Vascular complications of infective endocarditis: a retrospective analysis of 18 cases

OBJECTIVES: Among 82 patients hospitalized for infective endocarditis between June 1995 and June 2001 at the cardiology B unit of the Rabat University Hospital Morocco, 18 (22%) had one or more vascular complications. We present here a retrospective analysis. PATIENTS AND METHODS: The cohort included 12 men and 6 women, mean age 22 years. Infective endocarditis had grafted on a pre-existing cardiopathy among 17 patients: rheumatic heart disease (n=14), mechanical prosthetic valve (n=2), congenital heart disease (n=1). RESULTS: For 12 patients, vascular disease was the only complication, 1 had two complications and 4 three complications. This gave 26 lesions: 11 neurological complications, 10 arterial diseases involving the limbs including 5 mycotic aneurysms, 2 acute myocardial infarcts, 2 splenic infarcts, and 1 recurrent septic pulmonary embolism. Vascular disease was the inaugural manifestation in 9 patients and 54% of the complications occurred before the end of the second week of antibiotic treatment. Blood cultures were positive in 7 patients (40%). Oral streptococcus was isolated in 5 cases, Gram-negative bacillus in 1 case and Staphylococcus aureus in 1. Echography revealed valvular vegetations in the 16 cases of infective endocarditis on native valves: mitral (n=9), aortic (n=5), mitroaortic (n=1), tricuspid (n=1). Short term outcome was marked by 4 deaths including 3 directly related to the vascular complication. DISCUSSION: We emphasize the variable and diverse features of vascular complications of infective endocarditis. Prevention and early diagnosis are essential to institute optimal management of infective endocarditis.     

Infective endocarditis with multiple mycotic aneurysms mimicking vasculitis: A case report

The manifestation of infective endocarditis often resembles vasculitis. Approximately one in five infective endocarditis cases are referred initially to a nephrologist because of abnormal renal function or abnormal urinalysis; therefore, infection should be ruled out before diagnosing vasculitis.A case involving a patient with infective endocarditis who presented with migrating skin lesions, renal infarction and multiple pseudoaneurysms is reported. Echocardiography revealed mitral valve vegetation and viridans streptococci were identified in peripheral blood cultures. Although mitral valve annuloplasty and an aneurysm ligation operation were performed with proper antibiotic treatment, the remaining mycotic aneurysm progressed and caused neurological complications. The patient was cured completely after reoperation.     

Mycotic aneurysm of the right coronary artery

Mycotic embolism in patients with infective endocarditis is not uncommon, however, mycotic aneurysm of a coronary artery is very rare. We report the case of a 62-year-old woman with mitral valve endocarditis complicated by mycotic aneurysm of the right coronary artery. Mitral valve replacement and resection of the mycotic aneurysm with coronary artery bypass were performed.     

Endovascular treatment of intracerebral mycotic aneurysm before surgical treatment of infective endocarditis

Mycotic aneurysms are rarely seen in patients who have infective endocarditis, and the management of these patients remains controversial. We present the case of a patient who had infective endocarditis complicated by a mycotic aneurysm of the left middle cerebral artery. There was substantial mitral regurgitation, and Streptococcus viridans was isolated from the blood samples. Dysarthria appeared during the 4th week of the antibiotic therapy, but resolved completely 8 hours after onset. The left middle cerebral artery was embolized with platinum detachable coils. On the 7th day after the radiologic intervention, the native mitral valve was replaced with a 33-mm St. Jude Medical bi-leaflet mechanical mitral prosthesis. Most mycotic aneurysms show notable regression of symptoms with effective antibiotic treatment, and a very few may diminish in size. However it is impossible to predict the response of these aneurysms to therapy. To prevent the perioperative rupture of mycotic aneurysms and intracranial hemorrhage, priority should be given to endovascular interventions to treat cerebrovascular aneurysms in patients such as ours.     

Cerebral hemorrhage due to a ruptured mycotic aneurysm. Two cases

INTRODUCTION: Cerebral hemorrhages due to rupture of mycotic aneurysms are rare but severe complications of infective endocarditis. We report two cases with a good outcome. EXEGESIS: The first patient presented with a parieto-occipital hematoma which occurred in the course of a relapsing infective endocarditis due to Streptococcus mitis. She fully recovered after neurosurgical treatment. In the second case, a right frontal hematoma revealed two mycotic aneurysms and an infective endocarditis due to Streptococcus gordonii. Motor weakness partially recovered after antibiotic therapy and angiography demonstrated complete resolution of aneurysms. CONCLUSION: Ruptured mycotic aneurysms are poor prognosis factors in infective endocarditis. Adapted antibiotic therapy is the first-intent treatment. Neurosurgery is indicated when hematomas are poorly tolerated and in cases requiring anticoagulant therapy.     

Cardiac complications of infectious endocarditis

Factors predisposing to cardiac complications and influencing hospital survival, were analysed in a retrospective study of 101 cases of infective endocarditis. Heart failure occurred in 52 p. 100 of our patients. A significantly greater incidence of heart failure was observed in endocarditis with no preexisting heart disease (p less than 0.01), aortic and mitral valve involvement (p less than 0.01), staphylococcus aureus infections (p less than 0.05), arrhythmias (p less than 0.001), and conduction disturbances (p less than 0.01). Significantly more patients with congestive cardiac failure died in hospital (51 p. 100) than those without congestive cardiac failure (17 p. 100) (p less than 0.001). Severe heart failure before treatment (p less than 0.05), streptococcus D endocarditis (p = 0.05), supraventricular arrhythmias (p less than 0.05), and intracardiac conduction disturbances (p less than 0.05), significantly increased the hospital mortality in patients with congestive heart failure. Electrocardiographic findings revealed arrhythmias in 34 p. 100 of cases, more commonly with mitral valve involvement (71 p. 100) and 52 p. 100 died in hospital. The development of intracardiac conduction disturbance during the course of 18 cases of endocarditis (aortic valve in 11 cases) was associated with a hospital mortality rate of 60 p. 100. The incidence of pericarditis and pulmonary embolism was 4 and 7 p. 100 respectively, and all patients died in hospital. Acute inferior myocardial infarction compatible with coronary embolism was suspected in one patient. Early cardiac valve replacement improved the hospital survival in patients with cardiac complications of infective endocarditis.     

二尖瓣脱垂与感染性心内膜炎

为了解二尖瓣脱垂与感染性心内膜炎之间的关系，对本院１９８４年１月至１９９６年１２月诊断为原发性二尖瓣脱垂（ＭＶＰ）并发感染性心内膜炎（ＩＥ）２１例患者的临床资料进行分析。结果显示：占同期ＩＥ发病总数的２３％，占二尖瓣脱垂的４８％；其中男１３例，女８例，男女比例为１．６∶１；平均年龄３２岁（９～６１岁），２０～５０岁者１７例（占８１％）。其临床特点为起病隐匿，心力衰竭、体循环栓塞（尤其脑栓塞）等并发症的发生率较高。超声心动图检查对本病的诊断具有重要价值。     

Abdominal mycotic aneurysm and cerebral embolic event associated with infective endocarditis in a patient with chronic rheumatic valvar disease

We report the case of a girl with chronic rheumatic valvar heart disease who developed infective endocarditis and two complications, ischemic stroke due to cerebral embolic event and mycotic aneurysm of the superior mesenteric artery.     

Mycotic aneurysm complicating staphylococcal endocarditis

OBJECTIVE: To emphasize the role of noninvasive diagnostic investigative methods and their importance in early detection of mycotic aneurysm related to staphylococcal endocarditis, and of monitoring therapy or identifying complications. PATIENTS AND METHODS: Two patients with mycotic aneurysm that developed as complications of staphylococcal endocarditis are presented. The first patient had mesenteric artery mycotic aneurysm and presented with sudden rupture one month after initial diagnosis of mitral valve infective endocarditis and completion of a full course of antimicrobial therapy. The second patient had multiple cerebral mycotic microaneurysms and presented with hemorrhagic cerebral embolization from aortic valve infective endocarditis. RESULTS: The first patient died because of ischemic cerebral edema 48 h after rupture of the mesenteric artery mycotic aneurysm and massive hemoperitoneum, which was treated surgically with distal ileal resection and ileostomy. The second patient was alive two years after prolonged antimicrobial therapy and aortic replacement to treat moderate aortic regurgitation and progressive left ventricular enlargement. CONCLUSIONS: Mycotic aneurysm is a rare complication of infective endocarditis but has a high mortality rate because of its early or late potential catastrophic rupture. Diagnosis by noninvasive diagnostic imaging techniques of mycotic aneurysm before rupture would be beneficial for its treatment.     

Surgical decisions for active infective endocarditis in patients with acute neurological complications]

The surgical management of 7 patients with active infective endocarditis and recent (within 16 days) neurological injury was presented. All patients had preoperative computed tomographic scans which revealed no evidence of intracranial hemorrhage and underwent successful corrective cardiac surgery. In the early postoperative period, 4 patients died of cerebral hemorrhage, subarachnoid hemorrhage, or progression of cerebral edema. Two of the 3 surviving patients showed no aggravation of cerebral infarcts postoperatively. In the remaining surviving patient, intracerebral mycotic aneurysms were resolved spontaneously after postoperative antibiotic therapy, although new cerebral hemorrhage, a complication of emboli, occurred after open heart surgery. The results of this study indicated that 1) cerebrovascular complications were the causes of the 4 deaths in this series, and 2) although heparinization during open heart surgery may result in intracerebral hemorrhage from mycotic aneurysm or infarction, early surgical intervention after recent cardiogenic embolic strokes may save patients with minor cerebral infarcts.     

右心瓣膜感染性心内膜炎的外科治疗

目的：总结右心系统瓣膜心内膜炎的特点和手术处理经验。方法：回顾性分析右心系统瓣膜感染性心内膜炎１７例,其侵犯三尖瓣６例、肺动脉瓣４例,同时侵犯三尖瓣＋肺动脉瓣３例,肺动脉瓣＋主动脉瓣３例,主动脉瓣、二尖瓣、三尖瓣与肺动脉瓣同时受累１例。合并心脏畸形１４例,室间隔缺损修补术后、主动脉窦瘤破裂修补术后、起博器安置术后各１例。施行三尖瓣瓣膜游离缘或瓣膜赘生物切除直接缝合５例、三尖瓣瓣膜赘生物切除用自体心包片修补２例、部分瓣叶和瓣下结构切除缝合瓣叶并行人工腱索成形术１例,施行三尖瓣置换术２例;单纯行肺动脉瓣瓣叶赘生物切除４例,部分肺动脉瓣切除用自体心包片瓣叶成形术６例,切除肺动脉瓣用自体心包瓣置换１例。结果：术后早期死亡２例,病死率为１２％,术后早期并发急性肾功能不全３例,肝功能不全１例。术后随访５个月～１８年,平均随     

人工生物瓣膜替换手术死因及并发症分析

目的：分析并了解人工生物瓣膜替换手术围术期主要的死亡原因及并发症。方法：收集７４５例人工生物瓣膜替换手术患者的原始临床病历资料，采用回顾性的分析方法进行总结。结果：围术期死亡率为１３．２％（９８／７４５）。围术期主要死因依次为：低心输出量综合征、心力衰竭（４７例），脑部并发症（１４例），严重室性心律失常（９例），肾功能衰竭（８例），人工瓣膜心内膜炎（５例），左心室破裂（３例）．围术期主要并发症依次为：低心输出量综合征、心力衰竭（５８例），二次开胸止血（２５例），脑部并发症（２１例），严重室性心律失常（１３例），肾功能衰竭（１０例），人工瓣膜心内膜炎（１０例），心包填塞（８例）。结论：低心输出量综合征、心力衰竭，脑部并发症，严重室性心律失常，肾功能衰竭和人工瓣膜心内膜炎是围术期人工生物瓣膜替换手术主要的并发症和死因。     

心脏瓣膜术后感染性心内膜炎再次手术后临床预后的分析

目的:分析心脏瓣膜置换或成形术后感染性心内膜炎再次进行外科手术后的近期及远期预后情况。方法:分析了2007年01月至2017年12月,在安贞医院就诊的心脏瓣膜术后感染性心内膜炎患者,以单纯感染性心内膜手术患者为对照组,并根据年龄、性别按1∶1的比例配对,每组67例。结果:与单纯感染性心内膜炎的患者相比,瓣膜术后感染性心内膜炎患者术前LVEF和心功能分级均明显较低[(61.2±7.5)%vs.(56.9±10.1)%,P=0.003;(2.9±0.9)vs.(2.4±0.7), P=0.006],其它基线资料无明显差异。瓣膜术后感染性心内膜炎患者再次手术后住院时间[12.0(19.5,20.5)vs. 7.5 (6.0,10.8)d,P=0.03]、体外循环时间[145.0 (118.5,203.0)vs.100.0 (81.0,132.0)min,P<0.001]均明显延长。经过平均(87.9±42.5)个月的随访,心脏瓣膜术后感染性心内膜炎患者总体不良心血管事件(26.9%vs.11.9%,P=0.03)发生率和远期死亡率(19.4%vs.7.5%,P=0.04)均明显增加,但术后30 d内病死率、再次手术率以及心律失常等不良事件的发生,两组并没有明显区别。Kaplan-Meier生存分析结果显示,心脏瓣膜术后感染性心内膜炎再手术后10年预期生存率约为59.4%,而单纯感染性心内膜炎进行手术后的10年生存率约为86.4%。结论:与单纯感染性心内膜炎患者相比,两组患者早期死亡率没有区别,但心脏瓣膜术后感染性心内膜炎患者远期死亡率明显较高。     

Cerebrovascular accidents in infective endocarditis: role of anticoagulation

Anticoagulation is still a matter of debate in infective endocarditis,since it can increase the risk of complications, mostly neurological.In our series of 269 patients with native valve endocarditisstudied between 1970 and 1982, 35 were anticoagulated. We observed14 patients with brain infarcts, of whom five died, and 12 patientswith cerebromeningeal or brain haemorrhage of whom six died.In a similar series of 63 patients with prosthetic valve endocarditis,all of whom were on anticoagulation and were studied between1972 and 1987, we observed five patients with brain infarcts,three of whom died, and two patients with brain haemorrhage,one of whom died. The frequency of cerebrovascular accident(CVA) was similar for both groups (111% in prosthetic endocarditisvs 11.5% in native valve endocarditis, P = ns), as was mortalityrate (57% vs 48–4%, P = ns). CVA are significantly morefrequent among anticoagulated patients (19/94 vs 19/238: P<0.01),but the mortality rate in CVA is similar for anticoagulatedand non-ant icoagulated patients (11/19 vs 8/19: P = ns). Theindications for anticoagulation in infective endocarditis remainsimilar to those in valvular heart disease. In patients withinfective endocarditis, anticoagulation with heparin shouldbe maintained whenever a brain infarct is present, unless itis large and/or haemorrhagic.     

心脏术后急性肾功能衰竭21例治疗效果分析

目的探讨心脏术后急性肾功能衰竭的治疗方法。方法回顾性分析广西梧州市红十字会医院心脏手术患者538例中术后发生急性肾功能衰竭21例的临床资料。其中,法洛四联症4例,感染性心内膜炎并主动脉瓣关闭不全7例,风湿性心脏病瓣膜置换10例。出现少尿型肾功能衰竭17例,非少尿型肾功能衰竭4例;非少尿型肾功能衰竭4例患者采取合理输液治疗,少尿型肾功能衰竭17例中4例采用腹膜透析及13例采用血液透析治疗。结果21例中14例治愈,7例死亡患者为少尿型肾功能衰竭合并有多脏器功能衰竭院内死亡,6例主要死亡原因为肾功能衰竭合并心力衰竭和肺部感染呼吸衰竭死亡,1例合并真菌性败血症。7例死亡患者中1例为法洛四联症患者、2例为感染性心内膜炎瓣膜置换术患者、4例为风湿性心脏病瓣膜置换术患者。结论心脏术后急性肾功能衰竭要早期发现、及时处理,加强利尿等方法无效时,及时进行腹膜透析或血液透析。     

Abiotrophia Endocarditis in Children with No Underlying Heart Disease: A Rare but a Virulent Organism

Infective endocarditis is extremely rare in children with structurally normal hearts. The most common etiological agents are staphylococcal and streptococcal species. Nutritionally variant streptococci also classified as Abiotrophia species are a group of fastidious organisms that account for only 5% to 6% of all cases of culture‐negative infective endocarditis. Only seven cases of Abiotrophia infective endocarditis have been previously reported in children with no underlying structural heart disease. We report two cases of Abiotrophia infective endocarditis in children without any predisposing factors. Both patients presented with nonspecific symptoms leading to delay in diagnosis. While bacteriological clearance was achieved in both cases, both had a complicated course including development of brain mycotic aneurysms, splenic infarction, renal failure, and irreversible damage to the mitral valve. Both patients required surgical removal of the native mitral valve and replacement. We also present review of seven cases with similar diagnosis published previously in literature and highlight important differences. Our cases highlight special challenges in management of Abiotrophia endocarditis in pediatric patients. As the organism may not be isolated in routine culture media, may present with atypical clinical symptoms and may have a complicated course even without antibiotic failure, a high index of suspicion should be maintained in children with subacute symptoms even with no underlying structural cardiac disease.     

Infectious endocarditis in a neurosurgical unit]

Clinico-pathological study of 15 cases of cerebral complications of bacterial endocarditis referred to a neurosurgical unit for suspected cerebral abcess. In all cases but one, cerebral symptoms appeared with the cardiac condition undiagnosed, and complete diagnosis was made only at autopsy. Cerebral lesions consisted mainly in focal softening due to embolisms, generally multiple, with in about half the cases histological manifestations of bacterial seeding, without any abcess such as could be amenable to neurosurgical treatment. Surgical treatment of mycotic aneurysms was unsuccessful, due mainly to their multiplicity.     

Echocardiographic observations in opiate addicts with active infective endocarditis: Frequency of involvement of the various valves and comparison of echocardiographic features of right- and left-sided cardiac valve endocarditis

Echocardiographic observations are described in 25 opiate addicts with active infective endocarditis involving apparently previously normal valves. Infective endocarditis was isolated to the tricuspid valve in 11 patients, involved both right- (tricuspid valve) and left-sided valves in 7 and was isolated to the left-sided valves in 7 (mitral valve in 6). Twenty patients (80 percent) had tricuspid valve regurgitation, 12 had mitral regurgitation, 3 had aortic regurgitation and none had pulmonary valve regurgitation. Considering the 75 cardiac valves (excluding the pulmonary) in the 25 patients, echocardiographic abnormalities consistent with active infective endocarditis were detected in 26 (74 percent) of the 35 clinically incompetent valves but in none of the 40 competent valves. Comparison of the 20 incompetent tricuspid valves with the 12 incompetent mitral valves indicated that (1) the echocardiogram was less sensitive in detecting tricuspid valve lesions, (2) rupture of tricuspid valve chordae tendineae was absent or not detectable, and (3) tricuspid valve vegetations tended to be larger.     

感染性心内膜炎急诊外科治疗

目的 总结感染性心内膜炎患者的急诊外科手术时机及围手术期处理.方法 12名患者因感染性心内膜炎在我科行急诊体外循环下心内直视手术,包括主动脉瓣置换3例、三尖瓣置换4例、三尖瓣修复2例、二尖瓣+主动脉瓣置换3例.结果 所有患者经手术及足疗程抗感染治疗后临床痊愈出院.术后病理证实均为感染性心内膜炎.结论 感染性心内膜炎出现药物难以控制的感染或出现急性心功能衰竭内科保守治疗难以纠正心功能时,急诊外科手术治疗能挽救患者生命.     

The Preoperative Evaluation of Infective Endocarditis via 3-Dimensional Transesophageal Echocardiography

Transesophageal echocardiography continues to have a central role in the diagnosis of infective endocarditis and its sequelae. Recent technological advances offer the option of 3-dimensional imaging in the evaluation of patients with infective endocarditis. We present an illustrative case and review the literature regarding the potential advantages and limitations of 3-dimensional transesophageal echocardiography in the diagnosis of complicated infective endocarditis.A 51-year-old man, an intravenous drug user who had undergone bioprosthetic aortic valve replacement 5 months earlier, presented with prosthetic valve endocarditis. Preoperative transesophageal echocardiography with 3D rendition revealed a large abscess involving the mitral aortic intervalvular fibrosa, together with a mycotic aneurysm that had ruptured into the left atrium, resulting in a left ventricle-to-left atrium fistula. Three-dimensional transesophageal echocardiography enabled superior preoperative anatomic delineation and surgical planning. We conclude that 3-dimensional transesophageal echocardiography can be a useful adjunct to traditional 2-dimensional transesophageal echocardiography as a tool in the diagnosis of infective endocarditis.