An analysis of autopsy findings in 108 patients who died after valve replacement

The pathological findings and the causes of death were reviewed in 108 patients who had received 142 heart valve prostheses (52 mechanical and 90 bioprostheses) at the National Cardiovascular Center in Osaka, Japan, from 1977 to 1991. Rheumatic heart disease was the major underlying disease (60.2%), and the age distribution at death ranged from 21 to 80-year-old. Survival duration after the surgery extended from 0 day to 9 years. Thirty-three patients (30.6%) died of perioperative complications such as myocardial haemorrhage and damage, or from heart failure which had been evident prior to the operation, a cause of death which predominated in patients who died within 1 week of surgery (15/17; 88.2%). Thirty-eight patients (35.2%) died of prostheses-related problems such as prosthetic valve failure (cuspal tears and calcifying destruction of the xenograft), thromboembolism, and prosthetic valve endocarditis. Endocarditis was frequent in patients who had survived longer than 1 year (25/33; 75.8%). None of the patients died of prostheses-related problems within 1 week. Non-infectious valve failure was more common in patients with bioprostheses than in those with mechanical valves; thromboembolism showed the opposite association. Prosthetic valve infective endocarditis was nearly equal in frequency in both types of valve.     

Emerging infectious endocarditis due to <Emphasis Type="Italic">Scedosporium prolificans</Emphasis>: a model of therapeutic complexity

Scedosporium prolificans is an emerging agent for severe infections. Although among the dematiaceous fungi Scedosporium is the most frequently isolated in blood cultures, Scedosporium endocarditis is rarely reported. We show herein a patient with acute leukaemia who developed S. prolificans endocarditis. Twelve cases were found in an extensive review of the English literature. In six cases (46%), there was predisposing heart conditions such as a prosthetic valve or an intracavitary device. Only 4 patients (31%) were immunocompromised hosts with haematologic neoplasia, solid-organ transplantation or acquired immunodeficiency syndrome (AIDS). Exposure to Scedosporium was observed in immunocompetent patients who developed infection while in the community. Scedosporium endocarditis occurred on both sides of the heart. Systemic and pulmonary emboli and other metastatic complications were seen in all of these patients. The overall mortality was 77% and, specifically, all of the immunocompromised hosts and 6 out of 7 patients with mitral or aortic valve endocarditis died. Patients with right-sided endocarditis associated with a removable intracardiac device exhibited a better prognosis. Scedosporium endocarditis, although still rare, is an emerging infection with an ominous prognosis. At the present time, valve replacement or the removal of cardiac devices plus combined antifungal treatment may offer the best possibility of cure.     

Role of surgery in infective endocarditis

One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (less than 60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71% early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.     

Multi-valvular endocarditis

Objective   Seventy-seven cases of native valve infective endocarditis as determined by the Duke criteria, were reviewed to determine the incidence and clinical features of multi-valvular endocarditis.
Methods   Fourteen of 77 patients (18%) had multi-valvular endocarditis most commonly involving the mitral and aortic valves. Staphylococcus aureus (43%) and viridans streptococci (36%) were the most common organisms causing multi-valvular endocarditis.
Results   Definite or probable vegetations were found in 50% of the patients by two-dimensional transthoracic echocardiograph and/or transesophageal echocardiograph, and possible vegetations were detected in 21%. The overall mortality in our series was 21%; 29% underwent valve replacement and 50% were treated medically. The major complications of multi-valvular endocarditis were congestive heart failure (64%), acute renal failure (50%), embolic events (21%), and splenic abscess/infarcts (21%).
Conclusions   Our data suggests complications of multi-valvular endocarditis, compared with uni-valvular endocarditis are similar except for heart failure. Heart failure is statistically more common in multi-valvular endocarditis ( P 0.002).     

Q fever endocarditis; not always expected

Q fever endocarditis is a chronic disease with protean manifestations. The clinical and serological manifestations of nine patients diagnosed as having Q fever endocarditis during a 19-year period are reviewed. Four patients (44%) required valve replacement due to congestive heart failure. Three of these four patients were diagnosed as having Q fever endocarditis only after elective valve surgery, by histopathological examination of the valve and subsequent serological tests. Prior to surgery they were afebrile and had no other symptom or sign indicative of endocarditis. The antibiotic treatment and the decreasing titres of Q fever antibodies of all nine patients during several years of follow-up are summarized. Careful assessment of heart valves for histopathological evidence of inflammation is suggested, even after elective replacement. If found, clinical and laboratory evaluation should include determination of anti-Coxiella burnetti antibodies.     

Cerebral infarction due to systemic necrotizing vasculitis in a patient with rheumatic heart disease, subacute bacterial endocarditis and status epilepticus

Systemic necrotizing vasculitis involving cerebral blood vessels is described in a 30-year-old man with rheumatic heart disease and subacute bacterial endocarditis. Fever, anaemia, splenomegaly and positive blood cultures for Gram-negative bacteria were found on admission. The fever resolved with antibiotic therapy on the third hospital day but he then developed hemiplegia and multifocal seizures. The seizures progressed to uncontrollable status epilepticus accompanied by congestive heart failure and the patient died 20 d after admission. At autopsy, exudative and necrotizing vasculitis involving medium- to small-sized arteries was seen in the brain, the heart and the skeletal muscles. Rheumatic myocarditis and endocarditis and old rheumatic mitral valve deformities were also present. In addition, verrucous endocarditis in the mitral valve and Löhlein's focal glomerulonephritis were noted. We discuss the possible mechanism of the systemic necrotizing vasculitis in relation to rheumatic fever.     

Aortic valve endocarditis in a dog due to Bartonella clarridgeiae

We report the first documented case of endocarditis associated with Bartonella clarridgeiae in any species. B. clarridgeiae was identified as a possible etiological agent of human cat scratch disease. Infective vegetative valvular aortic endocarditis was diagnosed in a 2.5-year-old male neutered boxer. Historically, the dog had been diagnosed with a systolic murmur at 16 months of age and underwent balloon valvuloplasty for severe valvular aortic stenosis. Six months later, the dog was brought to a veterinary hospital with an acute third-degree atrioventricular block and was diagnosed with infective endocarditis. The dog died of cardiopulmonary arrest prior to pacemaker implantation. Necropsy confirmed severe aortic vegetative endocarditis. Blood culture grew a fastidious, gram-negative organism 8 days after being plated. Phenotypic and genotypic characterization of the isolate, including partial sequencing of the citrate synthase (gltA) and 16S rRNA genes indicated that this organism was B. clarridgeiae. DNA extraction from the deformed aortic valve and the healthy pulmonic valve revealed the presence of B. clarridgeiae DNA only from the diseased valve. No Borrelia burgdorferi or Ehrlichia sp. DNA could be identified. Using indirect immunofluorescence tests, the dog was seropositive for B. clarridgeiae and had antibodies against Ehrlichia phagocytophila but not against Ehrlichia canis, Ehrlichia ewingii, B. burgdorferi, or Coxiella burnetii.     

Isolated infective endocarditis of the pulmonary valve: an autopsy analysis of nine cases

IntroductionInfective endocarditis (IE) of the pulmonary valve is uncommon and usually occurs in conjunction with tricuspid and/or left-sided valvular endocarditis. There have been only sporadic reports of isolated pulmonary valvular infective endocarditis (PVIE). This report documents the pathological features of nine such cases at autopsy.MethodsAmong 155 cases of IE encountered in a 14-year period, we selected nine cases that had isolated PVIE for analysis. The clinical records were reviewed for the patient demographics, presence or absence of underlying cardiac disease or other predisposing factors, and modes of presentation; these were correlated with the relevant investigations. A detailed study of the heart was done in all with special attention to the pulmonary valve morphology.ResultsThe nine cases of isolated PVIE formed 5.8% of the IE cases, seen in six males and three females, largely adults. Seven patients (77.8%) had admissions for about 24 h. Hospital admission was sought for mainly progressive shortness of breath (66.7%) and fever (44.4%). Congenital heart disease was seen in seven (77.8%); two (an infant and an adult) had normal hearts. A single blood sample for blood culture in two patients was negative. Two-dimensional echocardiography, performed in eight, revealed vegetations on the pulmonary valve in four. The pulmonary valve was tricuspid in six cases, bicuspid in two, and unicuspid in one. The vegetations (active in three, active and healing in two, healed in four) were accompanied by concomitant thickening, shortening, perforations, or complete destruction of the cusps. Involvement of the right ventricular outflow tract or the main pulmonary artery was identified in five hearts. Five patients (55.6%) developed pulmonary complications, related to the endocarditis.ConclusionsDetection of PVIE, especially the isolated type, may be underdiagnosed. This condition should be kept in mind during evaluation of patients especially with cardiac anomalies, who present with fever, prominent respiratory symptoms, and negative blood cultures.     

Infective endocarditis at a Hospital of the University of Kiel, 1958–1987

Summary The clinical courses of 214 patients with infective endocarditis treated between 1958 and 1987 at the First Medical Hospital of the University of Kiel (FRG) were analyzed retrospectively. A decrease in the incidence of endocarditis occurred during the 30-year observation period. The mean age of patients was 48 years, and men were more frequently affected than women. In the course of the investigation, a rise in isolated aortic valve disease was noted, whereas the number of patients with isolated involvement of the mitral valve and combined mitral-aortic valvular defects declined. Streptococci (57%) were the most frequent pathogens isolated; as opposed to their increase, the percentages ofStaphylococcus aureus and enterococci decreased. Otolaryngological, dentogenic and urogenital diseases were most frequently held to be responsible for the development of infective endocarditis. Prior cardiosurgical interventions became increasingly significant as a cause of the disease. In this connection, a rising percentage of endocarditis cases was linked with prosthetically replaced heart valves. Complications and concomitant symptoms of endocarditis included the development of heart failure, cerebral embolism and encephalitis, splenomegaly, and renal inflammation. Finally, the marked decrease in mortality contrasted with a simultaneous rise in the number of endocarditis cases achieving full recovery.     

Tricuspid Valve Endocarditis in Adult Patients Without Known Predisposing Factors

 Four patients with no known predisposing conditions developed tricuspid valve endocarditis. All patients had community-acquired infection with a rapidly progressive course that was complicated by right heart failure and respiratory insufficiency. Pulmonary involvement was prominent in all cases. The infectious process was due to Staphylococcus aureus in three patients and to Streptococcus intermedius in one patient. Three patients underwent early surgical intervention; the outcome was favourable in all cases. It is clear that tricuspid valve endocarditis can occur in the absence of known predisposing factors, and when Staphylococcus aureus is involved, the course of the disease may be acute and rapidly progressive.     

先天性心脏病合并感染性心内膜炎的临床及预后分析

目的总结分流型先天性心脏病合并感染性心内膜炎(IE)患者的临床特点、治疗及影响预后的因素。方法分析我院2001年1月-2010年12月收治的51例分流型先天性心脏病合并IE患者的临床资料。结果合并于分流型先天性心脏病的IE占全部IE患者的20.6%,其中室间隔缺损和动脉导管未闭是最常见的先天性心脏病。链球菌属(47.1%)是最常见的致病菌。52.9%的患者出现并发症,主要为瓣膜受损和系统性栓塞。38例患者(58.8%)行手术治疗,其中21例于IE活动期行早期手术。先心病合并IE的死亡率为19.6%。回归分析显示,严重心力衰竭(P<0.05)和神经系统并发症(P<0.05)是死亡率的预测因子,而手术治疗是死亡率降低的独立预测因子(P<0.05)。结论先天性心脏病合并IE者死亡率较高。出现严重心力衰竭和中枢神经系统并发症提示预后不良,手术治疗可显著降低死亡率。     

Anti-myosin humoral immune response following cardiac injury

A sensitive and highly specific ELISA assay was developed to determine the anti-myosin humoral immune response (AMA) in various heart diseases: acute viral myocarditis, infective endocarditis, acute myocardial infarction, and valve and coronary bypass surgery. The mean study entry AMA titer of each patient group was already significantly increased compared with age matched controls. During further follow-up (90 d) all the groups except for endocarditis showed a significant increase of AMA titer compared with their entry titer. Anti-myosin antibody titer were higher after cardiac surgery than after myocardial infarction or inflammatory heart disease. These results suggest that anti-myosin immune response is not limited to infectious processes in which the pathogen induces antibodies which cross-react with heart constituents but is merely caused by direct cardiac injury. Myosin as a major compound of heart cellular proteins turned out to be a good candidate to trigger immune response after cardiac injury.     

Anti-Myosin Humoral Immune Response Following Cardiac Injury

A sensitive and highly specific ELISA assay was developed to determine the anti-myosin humoral immune response (AMA) in various heart diseases: acute viral myocarditis, infective endocarditis, acute myocardial infarction, and valve and coronary bypass surgery. The mean study entry AMA titer of each patient group was already significantly increased compared with age matched controls. During further follow-up (90 d) all the groups except for endocarditis showed a significant increase of AMA titer compared with their entry titer. Anti-myosin antibody titer were higher after cardiac surgery than after myocardial infarction or inflammatory heart disease. These results suggest that anti-myosin immune response is not limited to infectious processes in which the pathogen induces antibodies which cross-react with heart constituents but is merely caused by direct cardiac injury. Myosin as a major compound of heart cellular proteins turned out to be a good candidate to trigger immune response after cardiac injury.     

Fatal right-sided endocarditis due to Aspergillus in a kidney transplant recipient.

Invasive aspergillosis (IA) is an emerging infectious disease in different groups of immunocompromised patients. In transplant recipients, intensification of immunosuppressive therapy to treat allograft rejection poses a major risk factor for IA. We present the clinical features, diagnostic findings and outcome of a kidney transplant recipient who developed pulmonary aspergillosis complicated by endocarditis of his native tricuspid valve. Despite replacement of the valve and treatment with combined antifungal therapy, the patient died of an acute pulmonary bleeding.     

Paecilomyces javanicus endocarditis of native and prosthetic aortic valve

A 41-year-old diabetic woman developed endocarditis of the aortic valve caused by Paecilomyces javanicus six years after insertion of a porcine mitral valve heterograft. The patient died shortly after aortic valve replacement. Autopsy revealed vegetations of the aortic heterograft, valve ring abscess and ascending aortitis due to Paecilomyces. There was no involvement of the mitral valve heterograft. Lesions due to mycotic emboli were found in the kidneys, spleen, and brain. Cultures of the surgically removed aortic valve and of the kidney at autopsy produced rapid growth of P. javanicus. The gross and microscopic pathologic and cultural characteristics of this organism are described with a review of the literature. Previously reported cases of Paecilomyces endocarditis occurred only in prosthetic heart valves. This is the first known report of P. javanicus endocarditis of a native valve and its prosthetic heart valve heterograft.     

Tricuspid valve surgery: 15-year experience.

Tricuspid valve surgery has been associated with a high operative mortality. This study reviewed 51 patients who underwent 53 tricuspid valve procedures between 1975 and 1989. Most patients (82%) had evidence of rheumatic heart disease. Twenty-six patients (51%) had 42 previous cardiac operations, most involving the mitral valve. Eighty-two percent of patients were New York Heart Association (NYHA) class III or IV preoperatively, and almost all patients had associated disease of other valves. The indication for operation was tricuspid regurgitation in 45 patients, infectious endocarditis in 4, and tricuspid stenosis in 2. The tricuspid abnormality was functional in 67% and organic in 33%. There were 32 tricuspid valve replacements, 20 annuloplasties, and 1 tricuspid valve excision. The hospital mortality rate was 11.8% (six patients). On statistical analysis, none of the perioperative variables were a significant risk factor for hospital mortality. Twenty-nine patients (51%) had postoperative complications. Postoperative functional status improved markedly with 80% in NYHA class I and 13% in class II. Long-term follow-up was attempted but was unsatisfactory in this transient, indigent population.     

Characterization of clinically significant isolates of Staphylococcus epidermidis from patients with endocarditis.

Biotyping, slime production, bacteriophage typing, serotyping, antibiograms, and plasmid profiles were used to characterize 19 Staphylococcus epidermidis strains isolated from 12 patients with prosthetic valve endocarditis and from 7 patients with native valve endocarditis. With the API Staph battery, 12 different biocodes with, at the most, three differences were obtained. Slime production was found for 10 strains (53%). Agglutinogens investigated by agglutination with two specific sera were found for 12 strains (63.1%). Three strains were phage typable (15.2%). Against a panel of nine antimicrobial agents, 15 different profiles were found. Multiply antibiotic-resistant strains were isolated from patients with prosthetic valve endocarditis when disease onset occurred less than 18 months after heart surgery and from patients with native valve endocarditis who received antibiotics immediately prior to their illness. All of the strains were available for plasmid analysis, and all the DNA profiles were distinct. On gels run in Tris-borate buffer, 73.7% of the strains had large plasmids of more than 30 megadaltons. A small plasmid of 2.8 megadaltons was found in multiply resistant strains and in strains resistant only to tetracyclines. None of the isolates appeared to be the same strain, and the bacteriological differences between the strains were confirmed mainly by the antibiotic susceptibility profile and the plasmid pattern analysis. These bacteriological results were in agreement with the clinical data.     

Changing Epidemiology of Infective Endocarditis: A Retrospective Survey of 108 Cases, 1990–1999

The aim of this study was to report the experience with infective endocarditis over the past decade, describe the changing clinical and epidemiological features of the disease, and attempt to determine the optimal number of blood culture sets required for diagnosis. All cases diagnosed during a 10-year period were reviewed clinically and microbiologically. In addition, a retrospective assessment of blood culture data was performed. From the period 1990–1999, 108 cases that met the von Reyn or Duke's criteria were recorded. The major underlying cardiac condition was the presence of a prosthetic valve (n=33 patients, 31%). Among patients with native valves, nonrheumatic valvular heart disease of the elderly was the most common underlying factor (n=19 patients, 25%). Overall, 13 patients (11%) died. Predictors on admission for increased mortality were shortness of breath, age >60 years, time to defervescence, erythrocyturia, hemoglobin level <10 g/dl, and leukocytosis >15,000 (all P<0.05). Analysis of blood culture data showed that the diagnostic yield among groups from whom either only one or more than six blood culture sets were drawn was reduced compared with that among groups from whom between two and five culture sets had been taken. The outcome of endocarditis in this series from a community hospital was much more favorable compared with that reported in surveys from large tertiary centers. Moreover, obtaining more than two or three blood cultures is neither helpful nor cost-effective in the initial assessment of patients with suspected endocarditis. Electronic Publication     

Valvular heart disease in patients with hypocomplementemic urticarial vasculitis syndrome associated with Jaccoud's arthropathy.

BACKGROUND: Since 1973, more than 75 patients with hypocomplementemic urticarial vasculitis syndrome (HUVS) were reported, but valvular heart disease does not seem to have been noted in these patients. Since 1993, however, five patients with HUVS accompanied by Jaccoud's arthropathy (JA) were found to have serious valvular heart disease. METHODS: To characterize the cardiac valvulopathy of the third patient with HUVS/JA to have undergone valve replacement, this study included the use of routine and special tissue stains, as well as immunohistochemical staining. We compared gross and histologic findings of this patient's valve to those of two other patients with this complex syndrome who underwent valve replacement. Pathologic findings of these latter two patients were described in separate earlier reports. RESULTS: Histologic examination of the resected valves in all three patients showed an acute necrotizing endocarditis and fibrin deposition on the surface of valve leaflets. Beneath the surfaces of the leaflets, there was evidence of chronic inflammation, consisting of lymphocytes and histiocytes. A fibrocalcific degenerative change was also present in all three valves. Positive staining for IgG, IgA, IgM, and light-chain determinant-bearing proteins was detected primarily at the valve surface in special studies of the aortic valve of the patient described in the current report. CONCLUSION: Patients with HUVS and associated JA should be evaluated for the presence of valvular heart disease. The latter is probably a nonrheumatic, inflammatory, and degenerative process, mediated by immune complex, as well as cellular immune mechanisms.