Quadricuspid aortic valve: a rare cause of aortic insufficiency diagnosed by doppler echocardiography. Report of two cases and review of the literature.

Quadricuspid aortic valve is an uncommon congenital valve disease mostly occurring as isolated lesion or sometimes in association with truncal anomalies. Approximately 50% of patients with quadricuspid aortic valve have aortic regurgitation. Before the advent of echocardiography most cases were diagnosed at the time of surgery or at post-mortem examination. We describe 2 cases of patients with quadricuspid aortic valve diagnosed by echocardiography. The first case, a quadricuspid aortic valve with four equal-sized cusps (type A, according to the classification of Hurwitz and Roberts), was identified in a 26-year-old man undergoing echocardiography because of a heart murmur. The second case, a quadricuspid aortic valve with three relatively equal cusps and one smaller cusp (type B, according to the classification of Hurwitz and Roberts), was identified in a 47-year-old man with a history of murmur. The identification and periodical non-invasive evaluation of a quadricuspid aortic valve is important, because such valves are more vulnerable to infection and need adequate prophylaxis against endocarditis.     

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.     

A case of infective Aerococcus urinae endocarditis successfully treated by aortic valve replacement

Aerococcus urinae is a endocarditis rare causative organism with low virulene. We report an A. urinae endocarditis case treated by aortic valve replacement. An 80-year-old woman hospitalized for urinary tract infection and hydronephrosis due to three-week renal calculi. Blood culture on admission isolated Streptococcus acidominimus. During the course, she was transferred to our care for surgical intervention after developing congestive heart failure due to severe aortic regurgitation. Echocardiographic findings indicated infective endocarditis. She underwent aortic valve replacement, and gram staining of the resected valve tissue showed gram-positive cocci, although valve culture was negative. PCR amplification and DNA sequencing using the valve material matched an A. urinae sequence. The woman recovered and was discharged six weeks after antibiotic treatment.     

Tricuspid regurgitation due to sinus of Valsalva-right heart fistula diagnosed by two-dimensional echocardiography

The case of a 31-year-old woman with severe right heart failure in the course of bacterial endocarditis and systolic and diastolic murmur at the third left intercostal space is described. Two-dimensional echocardiography showed a vegetation moving from the noncoronary aortic sinus of Valsalva to the right atrium, encroaching upon the septal leaflet of the tricuspid valve. An acquired fistula was confirmed by aortography and surgery. This is an unusual case of tricuspid regurgitation due to acquired aortic sinus of Valsalva-right heart fistula diagnosed by two-dimensional echocardiography.     

Spondylodiscitis and endocarditis caused by S. vestibularis

Streptococcus vestibularis is a recently described member of the viridans group that was first isolated from the vestibular mucosa of the human oral cavity and described as a new species in 1988. It has been rarely associated with human infections. In few papers, it has been reported as a causal agent of systemic infection in immunosupressed adults and in those with other severe underlying diseases, like coronary valve diseases. A 65-year-old woman was admitted to the hospital with complaints of fever for three months, general malaise, effort dyspnea, weight loss, back pain and myalgia. Both native aortic valve endocarditis and spondylodiscitis due to Streptococcus vestibularis were detected. The patient was successfully treated with intravenous potassium penicillin G and gentamicin for six weeks, followed by oral amoxicillin for three months, in addition to aortic valve replacement. In all patients with spondylodiscitis, infective endocarditis should be considered, particularly in patients with heart valve disease history, since spondylodiscitis may be the presenting sign of an infective endocarditis. Cardiac valve replacement surgery should be performed if the course of fever and inflammatory syndrome is unfavorable after appropriate antibiotic treatment. We report the first case with both native aortic valve endocarditis and spondylodiscitis due to Streptococcus vestibularis.     

Left atrial appendage thrombus in a patient in sinus rhythm with endocarditis and a severe aortic valve insufficiency

A left atrial thrombus is most often associated with atrial fibrillation and/or rheumatic mitral stenosis. It is very infrequently detected in the presence of sinus rhythm. The present report describes the case of a 66-year-old woman who presented with a stroke and was subsequently found to have two potential sources of embolization, including a vegetation on the native aortic valve, with associated severe aortic insufficiency, and a left atrial appendage thrombus despite being in sinus rhythm. To the authors' knowledge, the present report is the first to describe a left atrial thrombus in sinus rhythm associated with aortic valve endocarditis.     

Corynebacterium striatum first reported case of prosthetic valve endocarditis

We describe the case of a prosthetic valve endocarditis in a 72-year-old woman. Corynebacterium striatum was isolated in the blood samples. This organism has been described in a few cases of native valve endocarditis, but this is the first case reported of prosthetic valve endocarditis.     

Prosthetic valve endocarditis caused by Trichosporon cutaneum

We report, to our knowledge, the first case of Trichosporon cutaneum endocarditis which developed in a 58-year-old woman 14 months after mitral valve replacement. The patient had not had antibiotic therapy. She was treated with an oral antifungal agent, ketoconazol, and prosthetic valve replacement. The initial outcome was favorable, but she died 5 months later of aortic valve endocarditis. Fungal infection was documented by isolation of the fungus from blood cultures, by anatomical and pathological examination and by the changes in serology.     

Q Fever Endocarditis Presenting with Superior Mesenteric Artery Embolism and Renal Infarction

Q fever is a zoonotic disease with a reservoir in mammals, birds, and ticks. Acute cases in human beings can be asymptomatic, or they can present with a flu-like illness, pneumonia, or hepatitis. Approximately 5% of cases progress to chronic Q fever. Endocarditis, the most typical manifestation of chronic Q fever, is usually associated with small vegetations that occur in patients who have had prior valvular damage or who are immunocompromised. We present what we think is the first reported case of superior mesenteric artery embolism from Q fever endocarditis of the aortic valve, in a 39-year-old woman who needed surgical embolectomy and subsequent aortic valve replacement.     

The pitfall of coagulase-negative staphylococci: A case of Staphylococcus lugdunensis endocarditis

We report a case of a 60-year-old woman. She was transferred from a local hospital to our cardiovascular medicine department with a diagnosis of infectious endocarditis due to Staphylococcus lugdunensis. Transthoracic echocardiograph confirmed the presence of large vegetations on the native aortic and mitral valve, and subsequent severe regurgitation due to the aortic and mitral valve destruction. Emergent operation was performed and patient's life was barely rescued.However, S. lugdunensis belongs to coagulase-negative staphylococci, which are generally regarded as relatively avirulent bacterium, the endocarditis caused by S. lugdunensis can be invasive and often resembles endocarditis due to Staphylococcus aureus. Therefore, whenever this organism is found in patients with endocarditis, early surgical treatment of the infected valve should be considered.     

Legionella micdadei prosthetic valve endocarditis complicated by brain abscess: case report and review of the literature

Legionella endocarditis is extremely uncommon, and embolic phenomena have never been reported. We report the first case of Legionella micdadei prosthetic valve endocarditis complicated by brain abscess. A 57-y-old immunocompromised woman with a history of mitral valve replacement developed confusion and left-sided weakness. Brain magnetic resonance imaging showed a 3-cm peripheral-enhancing mass. Transoesophageal echocardiography suggested a perivalvular abscess. Blood cultures and valve cultures were negative. She was diagnosed with 16S rRNA polymerase chain reaction and silver stain, and was discharged with levofloxacin after a redo mitral valve replacement. Twelve cases of Legionella endocarditis were reviewed. Only one case had a native valve, and her endocarditis occurred after pneumonia. All cases were cured. The duration of antibiotic therapy was variable. Legionella species should be considered in the differential diagnosis of culture-negative endocarditis in both immunocompetent and immunocompromised patients. Molecular techniques and silver impregnation stains are useful, especially when cultures using buffered charcoal-yeast extract agar are negative.     

Pasteurella multocida aortic valve endocarditis: case report and literature review

Pasteurella multocida is a rare cause of infective endocarditis that occurs mostly in immunocompromised patients and is therefore associated with a high mortality rate. The case is reported of a 48-year-old male patient with liver cirrhosis, who developed aortic valve endocarditis caused by P. multocida. The infection was detected by blood cultures. The patient presented with generalized symptoms and initial neurologic symptoms suggestive of meningitis. Transthoracic echocardiography conducted after the discovery of a diastolic murmur revealed a large vegetation on the aortic valve, and notable insufficiency. These findings were confirmed at surgery, where-upon the patient underwent aortic valve replacement using a bioprosthetic valve. Subsequently he developed a recurrent episode of endocarditis that was successfully treated with antibiotic therapy. Other similar cases reported in the literature are reviewed.     

Surgical management of mycotic aneurysm of the left anterior descending artery

Mycotic aneurysms of the coronary artery with underlying infective endocarditis are rare. The present report discusses the case of a 53-year-old woman with acute ST elevation myocardial infarction in the setting of native aortic valve endocarditis. Percutaneous transluminal coronary angioplasty was performed. Approximately four weeks after hospital admission, the patient had systemic embolization to the extremities with resulting cyanosis of the left toes. She was evaluated for replacement of the aortic valve and underwent a repeat angiogram, which demonstrated a mycotic aneurysm at the site of the angioplasty. She subsequently underwent successful excision of the aneurysm with coronary artery bypass grafting and replacement of the aortic valve with a 21 mm St Jude aortic valve prosthesis. The remaining hospital course was unremarkable.     

“(Pseudo)cavities inside the heart: What may they unfold?”

Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve (AoV) or, less frequently, the left ventricular outflow tract (LVOT). We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.     

Quadricuspid aortic valve in a patient with Turner syndrome

A quadricuspid aortic valve is an uncommon congenital anomaly that is often associated with other cardiac disorders. Most reported cases of quadricuspid aortic valves are detected incidentally during necropsy or aortic valve replacement and, therefore, the potential clinical course still remains unclear. A case of a 47-year-old woman with grade III to IV aortic insufficiency and mild left ventricular dilation with an end-diastolic diameter of 59 mm is presented. During surgery for aortic valve replacement (Ross procedure), a quadricuspid aortic valve was identified. Two years after the successful Ross procedure, a molecular genetic study of this rare anomaly was performed using karyotyping, fluorescence in situ hybridisation and polymerase chain reaction. Cytogenetic analysis detected chromosomal aberration 45,X0/46,XX, indicating a low-level X chromosome mosaicism; repeat karyotypes were normal. This is the first reported case of a quadricuspid aortic valve in a woman with Turner syndrome.     

Late infective endocarditis of an Amplatzer atrial septal device twelve years after implantation

Infective endocarditis was initially defined as a disease of patients with pre-existing valvular abnormalities. In contemporary medicine a valvular prosthesis and implanted medical devices are the most common risk factors for infective endocarditis.A case report is presented regarding an 18-year-old female with a medical history of a 12-year implanted Amplatzer occluder. Echocardiography showed an endocarditis focus in the right atrium communicating to the left atrium and destruction of the non-coronary leaflet of the aortic valve, with aortic valve insufficiency. Blood culture was positive for multi-resistant Staphylococcus aureus. The aortic valve, the Amplatzer device and part of the anterior leaflet of the mitral valve were excised. Pericardium was used for reconstruction of the anterior leaflet of the mitral valve, the interatrial septum and the wall of the left atrium. A mechanical prosthesis of the aortic valve was implanted. Control echocardiography was done four months after surgery. The evaluation did not show any recurrence of endocarditis.The published literature shows, in correlation with the presented case report, the occurrence of endocarditis late in the course of Amplatzer implantation highlights the need for vigilance in the population of patients with the device.     

Prosthetic valve endocarditis due to Listeria monocytogenes. Report of two cases and reviews.

INTRODUCTION: Endocarditis due to Listeria monocytogenes is a rare but serious disease often leading to valve dysfunction and heart failure. Two cases of listerial prosthetic valve endocarditis are reviewed along with 66 cases previously reported. RESULTS: The mean age of patients with listerial endocarditis increased from 47.1 years in the decades from 1955-1984 to 65.5 years from 1985-2000. Chronic debilitating diseases, solid tumours and immunosuppression associated with organ transplantation, hematologic neoplasia or AIDS were found in 41.1% of cases. Listerial endocarditis was a vegetative and destructive process, with dehiscense of the prosthesis and occasionally, abscess formation, fistulization and pericarditis. Treatment with penicillin or ampicillin alone or combined with gentamicin was adequate therapy in most cases. Vancomycin together with gentamicin may be a reasonable alternative therapy. CONCLUSIONS: Despite problems associated with microbial persistence and relapses in other forms of human listeriosis, antimicrobial therapy alone may be a successful treatment for listerial endocarditis, including cases occurring on prosthetic valves. Valve replacement may be reserved for complicated cases with valve dehiscense, cardiac failure or myocardial abscess. Overall mortality was 35.3%, although most patients who died did so before 1985 and since then mortality has been significantly reduced to 12%.     

Nocardia asteroides native valve endocarditis.

A 39-year-old man with a history of injection drug abuse was given a diagnosis of Nocardia asteroides native aortic valve endocarditis, and he required valve replacement therapy, despite having received potent antimicrobial therapy. This is the first reported proven case of native valve endocarditis due to Nocardia species.     

Recurrent endocarditis in silver-coated heart valve prosthesis

BACKGROUND AND AIM OF THE STUDY: In order to prevent prosthetic valve endocarditis (PVE), the implantation of a new silver-coated sewing ring has been introduced to provide peri- and postoperative protection against microbial infection. METHODS: A 56-year-old woman with aortic stenosis had elective replacement with a St. Jude Medical mechanical valve fitted with a silver-coated sewing ring (Silzone). The patient developed early PVE, which necessitated reoperation after one month. Despite a second Silzone prosthesis being implanted, the endocarditis recurred. During a third operation an aortic homograft was implanted, and after six months a fourth operation was performed for a pseudoaneurysm at the base of the homograft, in proximity to the anterior mitral valve leaflet. RESULTS: The diagnosis of PVE was confirmed by the presence of continuous fever, transesophageal echocardiography and growth of penicillin-resistant Staphylococcus epidermidis from the valve prosthesis. CONCLUSION: The implantation of all prosthetic valves is encumbered with a risk of endocarditis. Although silver has bacteriostatic actions, the advantages of silver-coated prostheses in the treatment of this condition have yet to be assessed in clinical trials.     

Congenital disorders of the cardiovascular system and their complications in a 21-year-old woman with Turner syndrome--a case report

A 21-year-old woman with Turner syndrome was admitted to hospital because of progressive heart failure. Echocardiography revealed a bicuspid aortic valve with one cusp ruptured due to infective endocarditis and anomalous pulmonary venous drainage. The patient underwent successful aortic valve replacement.