Clinical profile and one-year outcomes of patients with mural infective endocarditis: – A tertiary care centre study based on data from a seven-year registry

BackgroundInfective endocarditis patients present very rarely with vegetations on the mural endocardium. Only very few studies are available comparing Mural infective endocarditis with commoner valvular or device related infective endocarditis.AimTo analyse the clinical features, microbiological profile and clinical course of mural endocarditis in comparison to valvular endocarditis.MethodsThis was a retrospective analysis of data from a registry of infective endocarditis. Patients enrolled between April 2012 and April 2019 were included. Patients who were reported to have vegetations on the mural endocardial surface were taken as a group and compared with rest of the patients. Clinical profile, laboratory parameters including culture and outcomes were compared between the two groups.ResultsOut of 278 patients in the study, 15 (5.38%) had vegetations on the mural endocardium. Of them, only 4 patients had structural heart diseases. All the patients with mural endocarditis were NYHA class II or below at presentation. Ventricles were the commonest sites of vegetations. Inflammatory markers like ESR and CRP were low in mural endocarditis compared to rest. Culture positivity was high in mural endocarditis and Staphylococcus Aureus was the commonest organism. Mural endocarditis patients had similar in hospital mortality to rest of the patients. Cardiac complications were not reported in mural endocarditis, but they had similar incidence of embolic complications including neurological events.ConclusionMural endocarditis is a rare clinical entity with similar morbidity and mortality to that of endocarditis with valvular vegetation.     

Right-sided infective mural endocarditis complicated by septic pulmonary embolism and cardiac tamponade caused by MSSA

The appearance of right-sided mural infective endocarditis has rarely been reported. Here, we report the case of a 40-year-old male with a history of alcoholic liver disease who presented with a partial loss of consciousness and fever. Chest computed tomography scans showed multiple pulmonary infiltration sites and cavities. A repeat transthoracic echocardiogram detected a vegetation on the right ventricular surface of the interventricular septum middle segment, as well as pericardial effusion. Blood, pericardial fluid, sputum, and scalp effusion cultures were positive for methicillin-sensitive Staphylococcus aureus. We diagnosed the patient with infective mural endocarditis complicated by septic pulmonary embolism, pericardial effusion, and cardiac tamponade. The patient was successfully treated with pericardiocentesis and appropriate antibiotics. Right-sided mural endocarditis complicated by pericardial effusion and cardiac tamponade is an uncommon condition in clinical practice. This case confirms the usefulness of transthoracic echocardiography in the early recognition of primary mural endocarditis and its associated complications.     

Endocardial lesion in a case of Takayasu's arteriopathy

The clinical findings and the necropsy report of a 14-year-old girl suffering from Takayasu's arteriopathy have been presented. In addition to the typical arterial changes, thickening and puckering of the aortic valve and a patch of thickening in the left atrial endocardium were shown at necropsy. The histology of this lesion was found to be identical with the arterial intimal changes. It has been postulated that Takayasu's arteriopathy may rarely extend to the valvular and mural endocardium of the heart, producing cardiac murmurs. Similar cases with cardiac murmurs reported earlier and attributed to associated rheumatic endocarditis were probably due to the same pathological process extending to the endocarditis.     

Endocardial lesion in a case of Takayasu's arteriopathy.

The clinical findings and the necropsy report of a 14-year-old girl suffering from Takayasu's arteriopathy have been presented. In addition to the typical arterial changes, thickening and puckering of the aortic valve and a patch of thickening in the left atrial endocardium were shown at necropsy. The histology of this lesion was found to be identical with the arterial intimal changes. It has been postulated that Takayasu's arteriopathy may rarely extend to the valvular and mural endocardium of the heart, producing cardiac murmurs. Similar cases with cardiac murmurs reported earlier and attributed to associated rheumatic endocarditis were probably due to the same pathological process extending to the endocarditis.     

Gram-negative bacteria causing infective endocarditis: Rare cardiac complication after liver transplantation

Bacterial endocarditis is a rare complication amongst solid organ transplant recipients and is often linked to bacteremia. Majority of these recipients do not have underlying valvular heart disease or congenital valvular abnormalities. Staphylococoocusaureus and Enterococcus species are the most commonly isolated organisms. There are very few reports of gram-negative bacteria causing endocarditis in liver transplant recipients. We report a 51-yearold male, a liver transplant recipient, who developed bacterial endocarditis of the mitral valve due to extended spectrum of betalactamase producing strain of Escherichia coli and was managed successfully with antibiotics.     

Prosthetic valve endocarditis caused by Veillonella parvula

Veillonella species is a rare cause of endocarditis. We report a case of a 49-year-old man with Veillonella parvula prosthetic valve endocarditis who presented with acute cardiac failure due to valvular dehiscence. His clinical course was complicated by cortical blindness and limb paresis as a result of cerebral embolism. The endocarditis was successfully treated with urgent valve replacement surgery and a prolonged course of metronidazole.     

Nosocomial methicillin-sensitive Staphylococcal aureus (MSSA) native mitral valve acute bacterial endocarditis (ABE) due to radiofrequency catheter ablation (RCA) procedure

Nosocomial endocarditis (NE) has been recognized with increasing frequency. Most cases of NE attributable to virulent pathogens (eg, Staphylococcus aureus) present as acute bacterial endocarditis (ABE). The increase in NE is related to the widespread use of cardio-invasive procedures involving cardiac catheterization or temporary or semipermanent central venous catheters. We present a 58-year-old man who developed nosocomial methicillin-sensitive S. aureus native mitral valve ABE a week after a radiofrequency catheter ablation (RCA) procedure. Cardiac valvular vegetations attributable to S. aureus ABE may be visualized by cardiac echocardiography as early as a week after the onset of valvular infection, as was the case here. Clinicians should be alert to the possibility of NE in patients who develop fevers and high-grade/continuous (MSSA / MRSA) bacteremias after cardiac catheterization-related interventions, eg, RCA procedures.     

Pathological studies in experimental Candida endocarditis.

Mycotic endocarditis was produced in rabbits by indwelling intracardiac catheters filled with a suspension of Candida albicans. Grossly, cardiac lesions consisted of massive fungoid valvular vegetations and/or "sleeve thrombi" surrounding the catheter. Microscopically, platelet-fibrin aggregates were observed to be loosely attached to the valvular cusps. With time, the vegetations became organized and more firmly attached against the endocardium. Also observed was a heavy neutrophylic collar often containing Candida cells which infiltrate the subendothelial tissues of the valvular cusps. Sterile endocardial lesions were produced by retained catheters. The lesions consisted of discrete, glistening, hemispherical nodules in the right heart; and similar elevated plaques on the mural endocardium of the left ventricle. Microscopically, these lesions consisted of fibrous connective tissues devoid of inflammatory cells. The lesions in the left ventricle were more extensive, extending into the myocardium.     

Les endocardites non infectieuses

Non-infective endocarditis, also referred to as non-bacterial thrombotic endocarditis, represent a wide range of rare pathologies, often severe. This review gathered the data available in the literature, to decipher the major information collected on the pathophysiology, the diagnosis and the treatment of these heterogeneous diseases, often misdiagnosed. Characteristics of non-infective endocarditis are similar to infective endocarditis in terms of valvular lesions (mostly left-sided, with regurgitations and vegetations), and their complications (embolism). The diagnosis of non-infective endocarditis is usually considered in patients with blood culture-negative endocarditis. Beyond the usual suspects – marastic endocarditis and systemic lupus erythematosus – which represent more than 75% of the cases, Behçet disease and hypereosinophilic syndrome are the main causes of non-infective endocarditis. More seldomly, rheumatoid arthritis, adult-onset Still disease, allergy to pork in patients with valvular procine bioprosthesis, systemic scleroderma, Cogan or Sneddon syndrome should be suspected. Diagnostic approach is based on history and physical examination, with a special focus on extra-cardiac manifestations, as well as echocardiography, and computed tomography. Treatment relies on intensive management of the underlying disease. Curative anticoagulation is often necessary. Although indications for cardiac surgery are poorly defined, as compared to infective endocarditis, data currently available suggest that an optimal control of the underlying disease before cardiac surgery is of utmost importance, as it dramatically reduces the risk of postoperative complications.     

Isolated Tricuspid Valve Repair for Libman‐Sacks Endocarditis

Cardiac involvement is a well‐known complication of systemic lupus erythematosus (SLE), which can involve most cardiac components, including pericardium, conduction system, myocardium, heart valves, and coronary arteries. Libman‐Sacks (verrucous) endocarditis is the characteristic cardiac valvular manifestation. Although isolated tricuspid valve involvement is quite rare, we report a patient with SLE who had tricuspid stenosis caused by Libman‐Sacks endocarditis. The patient underwent successful commisurotomy and Kay annuloplasty on the tricuspid valve under cardiopulmonary bypass.     

Successful treatment of Candida parapsilosis mural endocarditis with combined caspofungin and voriconazole

Background  

Fungal mural endocarditis is a rare entity in which the antemortem diagnosis is seldom made. Seven cases of mural endocarditis caused by Candida spp. have been collected from literature and six of these patients died after treatment with amphotericin B.     

Antibiotic pretreatment of heart valve prostheses]

Bacterial endocarditis on cardiac valvular prosthesis is still a frequent and dangerous complication: septicemia, embolism, valvular dysfunction and mortality. To prevent these complications, intraoperative treatment of prosthesis, by immersion in antibiotic solution, was performed in 1262 patients. The postoperative results have been compared with results of a nontreated group. The incidence of endocarditis in the treated group was 1.3%, in non-treated cases 5.45%. The cases of early endocarditis, was 0.08% of total cases of complications in the treated patients group; and 4.54% in the nontreated patient group. This study's results, confirm the utility of valvular prosthesis antibiotic treatment in cardiac surgery.     

Lyme Endocarditis

Background

Valvular involvement as a manifestation of Lyme carditis is rare. The first case describing a possible association between Lyme disease and cardiac valvular disease in the United States was published in 1993. Since that time there have been 2 cases of Lyme endocarditis confirmed by Borrelia-positive 16S ribosomal RNA polymerase chain reaction and sequencing from valvular tissue and reported from Europe. Here we describe a case of Lyme endocarditis that, to our knowledge, is the first reported case confirmed by molecular diagnostics in the United States.

Embolic Stroke Caused by Staphylococcus lugdunensis Endocarditis Complicating Vasectomy in a 36-Year-Old Man

Staphylococcus lugdunensis is part of the native flora in the inguinal region of the body. Inguinal surgeries, such as vasectomy, place carriers of this aggressive pathogen at risk for contamination. Native-valve endocarditis caused by coagulase-negative S. lugdunensis has a rapid and complicated clinical course. The pathogenicity of this organism is not limited to cardiac valvular destruction. We report the case of a 36-year-old man who presented with S. lugdunensis endocarditis, dysarthria, and hemiparesis 5 weeks after a vasectomy. To our knowledge, this is the first report of embolic stroke caused by S. lugdunensis endocarditis. In addition, we discuss the relevant medical literature.     

Rothia dentocariosa Endocarditis: An Especially Rare Case in a Previously Healthy Man

Rothia dentocariosa is a rare gram-positive bacterial organism, one of the group of microbes that normally resides in the mouth and respiratory tract. R. dentocariosa rarely causes disease. Documented cases occur chiefly in patients with valvular or dental disease, or both. We report the case of a previously healthy 58-year-old man who presented with evidence of bacterial endocarditis caused by this organism—which originated from an elusive source. His endocarditis was successfully treated with mitral valve replacement and the administration of antibiotic agents.     

When Enterococcus faecalis becomes a murderer

We describe the case of a 64 years old patient, known for an Enterococcus faecalis endocarditis on a 25 mm Edwards-Carpentier biological aortic valve in 2020, who was re-hospitalized one year later in cardiac surgery for a recurrence of Enterococcus faecalisbacteriemia. During hospitalization, the patient presented a cardiac arrest. The coronarography revealed an acute occlusion of the left coronary artery. The autopsy confirmed an Enterococcus faecalis thrombus on aortic valve and left coronary artery.Although systemic embolism is a common complication of infective endocarditis, septic embolism is an unsual cause of acute coronary syndrome and a very rare cause of cardiac arrest.Our case highlights a rare and potentially fatal complication of infective endocarditis: acute coronary syndrome on septic coronary embolism.     

Current status of endocarditis prevention

There are currently no randomized and carefully controlled human trials to definitively prove that endocarditis prophylaxis is efficient. Furthermore, most cases of endocarditis are not attributable to a medical procedure. Thus, even with a high level of application of endocarditis prophylaxis only a minority of cases could be prevented. Endocarditis is a rare disease. On the other hand, its morbidity is increasing! In addition, infective endocarditis remains still a major medical concern because of its mortality between 5% and 76%. In addition, in up to 40% of all patients suffering from endocarditis one or more heart valves have to be replaced in the following 5 to 8 years. Without treatment endocarditis has a lethality of 100%. Therefore, there is worldwide agreement that endocarditis prophylaxis is necessary. Combining the recommendations of the German and the American Heart Association, as well as the results of the European consensus conferences, with newer insights into the pathophysiology of endocarditis the following aspects are elucidated: depending on their risk of endocarditis patients are allocated into 3 groups. In the first group there are patients with prosthetic cardiac valves, patients who suffered from previous endocarditis and patients with complex cyanotic congenital heart disease and surgically constructed shunts or conduits of the aorta and/or pulmonary circulation. In these high-risk patients the prophylactic regimen for dental, oral, respiratory tract procedures is oral amoxycillin. In genitourinary and gastrointestinal procedures ampicillin and gentamicin i.v. is recommended. In patients with mostly congenital cardiac malformations, acquired valvular dysfunction, hypertrophic obstructive cardiomyopathy and mitral valve prolapse or thickened leaflets and valvular regurgitation oral amoxycillin is recommended for all medical procedures (second group). The third group consists of patients with isolated secundum atrial defect, previous coronary bypass graft surgery, patients with cardiac pacemakers or defibrillators. In this patient cohort the individual risk of endocarditis is not higher than in the general population. Therefore, endocardits prophylaxis is not recommended.     

Diagnosis and Management of Complicated Left Atrial Mural Endocarditis: The Role of Transesophageal Echocardiography

Mural endocarditis that involves the left atrial wall is rare. We report on the transesophageal findings in a patient with left atrial mural endocarditis and discuss its recognition, complications, and treatment.     

Etiology and pathogenesis of thromboembolism.

Thrombus formation in the left atrium and left ventricle is primarily due to stasis of blood which causes activation of the coagulation system. Migration of thrombotic material into the circulation depends on the dynamic forces of the circulation. Atrial fibrillation is the commonest underlying cardiac disorder predisposing to thromboembolism. Rheumatic mitral stenosis, left atrial enlargement, prior myocardial infarction, hypertension, and echocardiographic left ventricular hypertrophy are risk factors for thromboembolic stroke in elderly patients with chronic atrial fibrillation. Non-valvular atrial fibrillation accounts for 45% of cardiac sources of thromboembolic stroke and includes patients with ischemic heart disease, hypertension, thyrotoxic heart disease, hypertrophic cardiomyopathy, chronic sinoatrial disorder, and idiopathic atrial fibrillation. 15% of cardiac sources of thromboembolic stroke are associated with acute myocardial infarction, 10% with left ventricular aneurysm and mural thrombi remote from an acute myocardial infarction, 10% with rheumatic valvular heart disease, and 10% with prosthetic cardiac valves. Mitral valve prolapse, mitral annular calcium, nonischemic cardiomyopathies, infective endocarditis, nonbacterial thrombotic endocarditis, left atrial myxoma, paradoxical embolism associated with congenital heart disease, calcific aortic stenosis, and complex atherosclerotic plaque within the proximal aorta also contribute to thromboembolism.     

Isolated gonococcal pulmonary valve endocarditis: diagnosis by echocardiography.

The perplexing clinical course of a 23-year-old black male with isolated gonococcal pulmonary valvular endocarditis is presented. M-mode echocardiography provided the first clue to the presence of pulmonary valvular vegetations and the proper diagnosis. Since Neisseria gonorrhea appears to have a particular affinity for the pulmonary valve, the presence of isolated pulmonary valvular endocarditis should raise the strong possibility that Neisseria gonorrhea is the offending organism. This case report of pulmonary valvular vegetations detected by echocardiography strongly emphasizes that all four cardiac valves must be visualized in order to rule out the presence of echocardiographically detectable valvular vegetations.