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.     

A case of acute isolated (Fiedler's) myocarditis diagnosed by histopathological study with rapid unfortunate course]

A 65 year-old-man was admitted to our hospital complaining of orthopnea and precordial oppressive feeling. Chest roentgenogram revealed congestive heart failure. Electrocardiogram revealed acute myocardial infarction-like pattern. Serum enzymes (CPK, GOT, LDH) were slightly elevated, but serum antiviral antibodies were not elevated. Echocardiogram showed severe symmetrical left ventricular (LV) hypertrophy, but there was no abnormality of LV wall motion. He died of progressive heart failure and ventricular fibrillation on the second hospital day. A necropsy was performed within one hour of death. The heart was enlarged (690 g) with both left and right ventricular hypertrophy. The myocardium disclosed a diffuse infiltration predominantly of eosinophilic leucocytes. Histopathological study revealed giant cell formation and granulomatous lesions in the myocardium. There was no overt endocarditis or pericarditis. We concluded that the severe LV hypertrophy was due to myocardial inflammatory swelling. From these findings, we diagnosed this case as acute isolated (Fielder's) myocarditis.     

Multiple abscessing of valvular apparatus of the heart in a patient with secondary infectious endocarditis

Progressive growth of infectious endocarditis morbidity has been noted in the world during recent 10 years. Among secondary forms of endocarditis rate of congenital heart defects is 21%. According to data of M.K. Rybakova (2007) the highest risk of development of infectious endocarditis (74%) is noted on bicuspid aortic valve. We present a clinical case of the patient C. with bicuspid aortic valve, secondary infectious endocarditis of aortic and mitral valves complicated with multiple abscessing of valvular apparatus of the heart. The following operation was carried out: mitral valve replacement with mechanical prosthesis ON-X 27 - 29 with preservation of subvalvular structures of posterior mitral valve leaflet, and replacement of aortic valve with mechanical prostheses ON-X-23. Despite development of severe complications in the patient C the outcome of disease was favorable. After course of rehabilitation the patient returned to work.     

Cardiac failure due to traumatic aortic valve rupture]

Cardiac failure due to valvular dysfunction is frequent as a complication of acute myocardial infarction, endocarditis or penetrating thoracic trauma affecting the heart and large vessels. Less frequently it is associate with nonpenetrating chest trauma. We presented a 69-year-old male with acute left heart failure after nonpenetrating thoracic trauma and sternum fracture. Transesophageal echocardiogram confirmed severe aortic regurgitation. A bilateral tear in the right coronary and non-coronary cusp was found. The aortic valve was removed and replaced with a number 27 Carpentier Edwards prosthesis. The postoperative course was uneventful.     

Bacterial endocarditis; report of a case in which a true musical diastolic murmur appeared and disappeared

A case of acute bacterial endocarditis due to a gamma (nonhemolytic) streptococcus, in which death occurred in spite of massive penicillin therapy, has been reported. A true musical diastolic murmur, caused by perforation of two cusps of the aortic valve, occurred during the course of the disease. This was accompanied by severe congestive heart failure. With the disappearance of the musical quality of the aortic diastolic murmur, there was a prompt lessening of the pulse pressure and a progressive improvement in the symptoms and the degree of heart failure. What was interpreted as evidence of improvement was in reality increase in the size of vegetations on the aortic valve which produced occlusion of the perforations of the valve.     

The Ross procedure in the acute phase of infectious endocarditis in childhood]

The Ross procedure of aortic valve replacement with a pulmonary autograft has several advantages in childhood over mechanical prostheses or homografts, especially in infectious endocarditis requiring early surgery. Between January 1997 and July 1998, 3 children with no known previous cardiac disease, aged 14 months, 10 and 11 years, had aortic valve infectious endocarditis. The causal organism was not identified in 1 case and the other two were due to staphylococcus aureus and corynebacterium diphteriae. All children had severe, rapidly progressive aortic regurgitation complicated by pulmonary oedema in the baby and systemic emboli in the two older children. Surgery was performed within 9 days, 1.5 month and 2 months after the onset of the disease. The postoperative course was uncomplicated in the 3 cases. Postoperative Doppler echocardiography showed absence of autograft dysfunction or stenosis, with the presence of pulmonary regurgitation in 1 case. Pulmonary autograft has the advantages of not requiring anticoagulation, of allowing growth of the aortic ring, of not being limited by the age of the patient and of having a low risk of degeneration and infectious endocarditis. Therefore, it seems particularly indicated for cases of complicated infectious endocarditis requiring early aortic valve replacement. The early (4.8%) and late (4.3%) mortality rates were comparable to those of other techniques and are lower than those associated with valve replacement with mechanical prostheses in cases of endocarditis (8.5% versus 40%). The secondary morbidity is 18.8% with dysfunction of the autograft and/or stenosis of the pulmonary homograft. Despite a limited follow-up, aortic valve replacement by a pulmonary homograft seems better than aortic valve replacement with a homograft or mechanical prosthesis, especially in cases of complicated infectious endocarditis requiring surgery in the acute phase. Further studies are required to confirm these encouraging results.     

Pseudoaneurysm of the mitral-aortic intervalvular fibrosa following infective endocarditis in a patient with acute heart failure: a case report

A 22-year-old male presented with infective endocarditis and aortic regurgitation with congenital bicuspid aortic valve. Echocardiography revealed vegetation on the aortic valve and a pseudoaneurysm in the region of the mitral-aortic intervalvular fibrosa (MAIVF) with severe aortic and mitral regurgitation. His clinical condition, acute heart failure due to severe aortic and mitral regurgitation, became worse. Since the MAIVF complication indicates advanced disruption of tissue at the MAIVF, urgent cardiac surgery was indicated because of the evidence of pseudoaneurysm. He received successful aortic valve replacement and restoration of normal mitral-aortic continuity. Pseudoaneurysm of the MAIVF is a relatively rare complication of infective endocarditis, but should be considered in patients who are suspected to have vegetation because echocardiography can easily establish the correct diagnosis.     

Echocardiographic identification of an aortic valve ring abscess

A valve ring abscess was diagnosed in four patients with a prosthetic aortic valve by identifying an echo-free space on two-dimensional echocardiography. Three of the patients presented with severe aortic regurgitation and congestive heart failure after an episode of endocarditis, but two of them did not have evidence of active endocarditis. The fourth patient had endocarditis, but no evidence of aortic regurgitation or heart failure. All four patients required valve replacement. Similar findings in all 11 previously reported cases suggest that a valve ring abscess can be diagnosed by two-dimensional echocardiography. It may be found without clinical evidence of endocarditis, in the absence of aortic regurgitation, without echocardiographically identifiable vegetations or during resolution of endocarditis.     

Aortic valve endocarditis: is there an optimal surgical timing?

PURPOSE OF REVIEW: Patients with aortic valve infective endocarditis are likely to undergo surgery during the active phase of the disease. The indication and best timing for surgery, however, are still debated. The present review discusses the benefits and risks of early surgery in aortic endocarditis. RECENT FINDINGS: Patients with acute aortic regurgitation and clinical or echocardiographic signs of poor tolerance require urgent surgery. Other indications for early surgery include severe perivalvular involvement and high embolic risk. Echocardiography plays an important role in the assessment of embolic risk and helps in choosing the best therapeutic strategy. Several recent studies have identified high-risk subgroups of patients that, without surgery, face poor prognosis. Patients with complicated endocarditis, particularly those with congestive heart failure, will benefit most from surgery. Patients with prosthetic valve endocarditis and cerebral complications represent specific subgroups in which surgical decision is more difficult. SUMMARY: Patients with severe aortic leaflet destruction and congestive heart failure, patients with perivalvular extension or uncontrolled infection, and patients with high embolic risk have poor outcome under medical therapy. Early surgery is necessary in all such patients with 'complicated' endocarditis, unless severe comorbidity is present.     

Left-sided valvular active infective endocarditis. A study of forty-five necropsy patients

Clinical and anatomic features are described in forty-five necropsy patients with left-sided valvular active infective endocarditis. Vegetations in 53 per cent of the patients involved previously anatomically normal valves, and 76 per cent of all patients had previously functionally normal valves. Predisposing factors allowing entrance of virulent or unusual organisms or alterations of host defense mechanisms appear to account for the frequency of infective endocarditis on normal valves. Valvular dysfunction resulting from infective endocarditis occurred in at least 59 per cent and possibly as high as 74 per cent of the forty-five patients causing congestive heart failure in all. Myocardial lesions were present in 87 per cent of the thirty-eight patients in whom multiple histologic sections were examined, but in none did heart failure appear to result from these lesions. Papillary muscle necrosis was present in 58 per cent, but in none did it appear to cause mitral regurgitation. Congestive heart failure could not be attributed in any patient to myocardial lesions. Pericarditis occurred in eight patients (20 per cent), and in each a site of direct extension of the inflammation into the pericardium was apparent. Ring abscesses occurred in twelve of thirty-one patients with aortic valve vegetations and in none of twenty-six with mitral valve vegetations. Ring abscesses indicate severe destruction of valvular cusps and severe valvular dysfunction.     

感染性心内膜炎所致冠状动脉栓塞七例报告

本文报告7例感染性心内膜炎所致的冠状动脉栓塞,其中5例尸检证实,2例经心电图诊断。     

First reported case of bacterial endocarditis attributable to Actinomyces meyeri

A 48-year-old man presented to the Victoria General Hospital, Halifax, Nova Scotia in severe congestive heart failure. Echocardiographic studies revealed significant aortic valve insufficiency. Two anaerobic blood cultures performed two weeks apart were both positive for Actinomyces meyeri. The patient was treated with high dose intravenous penicillin. Three weeks after antibiotics were begun, he underwent aortic valve replacement. Intraoperative cultures were negative. Histopathological examination revealed findings in keeping with subacute bacterial endocarditis. The patient completed a six-week course of penicillin and was doing well three months after surgery. This is the first case of endocarditis attributable to A meyeri reported in the literature.     

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.     

Brucella endocarditis: the role of combined medical and surgical treatment

Brucella endocarditis, although a rare complication of brucellosis, is the main cause of death related to this disease. This report describes a case of aortic endocarditis due to Brucella abortus in an elderly farmer with known aortic stenosis. Urgent valve replacement was performed because of progressive heart failure despite appropriate antimicrobial treatment. The infection was cured with trimethoprim-sulfamethoxazole and rifampin given for 3 months after surgery. A review of the literature reports on the 38 other cases of cured brucella endocarditis made clear the need for combined antimicrobial treatment and surgical valve replacement.     

Ruptured Anterior Mitral Leaflet Aneurysm in Aortic Valve Infective Endocarditis—Evaluation by Three‐Dimensional Echocardiography

Ruptured aneurysm of the anterior mitral leaflet is a rare but a devastating complication secondary to aortic valve infective endocarditis. We report a case of 30‐year‐old male with native aortic valve endocarditis who was referred to us for evaluation of worsening of heart failure after an initial period of responsiveness to antibiotics. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed ruptured anterior mitral leaflet aneurysm with severe eccentric mitral regurgitation along with a large vegetation on the aortic valve. The patient underwent successful surgical closure of the defect along with aortic valve replacement.     

Echocardiographic and clinical correlations in infectious endocarditis of the left heart

The echocardiographic features were correlated with the clinical findings and outcome in 35 patients with aortic and/or mitral valve endocarditis. There were 26 males and 9 females with a mean age of 38 years. The infection involved native valves in 27 patients and prosthetic valves in 8 patients. Echocardiographically, fourteen patients had involvement of native aortic valve. All patients in this group required surgical intervention, nine patients during antimicrobial therapy. Congestive heart failure was the clinical indication for valvular replacement. A patient died immediately after surgery from low cardiac output syndrome. Six patients had echocardiographic evidence of aortic and mitral valves involvement. A patient in this group expired before surgery, five underwent surgery because of progressive heart failure (aortic or aortic and mitral valves replacement). Seven patients showed lesions on native mitral valve (6 in this group had prolapse syndrome). A patient died from cerebrovascular embolus, two underwent surgery because of persistent infection and embolic events, four were successfully treated with medical therapy. Among patients with prosthetic valve endocarditis, four showed signs of valvular dehiscence and required surgical intervention, during antimicrobial therapy, from congestive heart failure; one patient expired from recurrent infection. The pathological findings correlated well with echocardiographic findings. Conclusions: in IE the localization of lesions by echo has prognostic significance: most patients with aortic valve or aortic and mitral valves endocarditis require early surgical intervention because of congestive heart failure. On the contrary, mitral valve involvement carries a better prognosis, requiring less frequently valvular replacement; the patients with echocardiographic signs of prosthetic valve dehiscence require urgent intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Candida sp. infection-late complication of a double valve replacement

Severe complications prolonged the original hospital stay to over 2 months. After 5 months intermittent fever lead to readmission, but no cause could be found. After 7 months severe fever and heart failure developed. Initially valve endocarditis was suspected. After a blood culture had revealed Candida sp. antimycotic therapy was carried out. The reoperation showed surprisingly no valve endocarditis, but a mycotic lesion of the aortic suture.     

Severe and early stenosis of porcine heterograft mitral valve.

A patient who had aortic and mitral valves replaced by Carpentier porcine heterografts for bacterial endocarditis developed severe heart failure 18 days after operation. A second emergency operation revealed that the mitral prosthesis had become severely stenosed and calcified. A loud Graham Steell murmur had developed during the 12 hours before reoperation but no distinct murmurs of mitral stenosis had been detected.     

Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.     

Outcome of aortic homograft implantation in 24 cases of severe infective endocarditis

The objective of the study was to evaluate the results of treatment of severe aortic endocarditis with an aortic homograft (an aortic valve and root from a donor) in combination with antibiotic therapy. 24 patients with either aortic prosthetic valve endocarditis (n=16) or severe aortic native valve endocarditis (n=8) with destruction of 1 or more cusps, paravalvular abscess formation and/or cardiac fistulas caused by aggressive bacteria, underwent surgery in 1997-2006. Staphylococcal species were the most common pathogens followed by streptococci. Intravenous antibiotic therapy was started before surgery and continued for at least 4-6 weeks. Three patients with prosthetic valve endocarditis died within the first 24 h after surgery from heart failure. Two of these patients required an additional implantation of a mitral valve prosthesis. Five patients died from non-cardiac causes within 1-7 y of surgery. Within the follow-up period no patients had relapse of endocarditis, and only 1 episode of recurrent endocarditis in an intravenous drug abuser was registered. In conclusion, an aortic homograft in combination with intravenous antibiotics is an excellent option for treatment of severe aortic endocarditis.