Role of Echocardiography in Evaluation of Patients With Staphylococcus aureusBacteremia: Experience in 103 Patients

Objectives. The purpose of this prospective study was to examine the role of echocardiography in patients with Staphylococcus aureusbacteremia (SAB).Background. The reported incidence of infective endocarditis (IE) among patients with SAB varies widely. Distinguishing patients with uncomplicated bacteremia from those with IE is therapeutically and prognostically important, but often difficult.Methods. One hundred-three consecutive patients undergoing both transthoracic (TTE) echocardiography and transesophageal (TEE) echocardiography were prospectively evaluated. All patients presented with fever and ≥1 positive blood culture and were followed up for 12 weeks.Results. Although predisposing heart disease was present in 42 patients (41%), clinical evidence of infective endocarditis (IE) was rare (7%). TTE revealed anatomic abnormalities in 33 patients, but vegetations in only 7 (7%), and was considered indeterminate in 19 (18%). TEE identified vegetations in 22 patients (aortic valve in 5, mitral valve in 9, tricuspid valve in 4, catheter in 2 and pacemaker in 2, abscesses in 2, valve perforation in 1 and new severe regurgitation in 1; 26 total [25%]). Using Duke criteria for the diagnosis of IE, definite IE was present in 26 patients (25%). Clinical findings and predisposing heart disease did not distinguish between patients with and without IE. The sensitivity of TTE for detecting IE was 32%, and the specificity was 100%. The addition of TEE increased the sensitivity to 100%, but resulted in one false positive result (specificity 99%). TEE detected evidence of IE in 19% of patients with a negative TTE and 21% of patients with an indeterminate TTE. At follow-up, cure of staphylococcal infection occurred in a similar percentage of patients with and without IE (77% and 75%, respectively). However, death due to sepsis was significantly more likely among patients with IE (4 of 26 [15%]) than among those without IE (2 of 77 [3%]) (p = 0.03).Conclusions. Our results suggest that IE is common among patients admitted to the hospital with SAB and is associated with an increased risk of death due to sepsis. TEE is essential to establish the diagnosis and to detect associated complications. Therefore, the test should be considered part of the early evaluation of patients with SAB.     

Infective endocarditis: transesophageal echocardiography in all or in selected cases? When is echocardiography highly predictive for complications?

Echocardiography is currently considered one of the most important tools in the diagnosis and treatment of infective endocarditis (IE). However, its use leaves a number of issues open. Since transthoracic echocardiography (TTE) cannot define structures and vegetations < 4 mm, transesophageal echocardiography (TEE), though more costly and invasive, is superior to TTE in the diagnosis of IE. TEE should be recommended immediately in patients with valve prostheses and in those with a native valve and an intermediate or high pre-test probability of disease. In patients with a low probability of disease, a completely negative examination without the slightest valvular anomaly practically excludes the likelihood of IE; however, the patient should still be followed up. In patients with a very low probability of disease, echocardiography is not necessary; instead, reassessment can be performed at some future time. Echocardiography has a high prognostic value in IE since it may reveal intracardiac complications due to this disease and contributes to a better understanding of the clinical complications. Moreover, echocardiography may also aid in the choice of surgery timing and thus modify the clinical progression of the disease. Large and extensive vegetations that are more mobile and soft are more closely associated with the development of complications and embolic events. Despite numerous reports, uncertainty surrounds the approach to treatment when echocardiography discloses vegetations at risk of embolization in uncomplicated IE and in the absence of other indications for surgery.     

Update on Echocardiography in the Management of Infective Endocarditis

Echocardiography is the major imaging modality used for the diagnosis of infective endocarditis (IE). It is also useful in detecting the complications of IE which often necessitate surgical intervention and strongly influence patient outcomes. Transesophageal echocardiography (TEE), with proven superiority over transthoracic echocardiography (TTE) for the detection of vegetations and complications such as abscess, should be performed in the vast majority of cases especially when TTE image quality is poor or implanted devices are present. Three-dimensional (3D) TEE provides enhanced display of anatomic-spatial relationships allowing more precise delineation of complex pathology, particularly of the mitral valve and annulus. Importantly, echocardiographic findings can be non-specific and should always be interpreted in the context of the pre-test probability of IE based on careful clinical assessment. IE remains a challenging disease associated with variable clinical presentations, and high mortality. Whenever IE is suspected, echocardiography should be utilized early for both diagnosis and detection of complications.     

Infective endocarditis following percutaneous pulmonary valve replacement: Diagnostic challenges and application of intra-cardiac echocardiography

Background

Infective endocarditis (IE) following percutaneous pulmonary valve replacement (PPVR) with the Melody valve is rarely reported. Furthermore, there are challenges in this diagnosis; especially echocardiographic evidence of vegetation within the prosthesis may be difficult.

Method and result

This study is a retrospective review of all patients with Melody valve implantation in a tertiary centre. Between November 2006 and November 2012, 43 procedures were performed in 42 patients (mean age 25 years, 6–67 years). At a median follow-up of 27 months (2–66 months), six patients were suspected for IE. However, repeated transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) showed no evidence of IE and the patients were diagnosed as possible cases according to the modified Duke's criteria. Two patients did not respond to antibiotic treatment and underwent intra-cardiac echocardiography (ICE), which clearly demonstrated vegetations. These two cases required surgical explantation, while the other four patients were treated medically without complications.

Conclusion

IE after Melody valve implantation is uncommon, but difficult to verify since TTE and TEE often cannot demonstrate vegetations inside the stent. ICE should be considered in suspected cases of IE following PPVR with negative TTE and TEE examinations in order to early tailor the best treatment for the individual patient suspected for IE.     

Infective endocarditis due to Staphylococcus aureus: 59 prospectively identified cases with follow-up.

Fifty-nine consecutive patients with definite Staphylococcus aureus infective endocarditis (IE) by the Duke criteria were prospectively identified at our hospital over a 3-year period. Twenty-seven (45.8%) of the 59 patients had hospital-acquired S. aureus bacteremia. The presumed source of infection was an intravascular device in 50.8% of patients. Transthoracic echocardiography (TTE) revealed evidence of IE in 20 patients (33.9%), whereas transesophageal echocardiography (TEE) revealed evidence of IE in 48 patients (81.4%). The outcome for patients was strongly associated with echocardiographic findings: 13 (68.4%) of 19 patients with vegetations visualized by TTE had an embolic event or died of their infection vs. five (16.7%) of 30 patients whose vegetations were visualized only by TEE (P < .01). Most patients with S. aureus IE developed their infection as a consequence of a nosocomial or intravascular device-related infection. TEE established the diagnosis of S. aureus IE in many instances when TTE was nondiagnostic. Visualization of vegetations by TTE may provide prognostic information for patients with S. aureus IE.     

Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study

OBJECTIVE: Libman-Sacks endocarditis in patients with systemic lupus erythematosus (SLE) is complicated with thromboembolism, severe valve regurgitation, need for high-risk valve surgery, or death. Transesophageal echocardiography (TEE) is highly accurate for detection of valvular heart disease, but there are no prospective randomized controlled series comparing transthoracic echocardiography (TTE) to TEE for detection of Libman-Sacks endocarditis. METHODS: Eighty-one patients with SLE (73 women, 8 men) with a mean age of 39 +/- 11 years and 75 healthy volunteers (40 women, 35 men) with a mean age of 35 +/- 9 years underwent paired TTE and TEE to detect valve vegetations, thickening, or >or= moderate mitral, tricuspid, or pulmonic >or= mild aortic regurgitation. Paired TTE and TEE studies of patients and controls were randomized and interpreted by an experienced observer unaware of subjects' data. RESULTS: Libman-Sacks endocarditis: (1) was more common in patients than in controls by both TTE and TEE (p < 0.001); and (2) was more commonly detected by TEE than by TTE (p 相似文献   

经食管三维超声心动图在二尖瓣位感染性心内膜炎中的应用

目的评价经食管三维超声心动图（three-dimensional transesophageal echocardiography,3D-TEE）在二尖瓣位感染性心内膜炎（infective endocarditis,IE）中的应用价值。方法选择2008年6月至2012年5月期间,在广东省人民医院行超声心动图检查并结合临床诊断,最终经手术病理确诊为二尖瓣位IE患者20例为研究对象。所有患者术前均行经胸超声心动图（transthoracic echocardiography,TTE）及3D-TEE检查。以病理为金标准,比较TTE及3D-TEE对诊断心内膜受累各种表现形式的敏感性和特异性。结果手术病理证实二尖瓣位赘生物20例,合并瓣膜穿孔11例,瓣周脓肿3例,瓣膜瘤2例,人工瓣撕脱3例。TTE及3D-TEE诊断赘生物的敏感性为80%vs.90%,特异性为57%vs.86%;诊断瓣膜穿孔的敏感性为72%vs.91%,特异性为78%vs.89%;诊断瓣周脓肿的敏感性为33%vs.66%,特异性为82%vs.94%;诊断瓣膜瘤的敏感性为50%vs.100%,特异性为94%vs.94%;诊断人工瓣撕脱的敏感性及特异性均为100%。3D-TEE对赘生物的检出率均高于TTE,差异有统计学意义（P〈0.05）。结论 3D-TEE对诊断IE各种表现形式均有较高的敏感性和特异性,能准确显示赘生物位置、形态、大小及其与周围心脏结构的空间关系,对临床治疗方案的选择及预后评估有重要作用。     

经食管三维超声心动图在主动脉瓣位感染性心内膜炎中的应用

目的 探讨经食管三维超声心动图（three-dimensional transesophageal echocardiography,3D-TEE）在诊断感染性心内膜炎（infective endocarditis,IE）主动脉瓣病变中的价值.方法 对49例通过经胸超声心动图（transthoracic echocardiography,TTE）与3D-TEE诊断IE主动脉瓣病变患者的超声诊断特点进行分析,以心脏外科术中所见为“金标准”,将超声特点（赘生物、瓣叶穿孔、瓣周脓肿）与手术结果进行对照.结果 3D-TEE对赘生物、瓣叶穿孔、瓣周脓肿诊出的敏感性及特异性均高于TTE,差异有统计学意义（P＜0.05）.对于检测长度＜（4.5±0.7）mm的赘生物,3D-TEE较TTE更加敏感,差异有统计学意义（P＜0.05）.对于检测瓣周脓肿,3D-TEE较TTE更加敏感,差异有统计学意义（P＜0.05）,且容易发现瓣周脓肿早期组织水肿的情况.结论 与TTE相比较,3D-TEE能更准确检测IE主动脉瓣病变,有效评价此类患者瓣周脓肿情况,具有重要的临床应用价值.     

Infective endocarditis: diagnosis and management

Despite advances in antimicrobial therapy, diagnostic imaging and cardiac surgery, infective endocarditis (IE) remains challenging clinically and is associated with high morbidity and mortality. Diagnosis relies on several factors: initial clinical suspicion, microbiological data and echocardiographic findings. The use of an integrated diagnostic schema, such as the modified Duke criteria, is useful. Transthoracic or transesophageal echocardiography should be performed promptly for all suspected IE cases. Although the choice of investigation might be influenced by availability, the approach to imaging should be tailored to the individual's clinical situation. Promptly administered intravenous antimicrobial therapy is essential, while the use of antiplatelet or antithrombin therapy to prevent embolic complications is not supported by clinical data. Deciding whether to undertake cardiac surgery for the treatment of IE can be extremely difficult. The principal indications are the development of heart failure from acute, severe aortic or mitral regurgitation, or perivalvular extension of infection. The timing of surgery following central nervous system embolization is problematic because of the risk of hemorrhagic transformation. Prophylactic surgery to prevent embolization is currently advocated only for the management of large, mobile vegetations, when undertaken at centers performing high volumes of heart valve surgery. In this review, we describe diagnostic approaches for IE, particularly echocardiography, and provide recommendations for treatment, paying particular attention to surgery in the acute setting.     

Clinical Risk Factors for Infective Endocarditis Patients With Staphylococcus Aureus Bacteremia and the Diagnostic Utility of Transesophageal Echocardiogram

Approximately 25% of patients with staphylococcus aureus bacteremia (SAB) develop infective endocarditis (IE), which has a consequent mortality of 25-46%. Current guidelines recommend routine transthoracic echocardiography (TTE) for patients with SAB; transesophageal echocardiogram (TEE) is reserved for those in whom initial TTE is negative and clinical suspicion for IE remains high. We sought to elucidate high risk features of SAB associated with the development of IE that warrant a TEE after a negative TTE. This retrospective study included 213 patients who were diagnosed with SAB at the University of New Mexico Hospital between 2010-2020. A pre-determined list of clinical risk factors along with TTE and TEE status was extracted from the electronic medical record. The primary outcome was development of IE in patients with SAB. Multivariate logistic regression analysis was used to identify clinical risk factors for IE. Moreover, sensitivity and specificity of TTE and TEE was calculated. Out of 213 patients with SAB, 68 patients met diagnostic criteria for IE. Most patients (n = 209) underwent TTE and 171 patients underwent subsequent TEE. The overall sensitivity of TTE was 63% and overall sensitivity of TEE was 88%. Multivariate analysis showed significantly increased risk of IE in patients who had implanted permanent pacemaker (aOR 32.3, CI 5.23 - 281, p < 0.001) and persistent fever (aOR 6.97, CI 2.42 - 21.0 P < 0.001). Based on our analysis, we recommend that TEE should be strongly considered after negative TTE in SAB patients with intracardiac prosthetics or persistent fever despite appropriate antibiotic therapy.     

Improved diagnostic value of echocardiography in patients with infective endocarditis by transoesophageal approach. A prospective study

In a prospective study, the clinical value of transoesophagealtwo-dimensional echocardiography (TOE) as compared with transthoracictwo-dimensional echocardiography (TTE) was determined in patientswith suspected infective endocarditis. Ninety-six patients werestudied consecutively with an electronic sector scanner using2–25 and 3–5 MHz probes for TTE and a 3–5MHz probe embedded in the tip ofaflexible 12 mm gastroscopefor TOE. Results of surgery and autopsy were available for 20 of the96 patients with infective endocarditis and echocardiographicallydemonstrated vegetations and 70 control patients with valvularheart disease without infective endocarditis and no signs ofvegetations, who were studiedpreoperatively with TTE and TOE.For TTE and TOE, the measured sensitivity was 63% and 100%,specificity 98% and 98%, positive predictive accuracy 92% and95%, and negative predictive accuracy 91% and 100%, respectively.In 39 patients who had positive blood cultures, vegetationswere found by TOE in 32 patients (82%), but in only 27 patients(69%) by TTE. Image quality was the main factor contributingto the superiority of TOE over TTE: it was reduced in 11/20patients (55%) in whom vegetations were not detected by TTE.Another important factor was the size of vegetations. Only 6/24vegetations (25%) of <5 mm but 9/13 vegetations of 6–10mm, and 14/14 vegetations of > 11 mm detected by TOE werealso observed with TTE. The clinical importance of detectingvegetations was demonstrated by the rate of embolism. In patientswith vegetations embolism was 25% when blood cultures were positiveand 21% when they were negative. In patients without echocardiographicallydetectable vegetations signs of embolism were seen in no patientwith positive and 7% of the patients with negative blood cultures.Evidence of vegetations was found on the aortic valve in 14patients and on the mitral valve in seven patients in whom valvularincompetence was not present, indicating that the valve hadnot yet been damaged significantly. TOE is superior to TTE in detecting vegetations in suspectedinfective endocarditis because of better image quality, particularlywhen vegetations are small. TOE seems to be indicated in patientswith suspected endocarditis and reduced image quality or negativeTTE results. Early detection of vegetations on valves may helpconfirm the diagnosis of infective endocarditis at an earlystage and hopefully lead to an improved prognosis by reducingdelay in instituting appropriate therapy.     

Contribution of echocardiography and immediate surgery to the management of severe aortic regurgitation from active infective endocarditis

The timing of surgery in patients with severe aortic regurgitation and left ventricular (LV) failure, particularly when associated with active infective endocarditis (IE), is of the utmost importance. From July 1982 to May 1984, 34 patients, aged 15 to 60 years, with severe aortic regurgitation underwent immediate (within 24 hours of diagnosis) aortic valve surgery. All patients were in New York Heart Association class IV for LV failure. Eighteen patients had right-sided heart failure. Decision for immediate surgery was based on the echocardiographic demonstration of diastolic closure of the mitral valve or of vegetations on the aortic valve. Premature closure of the mitral valve was demonstrated echocardiographically in 17 patients, 13 of whom had diastolic crossover of LV and left atrial pressure tracings recorded at surgery. IE of the aortic valve was confirmed at surgery in 29 patients, 27 of whom had vegetations on echocardiography. Seven patients required replacement of both aortic and mitral valves. Antibiotic therapy for IE was started immediately after blood cultures were taken and continued for 4 to 6 weeks postoperatively. The mortality rate within 30 days of surgery was 6% for the group as a whole and 7% for those with IE. Mean follow-up period for the 32 survivors was 10.6 months. There were 2 late deaths. No patient had periprosthetic regurgitation or persistence of endocarditis. Procrastination in referral for surgery of these extremely ill patients is not justified and is likely to be associated with higher risks of morbidity and mortality.     

Subacute infectious endocarditis due to the agent of cat scratch fever: Bartonella henselae

The diagnosis of severe mitral stenosis with left atrial thrombus was rectified at valvular replacement in a 48-year old immuno-competent man who was a cat owner. The mass in the left atrium was, in fact, a large endocarditic vegetation. Pre- and postoperative blood cultures were negative as was culture of the excised mitral valve. The diagnosis of infectious endocarditis (IE) due to Bartonella Henselae was made from a positive serological test (1600) and identification of the germ by genetic amplification. Antibiotic therapy was continued for 6 months and the patient was cured with a follow-up of 4 years. Bartonella Henselae IE is very rare (14 reported cases) and affects mainly the aortic valve, often giving rise to very large vegetations which, in half the cases, are complicated by systemic emboli. Germs like Batonella are sensitive to most antibiotics, especially the aminosides and macrolides. In Bartonella Henselae IE, valve replacement is the rule (13 out of 14 cases) and the prognosis is usually good. Sero-diagnosis of Bartonellosis should be part of the systematic investigation of all blood culture negative IE.     

Infective endocarditis in elderly patients

Infective endocarditis (IE) in elderly patients is a serious disease with significant morbidity and mortality. IE presents unique diagnostic and therapeutic challenges in the elderly. A heightened index of suspicion is necessary due to the atypical presentations of IE among the elderly. Underlying degenerative valvular disease, mitral valve prolapse, and presence of a prosthetic valve are important predisposing risk factors for IE in the elderly. IE in the elderly is somewhat more common in men. The mitral valve is affected somewhat more frequently compared with the aortic valve. Streptococci and staphylococci are the predominant organisms, recovered in approximately 80% of elderly patients with IE. The presence of calcific valvular lesions and prosthetic valves often confound echocardiographic findings in the elderly. Aggressive diagnostic and therapeutic approaches are mandatory for a favorable outcome of IE in this group of patients.     

Perforated giant mycotic aneurysm of mitral valve in a drug‐addicted young man: Rare complication of infective endocarditis

Infective endocarditis (IE) affects patients at high clinical risk and may present as an acute and rapidly progressive, subacute or chronic infection. Transthoracic and transesophageal echocardiography represent the key diagnostic method in IE diagnosis. In particular, three‐dimensional transesophageal echocardiography represents the imaging technique that allows to establish with adequate accuracy dimensions, shape, and localization of endocarditis vegetations. In our case, we show a huge vermiform mycotic aneurysm in an immunodeficient young drug‐addicted man with severe mitral valve regurgitation and the additive value of three‐dimensional transesophageal echocardiography in this specific clinical setting.     

Has Transesophageal Echocardiography Changed the Approach to Patients with Suspected or Known Infective Endocarditis?

Infective endocarditis is still a great clinical challenge. Its diagnosis is difficult to establish, and mortality has remained around 30%. Early diagnosis and optimal treatment are crucial fo prognosis improvement. Echocardiography plays an indispensable role in the management of this disease, especially with the recently introduced approach, transesophageal echocardiography (TEE). TEE can overcome the limitations of transthoracic echocardiography (TTE) and is superior to TTE in almost every way in providing earlier and more information for the diagnosis and treatment of infective endocarditis. TEE detects valve vegetations with much higher sensitivity and specificity than TTE. It can demonstrate smaller vegetations in the early stage of the disease and vegetations on atypical locations (e.g., mitral valve annulus), and provides detailed characterization of vegetations (e.g., location, size, mobility, and changes during treatment). Such information is of great prognostic value and may help in selecting proper treatment. TEE is more sensitive for detecting complications, such as mitral valve perforation, abscess, and subaortic complications, which respond poorly to medicine and for which timely surgery may be the best treatment. For those with prosthetic valve endocarditis, TEE is especially useful because TTE is greatly limited by the acoustic shadow of prostheses. Both positive and negative results of TEE examination are valuable for confirming or excluding infective endocarditis. TEE also plays a unique role in intraoperative monitoring and can assess surgical results before the chest is closed. TEE has become an invaluable tool for the diagnosis and management of patients with suspected or known infective endocarditis.     

Echocardiography predicts embolic events in infective endocarditis

OBJECTIVES: The aim of our study was to assess the value of transesophageal echocardiography (TEE) in predicting embolic events (EEs) in a large group of patients with definite endocarditis according to the Duke criteria, including silent embolism. BACKGROUND: The value of echocardiography in predicting embolism in patients with endocarditis remains controversial. Some studies reported an increased risk of embolism in patients with large and mobile vegetations, whereas other studies failed to demonstrate such a relationship. METHODS: Multiplane transesophageal echocardiograms of 178 consecutive patients with definite infective endocarditis (IE) were analyzed. The incidence of embolism was compared with the echocardiographic characteristics (localization, size and mobility) of the vegetations. To detect silent embolism, cerebral and thoraco-abdominal scans were performed in 95% of patients. RESULTS: Among 178 patients, 66 (37%) had one or more EEs. There was no difference between patients with and without embolism in terms of age, gender and left valve involved. On univariate analysis, Staphylococcus infection, right-side valve endocarditis and vegetation length and mobility were significantly related to EEs. A significant higher incidence of embolism was present in patients with vegetation length >10 mm (60%, p < 0.001) and in patients with mobile vegetations (62%, p < 0.001). Embolism was particularly frequent among 30 patients with both severely mobile and large vegetations (> 15 mm) (83%, p < 0.001). On multivariate analysis, the only predictors of embolism were vegetation length (p = 0.03) and mobility (p = 0.01). CONCLUSIONS: Our study shows that the presence of vegetations on TEE is predictive of embolism and that the morphologic characteristics of vegetations are helpful in predicting EEs in both mitral and aortic valve IE. It also suggests that early operation may be recommended in patients with vegetations > 15 mm and high mobility, irrespective of the degree of valve destruction, heart failure and response to antibiotic therapy.     

The clinical implications (or lack thereof) of vegetations detected by echocardiography in patients not thought to have endocarditis

Background: The clinical impact of echocardiographic demonstration of a vegetation (Veg) in patients in whom infective endocarditis (IE) is not suspected has not previously been analyzed. Hypothesis: In this study, an echocardiographic database was interrogated to test whether discovery of a vegetation by echocardiography should result in treatment for endocarditis if IE is not suspected. Methods: In all, 2,750 serial transthoracic echocardiograms (TTE) were reviewed to generate a list of reports containing the word Veg or thickening (Thk). A chart review of cases identified the impact the report had on patient management. To analyze reader bias due to echocardiographic requests, stating “rule out Veg or IE” as the reason for the study, an additional 1,000 serial TTE requests were segregated into two groups with and without this term. The incidence of the terms Veg or Thk in TTE reports of these groups was tabulated. Results: Of 2,750 reports, 20 contained the word Veg. Blood cultures were drawn in 16 of 20, with 7 of 16 being positive. Therapy for IE was initiated in 5 of 7 patients with positive cultures. Of 1,000 requests reviewed in the second phase, 24% of those with rule out Veg as the indication for TTE (n = 29) had Veg and 7% had Thk, while in 971 cases with other indications for TTE 0.2% had Veg and 9.3% had Thk. Conclusions: Clinicians disregard TTE demonstration of Veg if clinical suspicion for IE is low. It is not clear whether the initial echo request biases the interpretation.     

Anévrysme rénal infectieux retardé, 3 mois après chirurgie cardiaque pour une endocardite infectieuse à Streptococcus pyogenes ; cas et revue de la littérature

Infective endocarditis (IE) due to Streptococcus pyogenes (SP) (Group A Streptococcus) is uncommon and infectious renal artery aneurysm (IRAA) is an exceptional complication of IE, with few cases reported in the literature.We describe a case of SP native mitral valve IE in a 58-year-old man, presenting with large valve vegetations, abscess and severe regurgitation. Initial CT-angiography showed bilateral kidney and splenic infarcts.He underwent successful emergent bioprosthetic valve replacement. Antibiotic regimen consisted in linezolid and rifampicin for 8 weeks. Three months later, CT-angiography for feet gangrene revealed a 16mm aneurysm of the left intraparenchymal renal artery, which was occluded by coil-embolization.This case shows that an infectious aneurysm may develop several months after antibiotic treatment and emergent valve replacement for IE.     

老年感染性心内膜炎住院患者合并脑卒中临床分析

目的:探讨老年感染性心内膜炎(IE)患者脑卒中的发生规律。方法:回顾性分析北京安贞医院,近10年收治的年龄>60岁诊断为IE患者的临床资料。结果:共纳入63例患者,其中男性47例,女性16例,年龄在60~82岁,平均年龄(68.0±5.6)岁。包含5例人工心脏瓣膜心内膜炎,其余为自然瓣膜性心内膜炎。左侧心内膜炎57例,其余6例为右侧心内膜炎。62例患者(98.4%)经过彩色超声心动图或手术所见发现赘生物。23例患者合并脑卒中,占36.5%,3例为静止性脑梗死,20例患者为症状性脑卒中,其中症状性脑梗死15例,脑出血1例,蛛网膜下腔出血1例,另外3例患者因未行神经影像学检查无法定性。脑梗死主要分布于颈内动脉系统。脑卒中组二尖瓣赘生物发生率显著高于不伴脑卒中的患者(69.5%vs.40%,P=0.024),二尖瓣赘生物对脑卒中的(OR=3.429,95%CI:1.152~10.202)。合并脑卒中组病死率显著高于不伴有脑卒中的患者(21.7%vs.2.5%,P=0.012),脑卒中对于死亡的(OR=10.833,95%CI:1.178~99.595)。结论:在老年住院IE患者中,脑卒中发病常见。二尖瓣赘生物是脑卒中发生的危险因素,而脑卒中显著增加老年IE患者病死率。