Paecilomyces varioti endocarditis on a prosthetic aortic valve

Fungal endocarditis following prosthetic valve surgery has assumed increased importance as a cause of postoperative death. We present, to our knowledge, the first case of the fungus Paecilomyces varioti producing endocarditis on a prosthetic aortic valve. This seems to be an extremely indolent organism which exhibits an apparent response to antibiotic therapyl. In vitro evidence suggests that this fungus is sensitive to attainable serum levels of both 5-fluorocytosine and amphotericin B. However, after viewing the extracted valve and the devastating embolic phenomenon in our patient, we believe that medical therapy alone would not suffice. Thus we suggest that prompt valve replacement be performed in future cases.     

Surgical reintervention in prosthetic valve endocarditis

Early successful conservative treatment and thereafter early surgical intervention on prosthetic-valve-endocarditis may reduced the mortality rate. Therefore, early surgical intervention in native valve endocarditis with perioperative antibiotic treatment in primary valve replacement reduced the incidence of PVE. Soaking of prostheses and suture material with bactericidal antibiotics during the first or second procedures with precise surgical sterility and short perioperative exposure time are successful points which should be taken. Mortality rate decreases from 100 to 60-90% to 10% with combined antibiotic and surgical treatment.     

Perioperative antibiotic prophylaxis and prosthetic valve endocarditis

A study of twenty-five cases of prosthetic valve endocarditis suggests that the antibiotics used for perioperative prophylaxis may alter the type and antibiotic sensitivity of organisms which subsequently infect the artificial valves. Based on the results of this study, the authors have been able to modify their prophylactic regime to encompass these organisms and to predict the antibiotics most likely to be effective in the treatment of prosthetic valve endocarditis in their unit. No single prophylactic or therapeutic regime will be equally effective in all centres, but by examining the different types and sensitivities of bacteria which cause prosthetic valve endocarditis in a locality, antibiotic regimes can be chosen which best suit the local situation.     

Infective endocarditis in Jerusalem. A comparative analysis of native and prosthetic valve endocarditis

Thirty patients with prosthetic valve endocarditis (PVE) and 62 patients with native valve endocarditis (NVE) observed during a concurrent period of time (1970-80) were analyzed. Patients with PVE were also compared with 697 patients who underwent cardiac valve replacement in the same period, in an attempt to uncover risk factors for PVE. In the operated patients the overall incidence of endocarditis was 4.3%. There were several significant differences between the NVE and PVE groups. Atrial fibrillation was more prevalent in the PVE group (33.4 vs. 11.5%, P less than 0.05), while infection with gram-positive organisms was more prevalent in the NVE patients (79 vs. 47%, P less than 0.01). The outcome of combined medical and surgical treatment showed a much higher mortality rate (50 vs. 6.4%, P less than 0.01) in the PVE group. Staphylococcal endocarditis resulted in 16% mortality in NVE vs. 100% in the PVE group (P less than 0.01). Careful surveillance may hopefully lead to early detection, treatment and better outcome of PVE.     

Candida prosthetic valve endocarditis. An autopsy review

Fungal endocarditis after cardiac surgery has been noticed increasingly in the past decade. We report a case of Candida parapsilosis endocarditis after mitral valve replacement in a patient with no predisposing factors. In this report we mainly examined the pathological findings in this patient with post-mortem examination.     

An outbreak of Candida parapsilosis prosthetic valve endocarditis

The histologic features of normal and hyperplastic epithelia of the extra-glandular excretory ducts of human minor salivary glands were studied, and their pathologic significance evaluated. Normal duct epithelium consisted of two layers: inner columnar cells, and basal cubical or squamous cells. A few goblet cells were present among the inner cells. Hyperplasia of the duct epithelia occurred focally or entirely, and was classified into the following histologic types: (1) simple hyperplasia, and (2) metaplastic hyperplasia, which were divided into (a) mucous cell hyperplasia, (b) oncocytic hyperplasia and (c) squamous cell hyperplasia. Squamous cell hyperplasia was subdivided into (i) acanthotic type and (ii) reserve cell-like type with or without dysplasia. Simple or metaplastic epithelial hyperplasia of the extra-glandular excretory ducts of minor salivary glands may be induced by chronic inflammation or other types of irritation, and proliferating cells of such regenerating tissue sometimes exhibit features reminiscent of a neoplastic process. Furthermore, it is suggested that metaplastic epithelial hyperplasia of the excretory minor salivary gland ducts could be the site of origin of tumor development, i.e., some oral squamous cell carcinomas may arise from primary lesions in the hyperplastic epithelium of the extraglandular excretory minor salivary gland ducts.     

Mid-diastolic aortic valve opening in bacterial endocarditis of aortic valve

Echocardiographic features of acute aortic regurgitation resulting from bacterial endocarditis have been well documented (Nathan et al., 1980; Weaver et al., 1977; Wray, 1975a), and include thick shaggy echoes from aortic valve in diastole, fine diastolic flutter of aortic valves suggestive of rupture of cusps, and premature closure of mitral valves. Echocardiography being a sensitive noninvasive technique for detecting aortic valve vegetations is heavily relied on for earlier diagnosis and prompt therapy of these patients. Prognosis of echocardiographically positive endocarditis is known to be worse than for echo-negative patients. The following case is being presented because of an unusual echocardiographic manifestation with mid-diastolic aortic valve opening secondary to flail aortic valve from staphylococcal endocarditis of the aortic valve.     

Enterococcal infective endocarditis on native aortic valve

Enterococcal endocarditis accounts for 10% of all bacterial endocardits. The infection progresses in a subacute way and when localized on the aortic valve it has a very poor prognosis since the valve is usually destroyed being death the fatal outcome. We report a case of a patient with infective endocarditis resulting from the implantion of the Enterococcus on the native aortic valve. Nor visk factors or an apparent main gate could be found. The patient was hospitalized after several months of a non especific febrile syndrome. The literature is reviewed. Diagnostic tests and clinical signs are discussed making emphasis on the refractoriness to chemotherapy.     

Q fever endocarditis and bicuspid aortic valve

Q fever is caused by the rickettsia Coxiella burnetti, an obligate intracellular bacterium acquired by inhalation of infected dust from subclinically infected animals. Q fever may be acute or chronic; the chronic form mostly presents as endocarditis. Immunocompromised states and underlying heart disease are the most important risk factors. Usually the symptoms of Q fever endocarditis are nonspecific and diagnosis is often established very late. New criteria for diagnosis include a single blood culture positive for Coxiella burnetti, positive Q fever serology and characteristic echocardiographic studies. We describe a 49-year-old man with bicuspid aortic valve admitted with fever, weight loss and a new heart murmur. The diagnosis of Q fever endocarditis was established by positive Q fever serology, and an echocardiogram showing vegetations and valvular dysfunction. This case suggests that Q fever endocarditis should be considered in patients with "sterile" endocarditis.     

Strategies for prophylaxis against prosthetic valve endocarditis: a review article

Prosthetic valve endocarditis (PVE) is an important cause of the morbidity and mortality associated with heart valve replacement surgery. Once established, it carries a mortality rate that may be as high as 70%. The only treatment for established PVE is rigorous intravenous antimicrobial therapy, although this has extremely limited success. The majority of cases require surgical removal and replacement of the infected prosthesis. At present, the only means of preventing PVE are scrupulous asepsis and prophylactic perioperative antibiotic therapy. If another strategy could be developed that is effective and safe, the incidence of this disastrous complication of valve replacement would be reduced. Such strategies have been extensively investigated from a variety of different perspectives for several years. The understanding of biofilms appears to be pivotal to the development of a successful approach. The historic background to the prevention of PVE, and the current state of research into this area are discussed.     

Aorto-left ventricular tunnel with origin in the left sinus of Valsalva: a rare cause of congenital aortic insufficiency

The effects of intravenous cisplatin (CDDP) administration on the generation of lymphokine-activated killer (LAK) activity in peripheral blood mononuclear (PBM) cells were investigated in cancer patients. The ability of PBM to generate LAK activity was significantly augmented 3, 5 and 7 days after a single dose, 50 mg m-2, of CDDP injection when compared to that before injection. NK activity of PBM was not altered. The distribution of lymphocyte subsets exhibited no significant change following CDDP injection, except CD2+ cells. However, the ability of monocytes in PBM to produce TNF-alpha was significantly enhanced 5 days after the drug administration, although IL-1-alpha and IL-1-beta production was not augmented.     

Prognostic factors of prosthetic valve endocarditis. Apropos of 122 cases

We examined relationships among the distance walked in 10 minutes (10 MD), pulmonary function, and pulmonary hemodynamics during exercise on a bicycle ergometer, in patients with chronic pulmonary emphysema who had dyspnea of grade III to IV on the Hugh-Jones scale. The 10 MD did not correlate significantly with desaturation during the 10-minute walk, but it did correlate significantly with the percent of predicted maximum voluntary ventilation, and it correlated negatively with airway resistance. These findings indicate that ventilatory impairment is an important factor limiting 10 MD in these patients. Also 10 MD correlated significantly and positively with %DLco; and it correlated negatively with the index of pulmonary vascular resistance and with the ratio of the change in pulmonary arterial pressure to the change in cardiac index during exercise. (delta Ppa/delta CI). These findings indicate that impairment of pulmonary circulation may also limit the 10 MD and exercise tolerance in patients with chronic pulmonary emphysema.     

Escherichia coli endocarditis of a native aortic valve

The spectrum of organisms causing native valve endocarditis is changing. Despite an increasing incidence of infections caused by gram-negative organisms, they remain a rare cause of native valve endocarditis. Escherichia coli is especially uncommon. We describe the case of a 47-year-old man with no previous history of cardiac problems, who presented with culture-positive E coli endocarditis of his native aortic valve. His complicated clinical course necessitated emergent valve replacement, emphasizing the virulence of this organism. The high mortality rate and significant morbidity associated with this entity necessitates aggressive medical management and early surgical intervention.     

A patient with aortic dissection and abdominal aortic aneurysm with fistula

Aneurysm of the abdominal aorta is not uncommon in later life. The frequency of aneurysm rupture varies with aneurysm diameter. In rare cases, the aneurysm may rupture intra-abdominally into surrounding structures and give rise to a fistula. When blood vessels are involved, the commonest form is aortocaval fistula, the presenting symptoms being those of severe right-ventricular heart failure. Although thoracic aorta dissection may be made manifest in acute intense chest pain, it is asymptomatic in up to 50 per cent of cases. The article consists in a case report of asymptomatic thoracic aorta dissection occurring concomitantly with a ruptured abdominal aneurysm the symptoms of which were severe right ventricular heart failure due to an aortocaval fistula causing increased pressure, and severe bilateral oedema of the legs. If the rare complication of an aortocaval fistula could be detected earlier, it might be possible to prevent progression to refractory cardiac failure. The possibility of a fistula should be borne in mind if haematuria is present in a case of abdominal aneurysm or a pulsatile abdominal mass is present in conjunction with a murmur.     

Repair of aortoesophageal fistula after aortic grafting

This report describes repair of an aortoesophageal fistula caused by a previously placed thoracic aortic graft. The diagnosis was made by esophagoscopy. The repair consisted of femoral-to-femoral cardiopulmonary bypass, excision of the old graft, placement of a new graft, esophagectomy, cervical esophagostomy, gastrostomy, and later reconstruction by cervical esophagogastrostomy.