Assessment of endocarditis and associated complications with transesophageal echocardiography

Intracardiac Fistulae: A Rare Complication of Infective Endocarditis

We present the case of a diabetic gentleman who was admitted to the hospital with an infected right foot. Swabs were positive for <i>Staphylococcus aureus</i> and <i>Pseudomonas aeruginosa.</i> His right big toe was amputated. Postoperatively, the patient experienced recurrent episodes of chest pain. He was therefore transferred to the coronary care unit, where he deteriorated rapidly. The patient was subsequently transferred to intensive care. Transthoracic and transesophageal echocardiograms revealed evidence of aortic dissection, but this finding was not confirmed in a computed tomography scan. The patient subsequently experienced cardiac arrest and died. The postmortem examination revealed no aortic dissection but did show a vegetation on the mitral valve with a fistula that tracked into a ruptured epicardium.

Role of echocardiogram in decision making for surgery in endocarditis

Infective endocarditis is a serious disease that carries significant morbidity and mortality. Adequate treatment is based on a high degree of clinical suspicion, accurate microbiologic diagnosis, and high-quality imaging. Echocardiography has been shown to be a fundamental tool for diagnosis and management. Currently accepted Duke criteria include blood cultures and echocardiography. Transthoracic and transesophageal echocardiography play a critical role in the decision-making process, especially when surgical treatment is contemplated. Because infective endocarditis is considered a medical and surgical disease, and considering that the current rate of surgery is about 50%, echocardiography has definite value in preoperative diagnosis and surgical planning, intraoperative confirmation of lesions and quality of repair or replacement before and after cardiopulmonary bypass, and postoperative assessment.

Clinical and echocardiographic features of aorto-atrial fistulas

Aorto-atrial fistulas (AAF) are rare but important pathophysiologic conditions of the aorta and have varied presentations such as acute pulmonary edema, chronic heart failure and incidental detection of the fistula. A variety of mechanisms such as aortic dissection, endocarditis with pseudoaneurysm formation, post surgical scenarios or trauma may precipitate the fistula formation. With increasing survival of patients, particularly following complex aortic reconstructive surgeries and redo valve surgeries, recognition of this complication, its clinical features and echocardiographic diagnosis is important. Since physical exam in this condition may be misleading, echocardiography serves as the cornerstone for diagnosis. The case below illustrates aorto-left atrial fistula formation following redo aortic valve surgery with slowly progressive symptoms of heart failure. A brief review of the existing literature of this entity is presented including emphasis on echocardiographic diagnosis and treatment.

Compiling the identifying features of bacterial endocarditis. Vague clues may point to this dangerous infection

Bacterial endocarditis is a life-threatening disease. Before the advent of antibiotics, its mortality rate was nearly 100%, but with today's diagnostic and therapeutic advances, it can be successfully managed in most cases. In this article, Drs Harris and Steimle explain the changes that occur when someone, who usually has an underlying cardiac defect, contracts bacteremia with an organism likely to adhere to heart valve surfaces. They describe risk factors, clinical presentations, identification of causative organisms, and empirical and specific therapy. A case report illustrates the many possible manifestations of the disease.

[Left atrial dissection and infective endocarditis]

A rare case of left atrial dissection as a consequence of infectious endocarditis is reported. We present a patient with infectious endocarditis with involvement of mitral and aortic valves; in whom the trans-esophageal echocardiography was able to visualise the left atrial dissection. This complication has been reported after surgical repair of the mitral valve, but never in infectious endocarditis.