmonary valve, to‐and‐fro flow across the pulmonary valve annulus, and dilatation of main pulmonary artery and branches. It is crucial to evaluate the degree of dilatation of pulmonary arteries and the presence of associated malformation and chromosomal anomalies affecting pregnancy decision. We described two‐ and three‐dimensional (3D) echocardiographic findings of one fetus with APVS and indicated the beneficial contribution of 3D technology in understanding the anatomy.     

Giant-Size Main Pulmonary Artery Aneurysm in an Adult Patient with Ebstein Anomaly and Dextrocardia

Main pulmonary artery aneurysms are rare, mostly asymptomatic and discovered accidentally. The main pulmonary artery aneurysms may be idiopathic or secondary to underlying diseases such as pulmonary hypertension, Behcet’s disease, connective tissue disorders, congenital heart disease, vasculitis, syphilis, tuberculosis and endocarditis. There are some indices that dextrocardia is associated with anomalies of the pulmonary arteries and pulmonary valve. A rare occurrence of main pulmonary artery aneurysms results in a lack of recommendations, so the remaining challenges are whether main pulmonary artery aneurysms should be treated, how, and when. The decision on surgical intervention or conservative treatment of the main pulmonary artery aneurysms depends on its size, etiology and accompanying diseases and includes a multidisciplinary heart team. Our case of the main pulmonary artery aneurysm and pulmonary valve abnormality associated with Ebstein anomaly and dextrocardia in a 67-year-old male patient brings causality considerations and treatment options in such a unique condition.     

Absent pulmonary valve syndrome: prenatal cardiac ultrasound diagnosis with autopsy correlation

Absent pulmonary valve syndrome (APVS) is a rare conotruncal anomaly consisting of a severely hypoplastic pulmonary valve with annular stenosis, aneurysmal dilatation of main pulmonary artery with dilatation of one or both pulmonary artery branches, and a ventricular septal defect. Here, we report a prenatal echo diagnosis of APVS in a 27-year-old primi gravida at 20 weeks of gestation confirmed on fetal autopsy. A 'bow tie'-like hypoechoic shadow in fetal cardiac ultrasound observed by us in a modified four-chamber view was suggestive of aneurysmal dilatation of branch pulmonary arteries. The consequences of continuation of pregnancy including immediate neonatal complications and possible medical and multistaged surgical interventions were well explained. Parents opted for medical termination of pregnancy. Autopsy findings of the fetus were consistent with the prenatal echo diagnosis of APVS. The presence of patent ductus arteriosus seen in the autopsy may be the cause of severe heart failure evidenced by the abnormally large congested liver, dilated right heart chambers, and tricuspid valve annulus. We infer that the prenatal diagnosis of APVS may be possible with a high degree of accuracy with characteristic fetal echocradiographic findings such as 'bow tie'-like or 'ballooning'-like shadows observed in this case. The presence of ductus confirms definite fetal loss and the parents can be counselled accordingly. However, when the ductus is absent, decision-making is difficult as the fetus is going to survive.     

Isolated pulmonic valve endocarditis

A 61-year-old man with no known cardiac history presented with septic arthritis of the right knee secondary to group B Streptococcus. During follow-up, echocardiography revealed a 1.8 cm x 1.2 cm mobile vegetation on the pulmonary valve. Despite parenteral antimicrobial therapy, the patient developed recurrent pulmonary emboli with enlargement of the vegetative mass, necessitating surgical debridement and replacement of the pulmonary valve. A diagnosis of pulmonic valve endocarditis should be considered in the differential diagnosis of any febrile patient with multiple pulmonary emboli.     

Foreign body in the tricuspid valve with valvular insufficiency and right-left shunt

We present the case of a 50-year old man who progressively developed tricuspid valve insufficiency with opening of a patent foramen ovale responsible for right-to-left shunt with polycythaemia. The tricuspid valve insufficiency was due to a foreign body, probably of surgical origin as suggested by its radiological image and by the patient's previous history. It would have been introduced, far away from the tricuspid valve (compound fracture of the wrist), several years previously. At surgery, we found the foreign body embedded in the valve system. As a possible mechanism for the mutilation, an undiagnosed endocarditis was suspected but could not be confirmed. Three cases tricuspid endocarditis (with foreign bodies in the right ventricle) and 3 cases of asymptomatic tricuspid valve foreign bodies have been published. Fifty-five cases of foreign bodies introduced peripherally and migrated into the heart, the pericardium and the pulmonary artery are reviewed.     

Transesophageal echocardiographic (TEE) evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve

The most important role of TEE in aortic valve disease is in the diagnosis of endocarditis and its complications. Examination of the annulus and subvalvular region is essential in any patient with possible aortic valve endocarditis. Assessment of the severity of aortic stenosis is a useful application of TEE when other data are either inconsistent or unavailable. TEE can provide a diagnosis of the origin of acute severe aortic insufficiency; this information may play a critical role in surgical planning. The diagnosis of a variety of aortic valve diseases can be made when TEE is performed to find an embolic source or to rule out dissection. In the case of mass lesions, such as papillary fibroelastomas and Libman-Sacks vegetations, the results of TEE carry major therapeutic implications. TEE offers generally excellent quality images of the LVOT and images of the RVOT and pulmonic valve that are superior to transthoracic echocardiography. The major clinical usefulness of TEE stems from its ability to identify pulmonic valve mass lesions and the causes of left and right ventricular outflow obstruction. TEE is also an important adjunct in the surgical management of left ventricular outflow obstruction.     

Prosthetic valve endocarditis with annulus destruction: technique for reconstruction

When endocarditis involves a mechanical prosthetic aortic valve, it is a certainty that the annulus is destroyed; the pathology may extend to produce aneurysms of the sinuses of Valsalva or progress to fistulization into juxtaposed cardiac chambers or the pericardium. Annular destruction breaks down the framework to which a new prosthesis is anchored; therefore, valve replacement requires the creation of a new annulus. This report describes the technique for reconstructing partial aortoventricular discontinuity caused by annular destruction from prosthetic valve bacterial endocarditis.     

Congenital absence of pulmonary valve leaflets with intact ventricular septum in a neonate.

Symptomatic infants with congenital absence of pulmonary valve leaflets suffer primarily from respiratory insufficiency caused by bronchial compression by the dilated pulmonary arteries, and have a high mortality rate. We report the successful treatment of absent pulmonary valve syndrome with intact ventricular septum in a neonate. The treatment consisted of resection of the pulmonary artery aneurysm and enlargement of the pulmonary annulus.     

Isolated pulmonic valve endocarditis in healthy hearts: a case report and review of the literature

The case of a 53-year-old man with isolated pulmonic valve endocarditis in a structurally normal heart is presented. The patient had a history of chronic obstructive pulmonary disease and was admitted to hospital with an apparent exacerbation with pneumonia. Blood cultures grew Staphylococcus aureus, and an echocardiogram identified a large vegetation on the pulmonic valve in a structurally normal heart. He was unsuccessfully treated with antibiotics and eventually required pulmonic valve replacement. The literature from 1960 to 1999 identified only 36 reported cases of pulmonic valve endocarditis in structurally normal hearts. The present report underscores the importance of suspecting pulmonic valve endocarditis in patients with multiple pulmonary lesions, and discusses the predisposing factors, clinical features, diagnostic role of echocardiography and the potential benefits of early surgical treatment.     

Pathologic findings after cardiac valve replacement with glutaraldehyde-fixed porcine valves.

Although approximately 20,000 glutaraldehyde-fixed porcine cardiac valve prostheses have been implanted in patients there is a lack of detailed pathologic studies of valves removed surgically or examined at necropsy. In this study, of 363 valves implanted in 311 patients, 26 valves (7 percent) from 23 patients (7 percent) were examined morphologically. Of the 23 patients, 14 died intraoperatively or less than 1 month after valve replacement—3 from coronary artery disease, 4 from hemorrhagic myocardial necrosis, 2 from postoperative hemorrhage, 2 from pulmonary disease and 1 from phycomycosis of the prosthesis; in 2 patients no anatomic cause of death was found. Six patients died 1 to 9 months after valve replacement—one from prosthetic thrombotic stenosis, one from prosthetic endocarditis and four from causes unrelated to their prosthesis. Three patients underwent surgical excision of a malfunctioning valve 12 to 31 months after implantation; incompetence was due to infective endocarditis in two patients and to a torn cusp in one.     

Premature pulmonary valve opening in a patient with absent tricuspid valve.

Echocardiography (M-mode and cross-sectional) disclosed premature opening of the pulmonary valve (very deep "a" wave) in a young man who underwent tricuspid valvulectomy without valve replacement 32 months before for refractory bacterial endocarditis. Cardiac catheterisation showed a prominent atrial wave on the pulmonary artery pressure curve. Thus, part of the right ventricular ejection appeared to occur before the onset of ventricular systole, as a result of powerful right atrial contraction.     

Current status of the Ross procedure in aortic valve surgery

The Ross procedure represents a unique surgical concept of unrepairable diseased aortic valve replacement by patient's own pulmonary valve (pulmonary autograft). After pulmonary valve removal, the right ventricle outflow tract is reconstructed by pulmonary allograft transplantation. Pulmonary valve in aortic position (pulmonary autograft) displays excellent haemodynamic features, viability with a growth-potential (in children) and a low risk of thromboembolism and infective endocarditis unparalleled to other heart valve substitutes. Despite the advantages of a pulmonary autograft the Ross procedures arouses controversies and surgical respect due to its technical complexity and involvement of another valve into a risk of complications and potential reoperation. Renaissance of interest in Ross procedure has been caused by recent operation standardisation, knowledge of critical procedural steps and confirmation of excellent long-term results. Ross procedure performed in dedicated centres with utmost attention to technical details securing long-term durability of both the autograft and allograft is an attractive option namely for young patients with aortic valve disease.     

Isolated pulmonic valve endocarditis caused by group B streprococcus (Streptococcus agalactiae)--a case report and literature review

The pulmonic valve is the least commonly involved valve in infective endocarditis. Pulmonic valve endocarditis is usually associated with tricuspid valve endocarditis, and isolated pulmonic valve endocarditis is exceedingly rare. The predisposing factors for developing pulmonic valve endocarditis include a congenitally anomalous pulmonic valve, intravenous drug abuse, and the presence of indwelling intravenous or flow-directed pulmonary artery catheters. More cases of group B streptococcus endocarditis are being reported. The risk factors for group B streptococcus endocarditis include diabetes mellitus, cancer, alcoholism, malnutrition, immunocompromised status, intravenous drug abuse, postpartum and postabortion states, and underlying valvular disease. The vegetations of this type of endocarditis are usually large and have a higher tendency to result in embolism. The presentation of group B streptococcus endocarditis is usually acute and may result in rapid valve destruction if not treated promptly. A case of isolated pulmonic valve endocarditis caused by group B streptococcus, Streptococcus agalactiae, is presented that was diagnosed with multiplane transesophageal echocardiography in a 40-year old, alcoholic, malnourished man, who was successfully treated with intravenous penicillin G. The literature on the isolated pulmonic valve endocarditis caused by group B streptococcus is reviewed.     

Prosthetic valve endocarditis caused by Legionella pneumophila

Prosthetic valve endocarditis due to Legionella pneumophila occurred in a woman who had aortic and mitral valve replacements with porcine xenografts. During surgery for persistent fever and aortic regurgitation due to presumed endocarditis, she had vegetations involving both the aortic and mitral valve prostheses with a circumferential abscess of the aortic annulus. Cultures, Dieterle stain, and direct fluorescent antibody stain of valve tissue, and subsequent measurements of serum antibody levels confirmed L. pneumophila as the infecting organism. This infection occurred in the absence of pneumonia. Legionella pneumophila must be considered a potential cause of culture-negative prosthetic valve endocarditis and should be sought in appropriate clinical circumstances.     

Echocardiographic diagnosis of infectious endocarditis on patent ductus arteriosus with involvement of the pulmonary artery and the pulmonary and aortic semilunar valves. Description of a case

Infective endocarditis is one of the most rare complications of patent ductus arteriosus (PDA). Usually vegetations are localised at the level of the patent ductus and can involve the left branch and the trunk of the pulmonary artery. We report the case of a young woman with PDA, who was admitted to the hospital in severe congestive heart failure due to infective endocarditis. A 2D echocardiographic examination revealed vegetations into the ductus with extension to the pulmonary artery, pulmonary valve and aortic valve. The results of the echocardiographic study enabled us to evaluate the extension of the lesions, to avoid heart catheterization and to decide the most suitable surgical approach for repairing all the damage in one surgical operation.     

Clinical and diagnostic features of pulmonary valve endocarditis in the setting of congenital cardiac malformations

We studied the clinical and diagnostic features of 5 cases of pulmonary valve endocarditis where morphologic documentation was available. All patients had congenital cardiac disease as thee predisposing factor and the infectious process involved only the pulmonary valve. None of the patients was addicted to drugs. Absence of systemic emboli, lack of pulmonary symptoms, acute course and high frequency of sterile cultures made the clinical recognition difficult and was possible only in three cases. The clinical picture of pulmonary valve endocarditis was characterised by fever, right-sided congestive cardiac failure and pulmonary incompetence. Echocardiography assumes a specific diagnostic role in such cases and cross-sectional echocardiography provides more information than M-mode echocardiography. Pulmonary valve endocarditis carries a high mortality and 3 patients died. Two patients underwent successful surgery of their underlying defect and excision of the pulmonary valve. Staphylococcus aureus was the organism grown from autopsy or surgical material in 3 cases.