Surgical Treatment of Infective Endocarditis in Pulmonary Position-15 Years Single Centre Experience

Isolated pulmonary valve endocarditis in a pediatric patient with down syndrome

BACKGROUND

Isolated pulmonary valve endocarditis (IPE) accounts for less than 2% of all infective endocarditis patients. It is commonly associated with several predisposing factors, including intravenous drug use (IVDU) and congenital heart disease. The most common causative pathogens of IPE are Staphylococcus aureus and Streptococcus viridans. We report a Down's syndrome patient with IPE and with no standard risk factors caused by the rare pathogen Acinetobacter spp. This led to respiratory failure and systemic infection due to septic pulmonary emboli. Early elective surgery was decided upon as the patient was no longer responding to medical therapy, and his clinical condition was worsening over time.

CASE PRESENTATION

A 15-year-old male with Down syndrome and no underlying heart defect presented with a 3-month history of episodic fever, nausea, vomiting, and diarrhea. Transthoracic echocardiography (TTE) revealed large vegetation on the pulmonary valve leaflet, another mobile mass at the pulmonary artery bifurcation, and severe pulmonary regurgitation. Serial blood cultures isolated Acinetobacter spp. Despite initial antibiotic therapy, the patient continued to have sepsis, unresolved vegetations, and developed life-threatening complications and respiratory distress, which convinced us to perform a pulmonary valve replacement surgery with a homograft. After surgery, the patient recovered and was discharged on the ninth postoperative day (POD).

CONCLUSION

This report highlights IPE's diagnostic and therapeutic challenges, alongside the importance of a comprehensive cardiopulmonary workup in patients with unexplained fever, sepsis, and pulmonary symptoms, even without typical risk factors. Based on the patient's aggravating condition despite medical treatment, early surgical intervention and pulmonary valve replacement were deemed crucial. However, there still needs to be a definitive guideline on when and how surgery should be performed in patients with complicated IPE, especially in pediatric patients.

The infected right ventricular outflow tract in children and adults with congenital heart disease

Abnormalities of the right ventricular outflow tract are common within the spectrum of congenital heart disease. Reconstruction of this outflow with or without the use of prosthetic material forms an integral part of many surgical procedures. Consequently, this part of the heart constitutes an important locus for infective endocarditis. Focused literature on infective endocarditis of the right ventricular outflow is sparse. This narrative review therefore attempts to collate the currently available data on a subject that is gaining importance because of the increasing numbers of surgical and catheter-based interventions on the right ventricular outflow.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-024-01748-z.

Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies

Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50-59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts' consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management.

Pneumonia, Arthritis, and Liver Injury: A Cardiac Diagnostic Conundrum

A 40-year-old intravenous cocaine user presented with non-specific symptoms, including fever, headache, myalgias, and fatigue. After being provisionally diagnosed with rhinosinusitis and discharged on antibiotics, the patient returned with shortness of breath, dry cough, and persistent high-grade fevers. Initial workup showed multifocal pneumonia, acute liver injury, and septic arthritis. Blood cultures were positive for methicillin-sensitive staphylococcus aureus (MSSA) which led to the evaluation of endocarditis with a transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). TEE was performed as the initial diagnostic imaging test, and it did not show any evidence of valvular vegetation. However, given the persistence of the patient's symptoms and clinical suspicion of infective endocarditis, TTE was performed which showed a 3.2 cm vegetation on the pulmonic valve with severe insufficiency, leading to a diagnosis of pulmonic valve endocarditis. The patient was treated with antibiotics and underwent a pulmonic valve replacement surgery, which showed a large vegetation on the ventricle portion of the pulmonic valve that was replaced with an interspersed tissue valve. The patient was discharged in stable condition after improvement of symptoms and normalization of liver function enzymes. It is important to note that TTE should be considered initially as a diagnostic tool in such cases. Sometimes, a TEE may not be required if the TTE provides a sufficient assessment.

Surgical outcomes of pulmonary valve infective endocarditis: A US population-based analysis

BACKGROUND

Pulmonary valve infective endocarditis (PVIE) represents a rare subset of right-sided IE. This study aimed to evaluate the population-level surgical outcomes of PVIE in the United States.

METHODS

We performed a retrospective observational study using the 2002-2017 National Inpatient Sample database. We included hospitalizations with both IE and PV interventions. We excluded Tetralogy of Fallot, congenital PV malformation, and those who underwent the Ross procedure. The primary outcome was in-hospital mortality. The secondary outcomes included major complications and length of hospital stay.

RESULTS

We identified 677 PVIE hospitalizations that underwent surgical treatment, accounting for 0.06% of all IE hospitalizations. The mean age was 35.2 ± 1.7 years; 60.0% were White, 30.3% were women, and 11.4% were intravenous drug users. Most were treated in large-sized (70.1%) urban teaching (88.8%) hospitals. Close to 30% of patients received at least one concomitant valve procedure. The in-hospital mortality was 5.5% for the entire cohort, and the median length of stay was 16 days. Major complications included complete heart block (8.7%), acute kidney injury (8.1%), and stroke (1.3%). The differences in mortality and complications rate comparing PV repair and replacement were not statistically significant. PV repair was associated with a longer length of hospital stay compared to PV replacement (median: 25 vs. 16 days, p = 0.03).

CONCLUSIONS

This study defines the population-level in-hospital outcomes after surgical intervention of PVIE. Surgically treated PVIE patients are associated with relatively low mortality and morbidities. The outcomes between PV replacement and repair are similar.

Pulmonary valve perforation with multiple cardiac anomalies: a case report

Background

Large pulmonary valve perforation, which is rarely seen with infective endocarditis, general atrophy, or congenital fenestration, often leads to potentially fatal outcomes, including heart failure.

Case presentation

Transthoracic and transesophageal echocardiographic evaluation of a 69-year-old woman revealed a severely eccentric pulmonary regurgitation with concomitant pulmonary valve stenosis, patent ductus arteriosus, patent foramen ovale, and pulmonary artery aneurysm. In the operation, a large perforation was found in the pulmonary valve leaflet. She underwent complicated surgery that involved closure of the congenital heart defects and replacement of a pulmonary valve with successful results. But the cause of her pulmonary valve perforation remained undetermined.

Conclusion

This case highlights two important points: the need for timely management of congenital heart disease and being aware of the possibility of pulmonary valve perforation, which in this case was indicated by an eccentric pulmonary regurgitant jet seen on echocardiography.

Unexpected isolated native pulmonary valve endocarditis; really benign as thought?

BACKGROUND

Isolated pulmonary valve endocarditis is extremely rare, accounting for <2% of cases. Major predisposing factors are intravenous drug use, implanted cardiac devices, congenital heart diseases, and central venous catheters. Most patients respond well to appropriate antibiotherapy.

AIM

We report a case with an isolated native pulmonary valve endocarditis due to methicillin-resistant staphylococcus-aureus infection which developed after a tooth abscess in a previously healthy non-drug user young male. After one week antibiotherapy, surgery was required due to acute severe pulmonary insufficiency and right heart-failure. After the operation, he had a multi-organ failure despite veno-arterial extracorporeal membrane oxygenation, antibiotherapy, and other supportive treatments, therefore the case concluded with mortality.

DISCUSION AND CONCLUSION

Our case showed that pulmonary valve endocarditis may occur in patients without risk factors in case of portal of entry for bacteremia and it may carry worse prognosis than previously known. Virulence of the microorganism and vegetation size are the major predictors of prognosis. Pulmonary valve endocarditis should be kept in mind even in patients without any known risk factors.

Outcomes of surgically treated infective endocarditis in a Western Australian population

Background

Infective endocarditis is a disease that carries high morbidity and mortality. The primary endpoint of this study is to assess factors associated with in-hospital mortality in patients undergoing valvular surgery for infective endocarditis. The secondary endpoint of this study is to assess the incidence of post-operative stroke, renal failure, complete heart block and recurrence.

Methods

Between the years of 2015 to 2019, a total of 89 patients underwent surgery for infective endocarditis at Fiona Stanley Hospital, Western Australia. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2019 as well as patients electronic medical record. A number of preoperative and perioperative factors were assessed in relation to patient mortality and morbidity. Univariate and multivariate logistical regression analysis was done to assess for the association between factors and in-hospital morbidity and mortality.

Results

A total of 89 patients underwent surgery for infective endocarditis from 2015 to 2019, affecting a total of 101 valves. The mean age of patients was 53.7 ± 16.5. A total of 79 patients had a positive blood culture pre-operatively, with Staphylococcus Aureus being the most frequently cultured organism (39%). Fourteen patients (16%) were deemed emergent and underwent surgery within 24 h of review. A total of five patients died within their hospital stay postoperatively. Variables significantly associated with mortality on univariate analysis were intravenous drug use, emergent surgery, perioperative dialysis, perioperative inotropes, cardiopulmonary bypass time and cross clamp time. Only CBP time was significantly associated with mortality on multivariate analysis. A total of 19 patients (21%) required hemodialysis after surgery, 10 patients sustained a postoperative stroke (11%), 11 patients developed a complete heart block post operatively (12%) and endocarditis recurred in 10 patients (11%).

Conclusion

Prolonged cardiopulmonary bypass times were significantly associated with mortality. This study is novel to report a lower mortality rate than previously quoted in the literature. We also report our findings of organisms, preoperative embolic phenomena and surgery in a Western Australian population. We recommend that all patients with endocarditis are discussed in multidisciplinary forum.

Pulmonary valve reconstruction using Ozaki's technique for infective endocarditis

Simultaneous pulmonary and aortic endocarditis is extremely rare, and there is no consensus on its surgical management. Here, we report a case of infective endocarditis of pulmonary and aortic valves complicated by severe pulmonary regurgitation due to complete damage of valve cusps. We performed pulmonary valve reconstruction using autologous pericardium using Ozaki's technique, with excellent outcomes.

Infective Endocarditis in Childhood: a Single-Center Experience of 18 Years

Introduction

We aimed to present the risk factors, clinical and laboratory findings, treatment management, and risk factors for morbidity and mortality of infective endocarditis (IE) as well as to relate experiences at our center.

Method

We retrospectively analyzed data of 47 episodes in 45 patients diagnosed with definite/possible IE according to the modified Duke criteria between May 2000 and March 2018.

Results

The mean age of all patients at the time of diagnosis was 7.6±4.7 years (range: 2.4 months to 16 years). The most common symptoms and findings were fever (89.3%), leukocytosis (80.8%), splenomegaly (70.2%), and a new heart murmur or changing of pre-existing murmur (68%). Streptococcus viridans (19.1%), Staphylococcus aureus (14.8%), and coagulase-negative Staphylococci (10.6%) were the most commonly isolated agents. IE-related complications developed in 27.6% of the patients and the mortality rate was 14.8%.

Conclusion

We found that congenital heart disease remains a significant risk factor for IE. The highest risk groups included operated patients who had conduits in the pulmonary position and unoperated patients with a large ventricular septal defect. Surgical intervention was required in most of the patients. Mortality rate was high, especially in patients infected with S. aureus, although the time between the onset of the first symptom and diagnosis was short. Patients with fever and a high risk of IE should be carefully examined for IE, and evaluation in favor of IE until proven otherwise will be more accurate. In high-risk patients with prolonged fever, IE should be considered in the differential diagnosis.

Isolated pulmonary valve endocarditis with rapid progression: a case report and literature review

BACKGROUND

Isolated pulmonary valve endocarditis (IPE) is rare, accounting for 1.5-2% of all cases of infective endocarditis. Herein, we describe a case of isolated pulmonary valve endocarditis with rapid progression in a 28-year-old male. Unlike most patients reported previously who were cured with only anti-infective therapy, without surgery at an early stage, multiple complications occurred in this patient in less than 2 weeks.

CASE PRESENTATION

The patient was diagnosed with pulmonary valve endocarditis with blood cultures showing Staphylococcus aureus and echocardiography revealing 2 masses (measuring 14*13 mm、11*16 mm in size). Only 12 days later, acute massive pulmonary embolism occurred. Then, repeated echocardiography revealed multiple masses attached to the pulmonary valve with severe pulmonary insufficiency and the possibility of pulmonary valve destruction. Finally, pulmonary valve replacement, vegetation removal, and right pulmonary thromboendarterectomy together with resection of the middle and lower lobes of the right lung were performed.

CONCLUSIONS

The role of surgery at an early stage might need to be reconsidered, and it may be viable to combine medical and surgical approaches.