Recurrent myocardial abscess during Streptococcus B endocarditis

The authors report a case of serious streptococcus B endocarditis with a myocardial abscess that recurred after surgery. Streptococcus B endocarditis is a rare disease which is characterized by a pronounced tropism of the organism for cardiac tissues, with severe cardiac valve mutilation and abscess formation in 40% of the cases. A myocardial abscess makes the prognosis worse and must be treated surgically during the acute phase of endocarditis. Modern imaging methods, notably trans-oesophageal two-dimensional echocardiography and computerized tomography should now be used to detect such abscesses.     

Nosocomial methicillin-resistant Staphylococcus aureus endocarditis with splenic abscess in a pregnant woman

A 36-year-old, 7-week-gravida patient with catheter-related nosocomial infective endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA) is presented in this paper. The patient was admitted to our hospital because of carbon monoxide intoxication. After 14 days, MRSA catheter-related bacteremia developed. The central venous catheter was immediately removed, and teicoplanin therapy was started. Because of persistent fever, leukocytosis, and high C-reactive protein values, endocarditis was suspected. A transesophageal echocardiogram revealed 19-mm vegetation on her mitral valve, confirming the diagnosis of endocarditis. Gentamicin and rifampicin were added to the therapy regimen, and the dose of teicoplanin was increased to 12 mg/kg-day. After 8 days, a splenic abscess was detected by ultrasonography. Vegetation excision, mitral valve replacement by open-heart surgery and splenectomy were performed in the same operation. Antibiotherapy was continued for 6 weeks after surgery, and the patient's condition improved. The development of endocarditis could be prevented by proper clinical practices.     

Echocardiographic demonstration of aortic root abscess after infective endocarditis.

We describe a patient with infective endocarditis in whom the diagnosis was apparent only on two-dimensional echocardiography. There was no clinical or haematological evidence of active endocarditis and the diagnosis was made by the demonstration of an abscess cavity and vegetation posterior and lateral to the aortic root, deforming the left atrial cavity. The findings were confirmed by cardiac catheterisation and operation.     

Methicillin-resistant Staphylococcus aureus prosthetic aortic valve endocarditis with paravalvular abscess treated with daptomycin

Prosthetic valves have been used extensively for severe cardiac valvular dysfunction for the past 3 decades. Prosthetic cardiac valves may be infected with organisms causing bacteremia, particularly gram-positive cocci. Staphylococcus epidermidis (coagulase negative staphylococci) and Staphylococcus aureus , both methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) strains, are the most frequent pathogens causing prosthetic valve endocarditis (PVE). Vancomycin has been the cornerstone of therapy for serious MRSA infections including bacteremia and endocarditis. Clinicians have noted that MRSA bacteremias treated with vancomycin often fail to clear even with prolonged therapy. Persistent or prolonged MRSA bacteremia unresponsive to vancomycin therapy has led to the treatment of these infections by other agents, that is, quinupristin, dalfopristin, linezolid, or daptomycin. These antibiotics have been found particularly useful in treating MRSA bacteremias unresponsive to vancomycin therapy. We report a case of a patient who presented with MRSA PVE complicated by perivalvular aortic abscess with persistent MRSA bacteremia unresponsive to vancomycin therapy. The patient's MRSA bacteremia was cleared with daptomycin therapy (6 mg/kg/d). Because the patient refused surgery, daptomycin therapy was continued in hopes of curing the endocarditis and sterilizing the perivalvular aortic abscess. Transesophageal echocardiogram revealed a decrease in abscess in the aortic perivalvular abscess after 1 week of daptomycin therapy. The patient made an uneventful recovery. The cure of PVE and perivalvular abscesses usually requires removal of the prosthetic device and abscess drainage. In this case, in which surgery was not an option, medical therapy of PVE and a decrease in size of the aortic perivalvular abscess were accomplished with daptomycin therapy. Daptomycin is an alternative to vancomycin therapy in patients with prolonged or persistent MRSA bacteremia secondary to endocarditis or abscess.     

Infective endocarditis complicated by abscess and perforation of mitral valve--a case report

A case of a 47-year-old male admitted to our department due to acute myocardial infarction, treated effectively with primary angioplasty, is presented. Three weeks earlier the patient was admitted to another hospital with a suspicion of infective endocarditis. Echocardiography performed in our department after the patient recovered from acute phase of MI revealed the presence of mitral valve abscess which caused valve perforation. The patient was transferred to another institution for cardiac surgery.     

Splenic abscess in a patient with fecal peritonitis

Splenic abscess is a rare entity normally associated with underlying diseases.We report a case of splenic abscess with large gas formation in a non-diabetic and non-immunosuppressed patient after surgery for colon perforation.The most frequent cause of splenic abscess is septic embolism arising from bacterial endocarditis.Splenic abscess has a high rate of mortality when it is diagnosed late.Computed tomography resolved any diagnostic doubt,and subsequent surgery confirmed the diagnosis.     

Myocardial abscess due to Klebsiella pneumoniae complicating acute infarction

A case is described in which Klebsiella pneumoniae urosepsis associated with acute myocardial infarction resulted in myocardial abscess and papillary muscle rupture. The diagnosis was made during surgery for mitral valve replacement. The patient improved after therapy with cefotaxime; however, cardiac rupture occurred on the sixth postoperative day. The pathogenesis of myocardial abscess and the use of non-invasive techniques for diagnosis are discussed.     

Diagnosis and successful management of septal myocardial abscess: a complication of bacterial endocarditis

A case of acute enterococcal aortic valve endocarditis is presented in which the complication of a septal myocardial abscess was diagnosed clinically and successfully treated surgically. This represents the first instant, to our knowledge, in which the preoperative diagnosis of a myocardial abscess served as the indication for emergency cardiac surgical intervention in active endocarditis with successful outcome. The diagnostic parameters permitting clinical recognition of a myocardial abscess include the development of advancing degrees of atrioventricular and bundle branch block, and the finding of pericarditis or pericardial effusion in aortic valvular infections. Two additional findings were noted in the present case: echocardiographic evidence of septal thickening, and loss of septal Q waves on the electrocardiogram. Since myocardial abscesses do not respond to medical therapy, continuous electrocardiographic monitoring and frequent echocardiographic determinations are recommended in cases of active aortic valve endocarditis to permit early diagnosis and surgical management of this complication.     

Left Atrial Wall Dissection: A Rare Sequela of Native-Valve Endocarditis

Left atrial wall dissection is a rare condition; most cases are iatrogenic after mitral valve surgery. A few have been reported as sequelae of blunt chest trauma, acute myocardial infarction, and invasive cardiac procedures. On occasion, infective endocarditis causes left atrial wall dissection.We report a highly unusual case in which a 41-year-old man presented with native mitral valve infective endocarditis that had caused left atrial free-wall dissection. Although our patient died within an hour of presentation, we obtained what we consider to be a definitive diagnosis of a rare sequela, documented by transthoracic and transesophageal echocardiography.     

Transoesophageal echocardiographic diagnosis of aortico-left atrial fistula in aortic valve endocarditis.

Intra-cardiac fistulas are rarely seen and they are estimated to account for <1% of all cases of infective endocarditis. Fistulization of paravalvular abscesses has been found in 6% to 9% of cases. This is a report of an unusual communication between the abscess region in the aortic root and the left atrium. A 44-year-old patient diagnosed with infective endocarditis had continuous fevers despite antibiotic therapy. Transoesophageal echocardiography revealed multiple vegetations on aortic valve, fistulization of an aortic root abscess to the left atrium and mitral regurgitation and moderate aortic regurgitation. At surgery, multiple vegetations on the aortic valve and a large abscess cavity establishing direct communication between aortic root and the left atrial cavity through a fistulous tract were discovered. This experience demonstrates the improved sensitivity and specificity of transoesophageal echocardiography in defining periannular extension of infective endocarditis.     

开胸心脏直视手术治疗起搏装置相关感染性心内膜炎

目的总结起搏装置相关感染性心内膜炎(CDIE)的外科治疗,为临床治疗此少见难治疾患提供方法。方法回顾性分析近10年收治的CDIE病例,对其发生原因、临床表现、治疗经验进行总结。结果 CDIE 8例,7例经开胸直视手术下取出起搏电极导线,术中均发现起搏电极导线上明确赘生物形成,其中1例合并冠心病同期行冠状动脉旁路移植术,1例合并主动脉瓣赘生物同时行主动脉瓣置换术,2例行三尖瓣成形术。术后临时心外膜起搏保证基本心律,感染完全控制后再次植入起搏装置,所有病例均痊愈出院,随访1~107个月,无一复发。结论开胸心内直视手术取出起搏电极导线及脉冲发生器是治疗CDIE的有效措施。     

Late chronic constrictive pericarditis following aortic valve replacement

The authors report a case of chronic constrictive pericarditis in a 54 year old patient who had undergone aortic valve replacement 6 years previously. The valve was replaced with a Starr-Edwards prosthesis because of aortic regurgitation due to infective endocarditis. The outcome after pericardectomy was favourable with a 3 year follow-up. This complication of cardiac surgery, of which there are now 45 reported cases, should not be overlooked because it can be cured surgically. The diagnosis is based on phonomechanographic, echocardiographic and, above all, haemodynamic investigations to distinguish the condition from irreversible myocardial dysfunction.     

Fatal cardiac tamponade in a young man with group C streptococcal endocarditis

The case of a previously healthy man with endocarditis due to the group C streptococcus, complicated by myocardial abscess and fatal cardiac tamponade, is presented. Group C streptococcus is an unusual cause of endocarditis which tends to produce extensive valve destruction. Early surgery should be considered in patients with endocarditis caused by this organism.     

Aortico-left atrial fistula in aortic valve endocarditis.

Aortic root abscess is a well-known complication of aortic valve endocarditis. This report describes the two-dimensional echocardiographic findings in a patient with aortic valve endocarditis whose course was complicated by a posterior aortic root abscess which ruptured into the left atrium creating an aortico-left atrial fistula, which, to our knowledge, has not been previously reported. These findings were confirmed at surgery.     

Vegetative cardiac metastases of oral cavity cancer: an autopsy case report

A 60-year-old man was admitted to our hospital for evaluation of intracardiac vegetative masses detected by echocardiography in September 2001. He had undergone surgery for oral cavity cancer in 1999. He presented with severe embolic symptoms including cerebral infarction, but had few symptoms of heart failure. Antibiotic therapy was started under the diagnosis of infective endocarditis, but the embolic symptoms persisted. An autopsy revealed that the intracardiac vegetative masses consisted of tumor cells originating from the oral cavity cancer. Intravascular tumor thrombi were also found widely distributed in other organs such as the liver, lung, spleen and kidney, and had similar histological features. This is a very rare case of cardiac metastases of oral cavity cancer without adhesion to the endocardium or other myocardial tissue.     

Escherichia coli endocarditis of the aortic valve with formation of a paravalvular abscess cavity

A 42-year-old male with a history of chronic aortic valve disease and urethra stenosis, was admitted with fever, dysuria, and vomiting. Escherichia coli (E. coli) was cultured from blood and urine. Repeated transesophageal echocardiographic studies performed during the early phase of the hospitalization did not exclude the possibility of infective endocarditis. A definite diagnosis was, however, not established until 6 weeks after admission. At that time a large paravalvular aortic abscess cavity had developed and urgent surgery was necessary. A possible explanation for the delayed diagnostic evaluation was the low level of suspicion, as the septicemia was believed to originate from the urinary tract, without involvement of other organs. The possibility of endocarditis due to E. coli should be considered, especially in subjects with underlying cardiac valve disease, despite an alternative source of septicemia and despite the rarity of this condition. Frequent echocardiographic studies are recommended since extensive tissue destruction may occur without any striking symptoms.     

Fungal Ascending Aortic Aneurysm after Cardiac Surgery

A 52-year-old diabetic male was admitted due to 1-month history of fever, fatigue, and mild shortness of breath. Three months prior to admission, he had undergone aortic valve replacement, with a prosthetic one, because of streptococcus viridans endocarditis complicated by severe aortic regurgitation. Transesophageal echocardiogram revealed prosthetic valve endocarditis with dehiscence of the aortic valve and an abscess cavity extending from the aortic root into the ascending aorta. Blood cultures and serology were negative. Due to clinical deterioration, despite antibiotic therapy, the patient was reoperated on and the aortic valve and ascending aorta were replaced with a homograft. Valve culture grew Aspergillus flavus. This case is an example of a rare but of increasing frequency complication after cardiac surgery. Considering the high mortality from this complication, early recognition is of paramount importance.     

Combined open-heart valve surgery and elective abdominal operations

From January 1970 to December 1984, at the "A. De Gasperis" Division of cardiac surgery in 73 patients an open-heart valvular operation and an elective abdominal surgical procedure were simultaneously performed. Abdominal surgery was indicated for: cholelithiasis (41 cases), hernia (22 cases), uterine fibroleiomyomas (7 cases), pregnancy (1 case), marginal ulcer after gastric resection (1 case), association of cholelithiasis and hernia (1 case). The etiology of valvular disease was: previous rheumatic fever (69 cases) and acute bacterial endocarditis (1 case); there were 3 cases of periprosthetic leak. All patients were classified in NYHA class III or IV. In all patients the abdominal procedure was carried out first. No significant differences were noted between this group of patients and patients with isolated open-heart operations regarding: postoperative bleeding, stay in Postoperative Intensive Care Unit, overall postoperative hospital stay. There were 5 hospital deaths, all related to cardiac causes. There were no infectious complications, nor early or late abdominal wound complications. The rationale for the combined approach to abdominal and cardiac diseases includes: risk of non cardiac surgery in patients with critical heart disease, risk of non cardiac surgery in patients with previous cardiac valve operations and anticoagulant therapy and risk of abdominal complications after cardiopulmonary bypass surgery. Simultaneous abdominal and cardiac surgery is suggested on clinical, psychological and social grounds.     

Cardiac echo-Doppler in the diagnosis and surveillance of the course of acute endocarditis

Infectious endocarditis is still currently a problem. Its frequency is not decreasing and new etiologies have developed, which are often responsible for acute endocarditis, resistant to hospital bacteria. The cardiac Doppler has a role in the positive diagnosis of endocarditis, especially on native valves. This examination permits an accurate evaluation of valvular and perivalvular lesions (abscess, mycotic aneurysms) and their repercussions on the ventricle. Studies in this last decade, have emphasized that the presence of vegetations is a factor of gravity. The Doppler permits an "active" monitoring in high risk forms: endocarditis of the aortic orifice, endocarditis with perivalvular abscess, endocarditis occurring on a prosthetic valve.     

Brucella endocarditis of bicuspid aortic valve. Surgical treatment with successful result

The authors report a case of Brucella Melitensis endocarditis of a bicuspid aortic valve which caused rapid progression of the hemodynamic signs of aortic stenosis, and was associated with a para-aortic abscess and a pericardial effusion. Surgery resulted in correction of the hemodynamic abnormalities and cured the infection: the results were sustained 10 months after operation. This case illustrates the precision of the Doppler, echocardiographic diagnosis of the lesions, which was confirmed at surgery so that potentially dangerous cardiac catheterisation could be avoided.