Preperitoneal suprahepatic pacemaker generator placement in the pediatric population

We report a case of partial replacement of the tricuspid valve by a mitral homograft in a young drug addict with right heart endocarditis. Operation was indicated because of sudden severe tricuspid regurgitation and persistence of vegetations despite appropriate antibiotic therapy. Partial tricuspid valve replacement was performed with a segment of mitral homograft reinforced by a semirigid prosthetic ring. At 30-month postoperative follow-up the patient was in excellent clinical condition with a satisfactory echocardiographic result.     

Fine-needle aspiration cytology of the breast: a preliminary report on telepathology through Internet multimedia electronic mail

BACKGROUND AND AIMS OF THE STUDY: Tricuspid valve endocarditis traditionally has been treated with either valve resection or valve replacement. To avoid implantation of foreign material in an infected area and to circumvent anticoagulation, tricuspid valve repair was applied and the results assessed. METHODS: Tricuspid valve repair was performed in five patients with right-sided endocarditis. All patients had tricuspid regurgitation grade 3-4 on preoperative transesophageal echocardiography, and developed progressive deterioration associated with heart failure. The indications for surgery were congestive heart failure, persistent sepsis, recurrent emboli, concomitant left-sided endocarditis, and fungal infection. Surgical procedures included cusp resection, annular plication and annuloplasty, pericardial patch replacement, and construction of artificial chordae. RESULTS: There were no hospital deaths and major associated morbidity. Follow up is complete at a mean of 20.4 months. There were no reoperations or cases of recurrent infections. All patients are in NYHA class I-II. Postoperative echocardiography revealed no signs of major valvular dysfunction. CONCLUSIONS: Valve repair in right-sided endocarditis is a relatively new application for repair techniques, but may become an attractive alternative to tricuspid valve excision or prosthetic valve replacement.     

An intravascular chemoattractant lectin inhibits neutrophil migration

Despite progress in the area of antimicrobial treatment and the surgical use of homografts, prosthetic valve endocarditis (PVE) remains one of the most dangerous complications following heart valve replacement. We present the case of a patient treated for acute endocarditis which affected the mitral valve and who developed recurrent PVE and native aortic valve endocarditis. After multiple valve surgery, the infection was controlled following aortic and mitral valve replacement using silver-coated prostheses. The St. Jude Medical (SJM) mechanical heart valve Masters Series with Silzone coating is intended to protect heart valve patients against microbial infection. The Silzone coating is formed by an ion beam-assisted deposition process that incorporates silver into the sewing cuff of the SJM heart valve. It has also been suggested that silver treatment may improve the healing characteristics of the heart valve sewing cuff. This technology may be a valuable option to prevent or cure PVE, in addition to homografts. Although the present patient is an isolated case, it was encouraging to find not only a well-healed mitral valve silver-coated prosthesis but also no persistent or recurrent infection during a nine-month follow up.     

Prosthetic valve endocarditis leading to valve replacement: a case study

Infective endocarditis (IE) is a pathologic condition of native or prosthetic heart valves or endocardium, which may result in valve destruction and congestive heart failure. It occurs more frequently in men than in women, and there is an increased trend in the elderly. The following conditions predispose patients to IE: congenital and rheumatic heart disease, calcification or stenosis of a valve, prosthetic valve surgery, a previous episode of endocarditis, poor dentition, parenteral drug abuse, and placement of intravascular lines or devices. Effective treatment frequently involves a combination of intense antibiotic therapy and surgical repair. Risk of death from IE is related to age over 60, diagnosis of staphylococcal infection, involvement of an aortic or prosthetic valve, and the presence of any of the following sequelae of endocarditis: congestive heart failure, embolic phenomenon, and neurologic deficit. Clinicians should suspect endocarditis in patients presenting with fever of unknown origin and who are at risk for endocarditis. Timely evaluation with transthoracic or transesophageal echocardiography may identify patients in the early stages of endocarditis and direct the patient to definitive therapy. Early treatment of native and prosthetic valve endocarditis may decrease its overall morbidity and mortality. This case study illustrates some of the challenges in effectively managing prosthetic valve endocarditis.     

Prosthetic valve endocarditis: clinicopathologic analysis of 22 necropsy patients with comparison observations in 74 necropsy patients with active infective endocarditis involving natural left-sided cardiac valves

Clinical and morphologic features are described in 22 necropsy patients with endocarditis involving rigid-framed prosthetic valves: aortic in 15 patients and mitral in 7. The interval from valve replacement to onset of symptoms of prosthetic valve endocarditis was less than 2 months in 8 patients and longer than 2 months in 14 patients. The most frequent infecting organism was the Staphylococcus (13 patients). In each of the 22 patients the infection was located behind the site of attachment of the prosthesis to the valve ring, and the infection spread to adjacent structures in 13 patients, 11 of whom had aortic prostheses. Prosthetic detachment causing severe regurgitation occurred in 12 of the 15 patients with an infected aortic valve prosthesis, and in 2 of the 7 with an infected mitral valve prosthesis. Prosthetic obstruction by vegetative material occurred in 5 of 7 patients with prosthetic mitral infection and in only 1 of 15 with prosthetic aortic infection. High degrees of conduction defects developed in seven patients with aortic prosthetic valve endocarditis: complete heart block in five, and complete left bundle branch block in two. Comparison of observations in the 22 patients with prosthetic valve endocarditis with those in 74 patients with active infective endocarditis involving natural left-sided cardiac valves revealed significant (P less than 0.05) differences in the percent with ring abscess, hemodynamic consequences of the endocarditis (valve stenosis), frequency of Staphylococcus as the causative organism and percent with complete heart block or left bundle branch block. No significant differences were observed between the two groups when comparing age, sex, type of underlying valve disease or frequency of organ infarcts of splenomegaly.     

Bartonella endocarditis on native valves. Apropos of 2 cases

The authors report two cases of Bartonella endocarditis in native valves. The first case was a 15 year old North African Girl who lived in poor social conditions and was admitted to hospital with pyrexia and congestive heart failure. Investigations revealed massive mitral regurgitation due to ruptured chordae tendinae, vegetations on the pulmonary valve with severe pulmonary hypertension due to persistent ductus arteriosus. After antibiotic therapy, the patient underwent surgery for mitral valve replacement, pulmonary valvuloplasty and closure of the patent ductus arteriosus. The second case was a 39 year old man with no fixed abode with a history of alcoholism who presented with a recurrent ischaemic stroke in a context of infection with a murmur of aortic regurgitation. Echocardiography showed a vegetation on the aortic valve with grade III/IV regurgitation requiring aortic valve replacement with a homograft after antibiotic therapy. The aetiological diagnosis was made a posteriori by the finding of high antibody titres and specific genetic amplification of Bartonella. In patients with negative blood cultures, Bartonella infection should be looked for systematically especially in those living under poor social conditions. The practical diagnostic investigation of endocarditis with negative blood cultures is reviewed.     

Homograft replacement of fungal endocarditic pulmonary valve

Right-sided infective endocarditis is uncommon but is increasingly seen as a reflection of the prevalence of drug abuse, chronic intravenous catheters and associated congenital malformations. Isolated pulmonary valve endocarditis has rarely been reported and there has been only one previous report of isolated pulmonary valve fungal endocarditis. This resolved with antimicrobials. We describe a case of isolated mycotic pulmonary valve endocarditis resistant to existing anti-fungal chemotherapy, which necessitated pulmonary valve resection and replacement with a homograft.     

T.D.F. (time-dose-fractioned irradiation) and tolerance to low flow and low fractioned irradiation (author''s transl)

A surgically treated material comprising 18 patinets with heart failure from aortic insufficiency during acute endocarditis has been reviewed. At the time of operation the mean duration of heart failure was 3 weeks and duration of endocarditis 9 weeks. Blood culture was positive in half of the patients, 39% had predisposing valve disease, 14 (78%) had a preoperative heart catheterization. The peroperatively measured regurgitation averaged 55%. All 18 patients had an artifical valve implanted, and the mean observation time for 13 long-term survivors was 3 1/3 years. There were 3 postoperative and 2 late deaths. A long-term survival rate of 73% strongly supports early surgical treatment in patients with aortic insufficiency and heart failure during acute endocarditis.     

Infectious endocarditis, risk factors, prevention. Research group for infectious endocarditis and jury of the consensus conference

Infective endocarditis, resulting from deposition of circulating microorganisms during a period of bacteremia on damaged endothelial heart valves, remains a serious disease. Its overall incidence did not decline in recent years, 24 cases/year/million inhabitants, in France. This can be explained by a modification of the type of underlying cardiac conditions with regression of rheumatic fever and increase of degenerative heart diseases, prosthetic valves and mitral valve prolapse. The risk of bacterial seeding on a damaged valve remains difficult to evaluate, the highest risk being for patients with prosthetic valve, previous infective endocarditis and cyanotic congenital heart disease. A case-control study, done in 1991, confirmed that procedures are risk factors for infective endocarditis and that the multiplicity of procedures increases the risk. A French consensus conference on the prophylaxis of infective endocarditis has updated the recommendations for antibiotic prophylaxis. Two groups of cardiac patients were identified, based on the incidence and the severity of endocarditis occurring in patients with these conditions, 1) patients considered at risk which require specific prophylaxis, and 2) patients considered non at risk which do not require antibiotic prophylaxis. Procedures which require antibiotic prophylaxis are dental procedures and specific gastrointestinal and urologic procedures. As complex protocols are associated with poor compliance by practitioners and patients, the jury has aimed for simplicity and feasibility.     

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.     

A review of infectious endocarditis due to Candida

OBJECTIVE: As fungal endocarditis is a serious disease, frequently requiring cardiac surgery, a review was made of the experience of our Departments in this pathology. DESIGN: A retrospective analysis of clinical, echocardiographic and surgical data. SETTING: Patients studied in a tertiary care Hospital with cardiac surgery available. PATIENTS: Between 1984 and 1994 there were ten cases of candida endocarditis in nine patients, four male and five female, mean age--45 +/- 12 years (31-65). INTERVENTIONS: The following parameters were analysed: clinical (predisposing factors, clinical evolution, complications, therapy and mortality), echocardiographic (presence of vegetations, abscesses, valvular regurgitations). Patients studied in other Centres and referred to our Department only for examination (echocardiograms) were excluded from this analysis. RESULTS: Eight cases in seven patients were prosthetic valve endocarditis and two native valve endocarditis. No patient was drug addicted. Seven cases of prosthetic valve endocarditis developed less than one year after surgery and another had a gynecological fungal infection as the cause of the endocarditis. Four patients had had previous endocarditis. There were four embolic events and three developed heart failure. There were three perivalvular infections, six valvular regurgitations and only one case with huge vegetations on echocardiography. Nine patients were treated with amphotericin B, in five fluocytosin was added and in four ketoconazol, which was replaced by flukonazol in one patient. Therapy was continued for at least eight weeks. Six patients were operated during the acute stage and one died. One patient was operated on late after the infection. Three patients died during the active stage. In a follow up of 5.2 +/- 4.8 years (8 months to 8 years) there was one fatal candida endocarditis relapse, one fatal candida sepsis, one non cardiac death, one patient developed a periprosthetic leak and one had recurrent systemic embolization. Abscesses/pseudoaneurysms were found in five out of seven patients submitted to surgery. CONCLUSION: Candida infective endocarditis has a bad prognosis, specially in those patients not operated early; it develops in patients with predisposing factors, which in our series were a previous infective endocarditis (four patients) and/or a prosthetic valve implantation less than one year before; it has important morbidity with multiple embolic events, perivalvular involvement, valvular regurgitation and heart failure.     

Can patient retention of rectal barium be guaranteed?

Homograft replacement of the aortic valve in cases of acute bacterial endocarditis is considered the ideal choice because of the resistance of the homograft to reinfection. We report a case of aortic and mitral valve bacterial endocarditis, secondary to Streptococcus viridans, with severe aortic and mitral valve regurgitation and hemodynamic instability requiring surgical interventions with the use of aortic and mitral valve homografts.     

Successful surgical treatment for fungal endocarditis involving the aortic valve: report of a case

A 50-year-old man who had undergone successful aortic valve replacement for fungal endocarditis was presented. He had been doing well until October 1993, when he suddenly developed shock with high fever. In two weeks he recovered from septic shock with vigorous medical treatment including intravenous administration of antibiotics. The infecting organism was not detected on repeated blood cultures. Four months later he was admitted to our hospital because of left heart failure. Although he was afebrile on admission, a two dimensional echocardiogram revealed vegetation on the aortic valve and massive aortic regurgitation. Inflammatory signs persisted and the vegetation increased in size, and therefore an aortic valve replacement was performed. A surgical specimen of the aortic valve revealed perforation in each of three cusps and vegetation on the non-coronary cusp. Pathological exploration revealed typical colonies of fungi. Following the diagnosis of fungal endocarditis, administration of an anti-fungal drug was started. His post-operative course was uneventful, and there was no evidence of recurrence with the anti-fungal medication for one year postoperatively.     

Polypoid ulcerating endocarditis aortalis caused by Streptococcus viridans with perforation of the right atrium. Pathology and clinical aspects of 2 autopsy cases

We report two cases of patients (one 65 and one 43 years of age, respectively) who died of Streptococcus-viridans induced endocarditis of the aortic valve with perforation into the right atrium. Whereas perforation in Staphylococcus-induced endocarditis is a common complication, it occurs rarely in Streptococcus-induced endocarditis. Because of its uncharacteristic symptoms, the endocarditis was clinically unknown in both cases and was recognized to be the cause of death only at autopsy. To reduce the large number of complications in patients suffering from endocarditis, it is necessary to confirm the diagnosis as soon as possible if endocarditis might be suspected.     

A successful repair of infective endocarditis accompanied by a pseudoaneurysm of the left ventricle

The present paper reports a successful surgical treatment of a 47-year-old male with a pseudoaneurysm of the left ventricle. The patient has also been administered Penicillin G for 5 months to treat endocarditis. Cardiac catheterization showed severe aortic stenosis and a pseudoaneurysm of the left ventricle which was dilating in systole. The patient underwent patch closure of the pseudoaneurysm whose ostium was situated at the miral-aortic inter valvular fibrosa followed by aortic valve replacement and direct closure of a right Valsalva sinus aneurysm. His postoperative course was uneventful. The patient had no recurrence of endocarditis nor malfunction of the prosthetic valve for one year postsurgery. This is the first report in Japan of successful surgical treatment of a pseudoaneurysm of the left ventricle due to perforation of the miral-aortic intervalvular fibrosa after endocarditis.     

Coxiella burnetti infectious endocarditis. Apropos of a case

Chronic forms of Q fever (endocarditis) are rare, but are responsible for severe and desperately recurrent infections, resulting in multiple valve replacements with a reserved prognosis. The authors report the case of a 35-year-old patient with a known history of rheumatic fever, who developed blood culture negative infectious endocarditis on a mitral bioprosthesis. The diagnosis of Q fever was based on serological arguments. Despite long-term antibiotic therapy, serology remained strongly positive and was associated with repeated mitral valve disinsertion. The patient died immediately after the fourth operation in a context of haemodynamic failure. This clinical case emphasizes the importance of performing Q fever serology in any case of culture negative endocarditis and the therapeutic difficulties encountered in chronic recurrent endocarditis.     

Molecular genetics of small bowel cancer

Streptococcus adjacens has never previously been reported as an etiologic organism of infective endocarditis in Taiwan. We describe a case of severe native valve endocarditis caused by S. adjacens, involving the mitral valve, the aortic valve, and the left atrium, in a 29-year-old woman with nephrotic syndrome on steroid therapy. Blood cultures yielded gram-positive cocci that grew poorly on blood agar but strongly on chocolate agar. Despite aggressive antibiotic treatment, the patients continued to have high fever and progressive congestive heart failure, which necessitated surgical intervention. Symptoms were alleviated after surgery; teicoplanin was continued for 4 weeks and the patient remained symptom-free at the 6 month follow up. To our knowledge, this is the first reported case of bacterial endocarditis involving the left atrium without preexisting myxoma.     

A case report of infective endocarditis with total rupture of the posterior papillary muscle after aortic valve replacement

We reported a case with severe mitral regurgitation caused by total rupture of the posterior papillary muscle two days after aortic valve replacement. A 62-year-old man was transferred to our hospital with high fever and dyspnea with severe aortic regurgitation caused by infective endocarditis. The left heart failure occurred suddenly two days after the initial operation. Echocardiogram revealed massive mitral regurgitation and rupture of the posterior papillary muscle. He underwent emergent mitral valve replacement. Histological examination of the papillary muscle showed typical ischemic necrosis without inflammation. The postoperative course was uneventful. We suggested the papillary muscle rupture in this case may be due to coronary artery emboli occurred in association with infective endocarditis.     

Propionibacterium acnes infectious endocarditis

BACKGROUND: Propionibacterium acnes, a Gram positive microaerophilic bacteria is considered to have a low level of virulence. Nevertheless, it can be associated with infective endocarditis. We report 2 cases and a review of the literature. CASE REPORTS: The first man developed an acute prosthetic valve infective endocarditis and died. The second case was also a prosthetic valve infective endocarditis in a patient who developed infectious spondylitis. DISCUSSION: P. acnes is an uncommon causal agent in infective endocarditis and appears to have a predilectio for prosthetic valves. A prior history of skin infection is rare. P. acnes grow quite slowly, often requiring 7 to 14 days for identification. All isolates of P. acnes from blood or valve do not necessarily mean contamination.     

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This paper includes a report on a case of prosthetic valve endocarditis due to Micrococcus luteus and a review of the sixteen cases of endocarditis due to Micrococcus species reported in the literature. The patient was successfully treated with rifampicin combined for two weeks with gentamicin and vancomycin and for another four weeks with teicoplanin. The hospital course was uneventful and no surgery was required.