Infected cardiac myxoma.

A 66-year-old male presenting with low-grade fever and general fatigue was diagnosed as having infected myxoma of the left atrium. Blood cultures grew Streptococcus mitis. He underwent urgent resection and histological examination revealed tumor cells in a mucopolysaccharide matrix and bacterial colonies along with active inflammation. Infected cardiac myxoma is extremely rare; however, it contains a potential risk of arterial embolization and so early diagnosis and urgent surgery should be considered.

Gallbladder infarction complicating infective endocarditis.

Infective endocarditis with systemic embolization of the gallbladder vasculature is very rare. We describe a case of subacute infective endocarditis in an adult complicated by embolization of the right hepatic artery with subsequent gallbladder infarction. In these cases, appropriate antibiotic therapy should be given before and after cholecystectomy. Gallbladder resection should be performed before valve replacement to decrease the potential seeding of a prosthetic valve.

Native valve endocarditis due to Bartonella henselae in an immunocompetent man.

Culture-negative endocarditis accounts for 2.5-31% of all endocarditis cases and remains a diagnostic and therapeutic challenge. Bartonella spp. has only recently been recognized as an important cause of culture-negative endocarditis. We report a case of Bartonella henselae endocarditis occurring in an immunocompetent man who owned a cat and had previously been diagnosed with valvulopathy. Diagnosis was made only after prolonged diagnostic work-up with serology and with PCR and subsequent sequencing to identify the microorganism in the excised valves. The duration of treatment in patients with bartonella endocarditis is not clearly defined, and we decided to treat our patient with a prolonged course of antibiotic. Surgical treatment is usually necessary and was also successful in our patient. To our knowledge, this is the first case of bartonella endocarditis occurring in our geographic area.

Autograft from quadrangular resection for floppy valve repair in endocarditis.

We present a case of reconstruction of the anterior leaflet in mitral valve prolapse and subacute bacterial endocarditis in which the resected prolapsing segment of the posterior leaflet was used as patch material. Competence of the valve was achieved with no recurrence of infection. Quadrangular resection of the posterior leaflet supplies presumably viable patch material for valve repair, which is particularly useful in bacterial endocarditis and when pliability is required.

Subacute bacterial endocarditis and complete endocardial cushion defect.

Subacute bacterial endocarditis involving the common atrioventricular (AV) valve is a rare complication of complete endocardial cushion defect. This report describes our experience with an 18-year-old patient who was seen with this problem. Diagnosis was established by two-dimensional echocardiography. The operative findings and technique of repair are described. We believe this to be among the first successful reports of complete repair of active endocarditis involving the common AV valve in this congenital anomaly.

Role of Bartonella henselae endocarditis in the nucleation of aortic valvular calcification.

A 6-year-old boy presented with fatigability, shortness of breath, and bulging neck veins. Echocardiography revealed large vegetations, aortic insufficiency, a dilated left ventricle, and bicuspid aortic valve. There was no history of immunocompromise, fevers, or feline exposures. Blood cultures were negative; antibodies against Bartonella henselae were positive. Gentamicin was administered intravenously. Ross procedure was performed and patient was discharged on antibiotics in 5 days. Native valve was thickened by scar and fibrinous vegetations. Warthin-Starry stain demonstrated coccobacilli. Light and ultrastructural morphology, and monoclonal staining implicated B. henselae. Bacterial membranes contain calcium apatite crystals. Antigenic material was present in bacteria and calcified nodules. This case illustrates calcified protobacteria becoming incorporated into scar tissue during endocarditis.

Vancomycin-induced thrombocytopenia: a case proven with rechallenge.

In a rare case of vancomycin-induced thrombocytopenia, a 50-year-old man with culture-negative subacute bacterial endocarditis underwent mitral valve replacement surgery and was treated with vancomycin. His platelet count dropped from 346 x 10(3)/mm3 to 13 x 10(3)/mm3 on postoperative day 4, and a differential diagnosis of heparin- versus drug-induced thrombocytopenia was considered. Antiheparin antibodies were detected in the patient's serum on day 5. He showed no signs of bleeding. His platelet count remained below 5 x 10(3)/mm3 despite two platelet transfusions on day 5. A hemorrhagic pericardial effusion with tamponade developed, requiring drainage. A trial with intravenous immunoglobulin led to fever and chills, and the infusion was not completed. Vancomycin was changed to clindamycin on day 9, and methylprednisolone therapy was started on day 11. On day 12, the patient's clinical condition improved, and his platelet count increased from 3 x 10(3)/mm3 to 32 x 10(3)/mm3 with no bleeding. On day 18, his platelet count was 424 x 10(3)/mm3, and he was scheduled for discharge with vancomycin therapy for a total of 6 weeks. He received a single dose of intravenous vancomycin 1 g at the hospital; his platelet count dropped to 160 x 10(3)/mm3 1 hour after the infusion and to 58 x 10(3)/mm3 12 hours later. Vancomycin was discontinued and clindamycin and prednisone were restarted. On day 20, the patient's platelet count increased to 105 x 10(3)/mm3 and he was discharged with warfarin, prednisone, and clindamycin therapy. We suspect that our patient's thrombocytopenia was due to vancomycin.

Infective endocarditis: a pathophysiologic approach to therapy.

The treatment of infective endocarditis requires a multidisciplinary approach, including the expertise of cardiologists, infectious disease specialists, and cardiothoracic surgeons. By drawing from the pathophysiology, this article discusses a multidimensional approach to the treatment of these difficult patients.

Is use of the pulmonary valve allograft justified as an aortic valve substitute?

Between January 1, 1990, and March 20, 1994, 56 patients had a homograft valve device placed in the aortic position. The mean age at operation was 53.3 years (range 5-77 years). Diagnosis included dominant aortic stenosis in 27 patients (48.2%) and aortic incompetence in 29 (51.8%). Thirteen patients (23.2%) had subacute bacterial endocarditis. Forty-three aortic homografts and 13 pulmonary homografts were placed. Concomitant procedures were performed in 12 patients (21.8%). The hospital mortality was 7.3% (four patients). On follow-up, three pulmonary valves have failed, two between 1 and 5 weeks post implantation. At reoperation a linear cusp fracture was found in all with no evidence of infection. All remaining patients have no, trivial, or mild, aortic regurgitation on echo and remain well. Pulmonary and aortic valves were compared for failure, P = 0.02 suggesting a significant difference between valve substitutes. In conclusion we advise caution in using pulmonary allografts in the aortic position.

Factors affecting the surgical management of infective endocarditis.

Congestive heart failure and septic embolism complicate the clinical course of patients with infective endocarditis (IE). This study reviews the clinical records of patients with systemic disease secondary to IE and stratifies their disease severity according to individual risk factors and medical, and surgical interventions. The hospital records of all patients presenting to our institution from 1992 through 1997 with heart valve destruction secondary to IE were reviewed. Ten patients with hemodynamically significant valve lesions were included in this study: seven with aortic valve disease and two with mitral valve disease, and one with combined aortic and mitral valve lesions. All were diagnosed by echocardiogram. All ten patients experienced systemic septic arterial emboli: four intracranial lesions, four visceral lesions, and three extremity arterial occlusive events. Two patients required peripheral arterial repair. Cultures revealed infection secondary to Staphylococcus aureus in five, Streptococcus species in three, Coxiella species in one, and an unidentified organism in one patient. Seven patients underwent valve replacement. Three patients died from their disease processes. Statistical significance was established by Wilcoxon rank analysis with a two-tailed P < 0.05. Patients with IE secondary to staphylococcal infections suffered a more acute and virulent disease process (P = 0.04), with a 40 per cent mortality rate in the first 48 hours. There was no increased incidence of embolization associated with longer duration of symptoms (P = 0.32). Surgical repair conferred improved clinical outcome as compared with no surgical intervention (P = 0.03). Improved patient outcome was associated with nonstaphylococcal infection (P = 0.02), and a successful initial antibiotic regimen (P = 0.03). Peripheral arterial repair was successful in both cases.

Replacement of aortic root with valved tubular prosthesis in a ten-year-old child with infective endocarditis--a case report.

Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.

Right ventricular and septal anomalies complicated by subacute bacterial endocarditis.

We report the case of a 31-year-old woman with no history of heart disease. She came to the hospital with fever, dyspnea, palpitation, and edema of the lower extremities. She was found to have aortic, mitral, and pulmonary valve insufficiency, and the initial diagnosis was subacute bacterial endocarditis. At surgery, we replaced the aortic and mitral valves with mechanical prostheses and the pulmonary valve with a bioprosthesis. The prostheses were soaked intraoperatively with fluconazole and the heart chambers were irrigated with povidone-iodine to prevent infection by bacteria and fungi. We also found 2 previously unsuspected anomalies: 1 was a muscular bundle that divided the right ventricle into 2 chambers, and the other was a ventricular septal defect, 1.0 cm in diameter. We resected the muscular bundle and patched the septal defect. The patient had an uneventful postoperative course and was in New York Heart Association functional class I at the 15-month follow-up visit. We speculate that this patient's congenital anomalies made the heart more susceptible to damage from the endocarditis. Therefore, any patient who has infective endocarditis should also be examined closely for congenital defects.

[Infectious endocarditis on native valves. Report of a series of 142 surgically treated cases]. / L'endocardite infectieuse sur valves natives. A propos d'une série de 142 cas opérés.

The results obtained in a series of 142 patients operated upon, between December 1978 and December 1987, for infective endocarditis on native valve are reported. 61 patients (group 1) had acute progressive endocarditis and 81 patients (group 2) had subacute old-standing endocarditis. In group 1 patients, hospital mortality (i.e. occurring during the first 30 post-operative days) was 11.5 p. 100. During a mean follow-up period of 37.6 months (1.5 to 104.5 months), the survival rates were 52 p. 100 at 72 months and 37.4 p. 100 at 104.5 months. Mechanical desinsertion without persistence or relapse of the infective process, and recurrent endocarditis accounted for 27.8 p. 100 of deaths of known cause. Prognosis was better in group 2 patients. Hospital mortality was 4.9 p. 100, and during a mean follow-up period of 58 months (2 to 124 months) the survival rates were 84 p. 100 at 72 months and 73.4 p. 100 at 124 months. 60 p. 100 of late deaths of known cause were due to heart failure. In native valve infective endocarditis the post-operative diagnosis depends upon the pre-operative haemodynamic status, and the assessment of this status (notably with echocardiography) is a crucial element in the decision to operate.

[Refractory heart failure and sepsis in a patient with hypertrophic cardiomyopathy]. / Insuficiência cardíaca refratária e sepse em portador de miocardiopatia hipertrófica.

A twenty one years old man with obstructive hypertrophic cardiomyopathy with resting gradient and which develops subacute infectious endocarditis and acute mitral regurgitation by valvular apparatus destruction. During the course occurs refractory heart failure and sepsis. The association between these diseases and difficulties in management are analyzed, and literature is reviewed. It is emphasized the high mortality of this condition and indication for surgical referral, as well the necessity for infectious endocarditis prophylaxis in patients with obstruction at rest.

Nephrotic syndrome associated with subacute bacterial endocarditis (SBE): a case report.

We experienced a female nephrotic patient associated with subacute bacterial endocarditis. Her proteinuria was completely normalized after antibiotic therapy and valve replacement. Immunofluorescence and an electron microscopic study of a renal biopsy specimen showed little evidence of immune complex in the glomeruli. Marked deposition of properdin in the glomeruli and the reduced level of serum complement may indicate involvement of the complement system in the pathogenic mechanism of massive proteinuria in this case.

[Delayed diagnosis of infectious endocarditis]. / Az infectiv endocarditis megkésett diagnózisa.

Three cases are presented to show examples of mistakes in the diagnosis and treatment of infective endocarditis which led to serious complications. The role of echocardiography in the early diagnosis and in the recognition of complications, the importance of bacteriologic diagnosis in the choice of antibiotic treatment and the need of timely surgical treatment are emphasized.

Rapidly progressive glomerulonephritis associated with PR3-ANCA positive subacute bacterial endocarditis.

Patients with bacterial endocarditis often have renal complications. This report presents the case of an elderly man with rapidly progressive glomerulonephritis (RPGN) associated with subacute bacterial endocarditis (SBE) due to Enterococcus faecalis infection. The patient was positive for anti-proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA) and rheumatoid factor (RF) with hypocomplementemia. Treatment for SBE with antibiotics and the surgical replacement of the affected valves resulted in an improvement of RPGN, the disappearance of PR3-ANCA and RF, and the normalization of hypocomplementemia. This rare case suggests the importance of recognizing the cause of positive PR3-ANCA, because SBE could be an occult cause of RPGN mimicking ANCA-associated vasculitis.