Plastia mitral en endocarditis infecciosa: reporte de un caso / Mitral valve repair in infective endocarditis: a case report / Plastia mitral em endocardite infecciosa: relato de um caso

La endocarditis infecciosa es una patología heterogénea con una alta mortalidad y requiere tratamiento quirúrgico en al menos la mitad de los casos. Cuando asienta en posición mitral, la reparación valvular en lugar de su sustitución, si bien representa un desafío técnico, ha ido ganando terreno en los últimos años. Describimos el caso de un paciente que se presentó con una endocarditis sobre válvula nativa mitral en quien se realizó una plastia valvular exitosa. Revisaremos la evidencia acerca de su beneficio.

Infective endocarditis is a heterogeneous disease with a high mortality and that requires surgical treatment in at least half of cases. When seated in mitral position, valve repair rather than replacement, while technically challenging, has been gaining popularity in recent years. We describe the case of a patient who presented with a mitral valve endocarditis in whom a successful valve repair was performed. Evidence supporting its use will be reviewed.

A endocardite infecciosa é uma doença heterogênea com alta mortalidade que requer tratamento cirúrgico em pelo menos metade dos casos. Quando sentado na posição mitral, o reparo da válvula, em vez da substituição da válvula, embora seja um desafio técnico, tem ganhado espaço nos últimos anos. Descrevemos o caso de um paciente que apresentou endocardite valvar mitral nativa, no qual foi realizada plastia valvar com sucesso. Vamos revisar as evidências sobre o seu benefício.

Minimally Invasive Surgery in Mitral Valve Endocarditis.

BACKGROUND: To minimize the surgical damage, minimally invasive mitral valve surgery (MIMVS) has become the therapy of choice. However, this approach is technically more challenging, especially in endocarditis. The data on MIMVS in endocarditis are scarce, we therefore retrospectively analyzed the result at our institute. METHODS: From January 2011 and July 2017, 420 MIMVS were performed, out of which 44 (10%) were for endocarditis. Mean age was 55 ± 17 years and 41% (n = 18) were male. RESULTS: Euroscore II was 7.3 (range: 2-38). Operation times, cardiopulmonary bypass times, and clamp times were 230 (±77), 158 (±56), and 84 (±39) minutes, respectively. Seven cases (16%) were cardiac redo operations. Mitral valve repair and replacement was performed in 46 (n = 20) and 54% (n = 24) of patients, respectively. Overall in-hospital mortality, apoplexy, and reoperation rates (all for bleeding) were 7 (n = 3), 0 (n = 0), and 11% (n = 5), respectively. New onset of dialysis was required in three patients (7%). No patient developed superficial wound infection. Overall intensive care unit and hospital stay was 3 (±3) and 24 (±32) days, respectively. CONCLUSION: MIMVS can be performed with acceptable outcome and low perioperative morbidity in patients with mitral valve endocarditis. Especially absence of any postoperative wound infections and low rate of endocarditis recurrence; use of MIMVS must be encouraged as an eligible approach in most cases.

Infective endocarditis following transcatheter edge-to-edge mitral valve repair: A systematic review.

OBJECTIVES: To assess the clinical characteristics, management, and outcomes of patients diagnosed with infective endocarditis (IE) after edge-to-edge mitral valve repair with the MitraClip device. BACKGROUND: Transcatheter edge-to-edge mitral valve repair has emerged as an alternative to surgery in high-risk patients. However, few data exist on IE following transcatheter mitral procedures. METHODS: Four electronic databases (PubMed, Google Scholar, Embase, and Cochrane Library) were searched for original published studies on IE after edge-to-edge transcatheter mitral valve repair from 2003 to 2017. RESULTS: A total of 10 publications describing 12 patients with definitive IE (median age 76 years, 55% men) were found. The mean logistic EuroSCORE/EuroSCORE II were 41% and 45%, respectively. The IE episode occurred early (within 12 months post-procedure) in nine patients (75%; within the first month in five patients). Staphylococcus aureus was the most frequent (60%) causal microorganism, and severe mitral regurgitation was present in all cases but one. Surgical mitral valve replacement (SMVR) was performed in most (67%) patients, and the mortality associated with the IE episode was high (42%). CONCLUSIONS: IE following transcatheter edge-to-edge mitral valve repair is a rare but life-threatening complication, usually necessitating SMVR despite the high-risk profile of the patients. These results highlight the importance of adequate preventive measures and a prompt diagnosis and treatment of this serious complication.

[Reconstruction of Anterior Mitral Leaflet Using Fresh Autologous Pericardial Patch for Active Infective Endocarditis;Report of a Case].

Several reports have described that the prognosis of patients with mitral valve regurgitation due to active infective endocarditis (IE) is better after mitral valve plasty (MVP) than replacement (MVR). However, extensive destruction of valve tissue might cause difficulties with MVP. We repaired a widely-affected anterior mitral leaflet (AML) using an autologous pericardial patch. A 44-year-old woman with mitral regurgitation presented with prolonged fever and backache. We made a diagnosis of active IE accompanied by mitral valve regurgitation. We performed MVP, widely resected the infected areas of the AML, and reconstructed the defective area using the pericardial patch. She was discharged after four weeks of antibiotic therapy, when she was free of recurrence. The pericardial patch facilitated MVP and was effective for treating mitral valve regurgitation due to active IE.

[Surgical Experience of Infective Aneurysm of Brachial Artery Complicated with Infective Mitral Valve Endocarditis].

We report a rare case of aneurysmal formation of the left brachial artery complicated with infective endocarditis of the mitral valve. A 67-year-old man was referred to our institution for further examination of pulsatile mass at the left upper extremity. Computed tomography showed a left brachial arterial aneurysm with a diameter of 4 cm and gradual expansion of the aneurysm was also recognized. Furthermore, echocardiography revealed severe mitral valve regurgitation with a vegetation. There was no feature of congestive heart failure. He was diagnosed with subacute infective endocarditis and infective left brachial arterial aneurysm. Considering these clinical findings, staged surgical treatment was planned. He underwent resection of the brachial arterial aneurysm and bypass grafting with an autologous saphenous vein on an urgent basis. One month after the initial operation, elective mitral valve plasty was successfully performed. Although aneurysmal formation of the brachial artery subsequent to infective endocarditis is rare, we should keep this potentially serious complication in mind.

First reported case of disseminated Nocardia kroppenstedtii sp nov. infection presenting with brain abscess and endocarditis in an immunocompromised patient with mantle cell lymphoma: challenges in diagnosis and treatment.

A 72-year-old man with a history of blastoid variant stage IV relapsed refractory mantle cell lymphoma presented with new central nervous system (CNS) symptoms. Brain imaging was positive for rim-enhancing lesions along with a mitral valve mass on the echocardiogram. It was a challenge to establish the exact aetiology of these lesions in this patient. He was empirically treated with chemotherapy on the presumption that the brain lesions were secondary to progressive malignancy. However, brain biopsy was negative for malignancy and blood cultures were found positive for Nocardia kroppenstedtii sp nov. He subsequently improved with antibiotic therapy. Disseminated Nocardia can present with multiorgan involvement. Clinical and microbiological diagnosis can be challenging. Antimicrobial treatment-related side effects require close monitoring, and dosage changes or therapy adjustments may be necessary.

Endocarditis after interventional repair of the mitral valve: Review of a dilemma.

BACKGROUND: The MitraClip procedure can be an alternative treatment option for patients with high surgical risk for whom surgical treatment is contraindicated. Patients with prosthetic material have an increased risk for infective endocarditis. HYPOTHESIS: Incidence, treatment and outcome of patients with endocarditis after interventional mitral valve repair are not known. METHODS: We searched for articles using PubMed using the terms "interventional mitral valve repair", "mitraclip" and "endocarditis". We have also searched for case reports in major congresses. Furthermore, we report two cases. RESULTS: Four cases of IE after MitraClip were found in addition to our cases. The leading cause is a bacterial infection, typically with staphylococcal bacteria. Approximately two thirds of these patients underwent surgery. Short-term outcome seems to be reasonable for these patients. During the early postoperative period and if Staphylococcus aureus can be cultivated mortality seems to be significantly elevated. CONCLUSION: IE after MitraClip procedure is a dilemma. While surgical bail-out seems to be the favorable treatment option, patients were rejected conventional surgery in first place due to their high operative risk. Best treatment recommendation must be made on an individual basis. Predisposing factors should be conscientiously addressed prior to the procedure.

Infective Endocarditis of the Aortic Valve with Anterior Mitral Valve Leaflet Aneurysm.

Mitral valve leaflet aneurysm is a rare and potentially devastating complication of aortic valve endocarditis. We report the case of a 48-year-old man who had endocarditis of the native aortic valve and a concomitant aneurysm of the anterior mitral valve leaflet. Severe mitral regurgitation occurred after the aneurysm perforated. The patient showed no signs of heart failure and completed a 6-week regimen of antibiotic therapy before undergoing successful aortic and mitral valve replacement. In addition to the patient's case, we review the relevant medical literature.

[Mitral valve repair for mitral regurgitation induced by infective endocarditis complicated with ulcerative colitis; report of a case].

Infective endocarditis is a rare complication of ulcerative colitis. We report on a 22-year-old man, who had been treated of ulcerative colitis for 5 years. He presented with dyspnea on effort. In spite of medical treatment, he developed congestive heart failure. Transthoracic echocardiography showed a large perforation on the anterior leaflet of the mitral valve, and prolapses of the posterior leaflet of the mitral valve with rupture of the chordae. The patient underwent mitral valve repair with an autologous pericardial patch on the anterior leaflet combined with butterfly resection and suture of the posterior leaflet. The postoperative course was uneventful.

Reconstruction of anterior mitral leaflet using autologous pericardial patch combined with posterior leaflet sliding for active infective endocarditis.

We report a case of active infective endocarditis in a young adult, affecting the anterior and posterior leaflets extensively. The patient underwent a mitral valve repair with extended sliding repair on the posterior leaflet and reconstruction using an autologous pericardial patch supported by an artificial chord on the anterior leaflet. Although we finally needed commissure closing for successful repair, we aggressively achieved a repair-oriented strategy using several techniques in a young patient who may have required mitral valve replacement.

Unusual heart transplantation for iterative disinsertion of mitral prosthesis.

Heart transplantation is the gold standard of care for end-stage heart failure, usually associated with an impairment of left ventricular systolic function. We describe a case of heart transplantation in a 58-year-old man with normal left ventricular systolic function, because of recurrent mitral prosthesis disinsertion after multiple reoperations for infective endocarditis.

Eradication of active infective endocarditis with submitral abscess infiltrating to annular calcification.

The case is reported of a 72-year-old man in whom surgery was performed to treat infective endocarditis in association with mitral leaflet vegetation, a submitral abscess that penetrated the pericardial cavity, and posterior mitral annular calcification. Extensive debridement of the posterior left ventricle and atrium, posterior mitral annulus and mitral annular calcification was performed, after which the atrioventricular wall was reconstructed using a theta-shaped patch and a biological mitral valve replaced.

Mitral and aortic valve endocarditis caused by a rare pathogen: Streptococcus constellatus.

Streptococcus constellatus endocarditis is associated with systemic embolism and frequently with a poor prognosis. We describe the first case reported in the literature of infective endocarditis by penicillin-resistant S. constellatus causing both mitral and aortic valve regurgitation, treated successfully with double-valve replacement.

Reconstruction of the free margin of the anterior mitral leaflet with autologous pericardium in active infected endocarditis.

In patients with active infective endocarditis mitral valve repair is better than mitral valve replacement, but it remains a challenge when there has been massive destruction of the rough zone of the anterior leaflet. We report a technical modification of mitral valve repair for advanced active infective endocarditis in which a widely infected rough zone and the chordae were successfully replaced with autologous pericardium and multiple artificial chordae. The procedure described here is capable of improving the prospects of mitral valve repair in advanced infective endocarditis.

Multisystem organ failure due to Gemella morbillorum native valve endocarditis.

Gemella morbillorum is a gram positive cocci, considered normal flora of the upper respiratory tract, gastrointestinal tract, and genitourinary tract in humans. As a pathogen, there are reported cases of infectious endocarditis, bacteremia, sepsis, and abscesses, primarily associated with dental instrumentation, prosthetic heart valves, colon cancer, and endovascular access. We report a case of an 87-year-old Caucasian male with a history of a ruptured chordae of the anterior mitral leaflet, severe mitral regurgitation (MR), and atrial fibrillation who developed multisystem organ failure due to Gemella morbillorum native valve endocarditis without any precipitating factor. He was diagnosed per Duke criteria, treated with intravenous fluids, packed red blood cell transfusion, and broad spectrum antibiotics, with improvement in his clinical course. Our patient survived despite his generalized poor health, where he was eventually discharged to a skilled nursing facility.