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.

Aortic Root Replacement for Destructive Endocarditis - Clinic and Microbiology

Abstract Introduction: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. Methods: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. Conclusion: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

Gender Based Analysis of a Population Series of Patients Hospitalized with Infective Endocarditis in Portugal - How do Women and Men Compare?

Abstract Background: The impact of gender on the outcome of patients hospitalized with infective endocarditis (IE) is not fully understood. Objective: To verify the association between gender and the clinical profile of patients hospitalized with IE, treatment strategies, and clinical outcomes. Methods: This is a retrospective nationwide study of patients hospitalized with IE, based on hospital admissions between 2010 and 2018 in Portugal. Descriptive statistics were used to present variables. An inferential analysis was performed using multiple logistic regression. A 95% confidence interval and a 5% significance level were considered. Results: In total, 3266 (43.1%) women and 4308 (56.9%) men were hospitalized with IE. The women were older (76 vs 69 years old, p<0.001), more frequently presented arterial hypertension (39.8% vs 35.4%, p<0.001) and atrial fibrillation (29.5% vs 21.2%, p<0.001), and had less cardiovascular comorbidities. Acute heart failure was more common in women (32.9 vs 26.9%, p<0.001) and acute renal failure (13.6% vs 11.7%, p<0.001) and sepsis (12.1% vs 9.1%, p<0.001), in men. Women were less likely to undergo cardiac surgery (OR 0.48 - 95%CI 0.40-0.57, p<0.001) and had a higher postoperative mortality (OR 1.84, 95% CI 1.19-2.84, p=0.006). In-hospital mortality rates were comparable between genders (20.3% vs 19.6%, p=0.45). Conclusions: Women were less likely to undergo cardiac surgery when hospitalized with IE, and the female gender was a predictor factor for postoperative mortality. Overall, in-hospital mortality was not influenced by gender. Further research is necessary to fully clarify the impact of gender on IE management and outcomes.

Tratamiento quirúrgico de la endocarditis infecciosa activa / Active infective endocarditis: surgical treatment

Resumen: La endocarditis infecciosa, la infección cardiovascular en general, es una enfermedad médico-quirúrgica compleja que requiere un tratamiento multidisciplinario precoz, específico y agresivo. A pesar de los avances médicos, ésta sigue siendo una enfermedad con una morbi-mortalidad elevada, por lo que el tratamiento antibiótico se complementa en un 40-50% de los pacientes mediante intervención quirúrgica. Por lo tanto, es necesario conocer las opciones que pueden llegar a ser utilizadas para extirpar el tejido infectado. El objetivo de este trabajo es discutir aspectos de interés en la cirugía de la endocarditis infecciosa.

Abstract: Infective endocarditis (IE) is a complex disease that requires a multidisciplinary approach and early and aggressive treatment. Despite médical and surgical advances, this disease still has high morbidity and mortality. The antibiotic treatment is complemented in 40-50% of the cases with surgical intervention. Thus, it is useful to be aware of the possibilities that might be contemplated in order to excise the infected tissues. The aim of this work is to discuss current surgical aspects of interest in the surgery IE.

Tricuspid valve repair with autologous pericardium in a patient with infective endocarditis

Abstract Infective endocarditis is a rather uncommon disease, but it has significant mortality rates in the pediatric population (5% to 10%). We report a case of an infant patient with multiple vegetation in the tricuspid valve secondary to infective endocarditis caused by Corynebacterium diphtheriae. A tricuspid valvuloplasty was performed with a fenestrated autologous pericardium patch, providing satisfactory outcomes. This technique is simple, innovative, effective, and it could be applied in similar cases.

Kissing lesion of mitral valve - a case report

Abstract Aortic valve endocarditis can lead to secondary involvement of aorto-mitral curtain and the adjacent anterior mitral leaflet (AML). The secondary damage to AML is often caused by the infected jet of aortic regurgitation hitting the ventricular surface of the mitral leaflet, or by the pronounced bacterial vegetation that prolapses from the aortic valve into the left ventricular outflow tract. This is called 'kissing lesion'. We describe a patient with infective endocarditis of the aortic valve causing perforation of both noncoronary cusp of aortic valve and the AML, which is rare.

Stentless root replacement versus tissue valves in infective endocarditis - a propensity-score matched study

Abstract Introduction: People with aortic/prosthetic valve endocarditis are a high-risk cohort of patients who present a challenge for all medically involved disciplines and who can be treated by various surgical techniques. Methods: We analyzed the results of treatment of root endocarditis with Medtronic Freestyle® in full-root technique over 19 years (1999-2018) and compared them against treatment with other tissue valves. Comparison was made with propensity score matching, using the nearest neighbor method. Various tests were performed as suited for adequate analyses. Results: Fifty-four patients in the Medtronic Freestyle group (FS group) were matched against 54 complex root endocarditis patients treated with other tissue valves (Tissue group). Hospital mortality was 9/54 (16.7%) in the FS group vs. 14/54 (25.6%) in the Tissue group (P=0.24). Cox regression performed for early results demonstrated coronary heart disease (P=0.004, odds ratio 2.3), among others, influencing early mortality. Recurrent infection was low (1.8% for FS and Tissue patients) and freedom from reoperation was 97.2% at a total of 367 patient-years of follow-up (median of 2.7 years). Conclusion: The stentless xenograft is a viable alternative for treatment of valve/root/prosthetic endocarditis, demonstrating a low rate of reinfection. The design of the bioroot allows for complex reconstructive procedures at the outflow tract and the annular level with at an acceptable operative risk. Endocarditis patients can be treated excluding infective tissue from the bloodstream, possibly with benefits, concerning bacteremia and recurrent infection. Furthermore, the use of the stentless bioroot offers varying treatment options in case of future valve degeneration.

Sobrevida a 10 años de pacientes egresados luego de cirugía por endocarditis infecciosa en un hospital público / Hospital mortality and long-term survival of 103 patients with infective endocarditis requiring surgery

Background Infective endocarditis (IE) is a serious disease with high mortality, especially among the most severe cases undergoing surgery. Aim To analyze the clinical features, perioperative mortality and long-term survival of patients with infective endocarditis requiring surgery. Material and Methods Review of medical records of patients who underwent heart valve surgery for active infective endocarditis in a public hospital between 1995 and 2008. Demographic characteristics and comorbidities were described. Perioperative and 10 year survival were analyzed retrieving death certificates from the Chilean Identification Service. Results Data from 103 patients aged 46 ± 14 years (74% males) was analyzed. Thirty five percent of patients had an underlying predisposing heart condition such as congenital heart disease in 18.5% and prosthetic valves in 10%. The most common location was the aortic valve and the most common surgical procedure was heart valve replacement with a mechanical prosthetic valve in 87% of the cases. Pathogen identification in blood cultures was achieved in 48% of the cases. The most common causative microorganisms were S. aureus in 12%, coagulase-negative Staphylococcus in 11%, S. viridans in 10% and Enterococcus in 7%. Hospital mortality was 20.4% and ten-year survival was 65%. Conclusions Patients with severe IE requiring surgical treatment still have high perioperative and late mortality.

Endocarditis infecciosa en válvula tricúspide: Presentación clínica y evolución en paciente sin factores de riesgo clásicos. Endocarditis infecciosa tricuspídea: a propósito de un caso / Infective endocarditis in the tricuspid valve: Clinical presentation and evolution in patient without classic risk factors. Tricuspid infectious endocarditis: a case report

Infective endocarditis (IE) correspond to a serious condition of the endocardium, with clinical and classic risk factors. Heart failure is described as the main complication and cause of mortality. A 58-year-old diabetic female patient, with fever, weight loss and history of 10 months of fatigue, is presented below. She is hospitalized in Hospital Regional de Talca, in Medicine Service, where she is diagnosed of right IE by blood cultures (Streptococcus Sanguis) and transthoracic echocardiogram, that showed vegetations in the tricuspid valve and severe insufficiency. Without clinical improvement despite antibiotic treatment, echocardiography is repeated, showing persistence of vegetations and insufficiency, so that surgical resolution is decided, taking place in Hospital Gustavo Grant Benavente Concepción, with clinical recovery after surgery. It highlights a classic and larval presentation of the disease, but without classic risk factors for right IE, also associated with glomerulonephritis. The antibiotic eliminated bacteremia, but the valve damage was already established.

Replacement of the native mitral valve due to endocarditis caused by stenotrophomonas maltophilia

Abstract We report a case of a 59-year-old female patient with vegetative native mitral valve endocarditis caused by Stenotrophomonas maltophilia (SM). She had hemodialysis-dependent chronic renal failure, but no immunosuppressive disease. Echocardiography showed mobile vegetation on her native mitral valve. Right femoral artery embolectomy and mitral valve replacement were performed simultaneously. She awakened from anesthesia, but she passed away due to septic shock complications. To the best of our knowledge, this was the first case in whom native mitral valve endocarditis caused by SM was observed (despite of absence of any immunosuppressive event) and needed to undergo valve replacement.

Fístula aorto-atrial direita: uma complicação pós-endocardite infecciosa. Relato de caso / Right aorto-atrial fistula: a post-infective endocarditis complication. A case report

A fístula aorto-atrial direita é uma comunicação anômala, que representa uma grave e infrequente complicação da endocardite infecciosa. Neste estudo, relata-se o caso de um paciente de 53 anos, do sexo masculino, com histórico evolutivo patológico de endocardite infecciosa e acometimento de valva aórtica. Sob imagem de ecocardiograma, demonstrou-se abscesso perivalvar aórtico, estendendo-se à parede atrial direita, com necessidade de abordagem cirúrgica. Foram realizados a anuloplastia valvar aórtica e implante de valva mecânica. Após 1 mês de evolução pós-cirúrgica, realizou-se novo ecocardiograma, que acusou shunt de débito da raiz da aorta para o átrio direito. A conduta diante do caso foi discutida entre equipe clínica e cirúrgica, visando a possíveis falhas na terapêutica inicial. (AU)

Right aorto-atrial fistula is an anomalous communication that represents a serious and infrequent complication of infective endocarditis. This study reports the case of a 53-year-old male patient, with a pathological evolutionary history of infective endocarditis and aortic valve involvement. The echocardiogram shows an aortic perivalvar abscess extending to the right atrial wall, requiring a surgical approach. Aortic valve annuloplasty and mechanical valve implantation were performed. After a month of post-surgical evolution, a new echocardiogram was performed, which showed aortic root to right atrium shunt. The behavior in this case was discussed between the clinical and surgical teams, aiming at possible failures in the initial therapy. (AU)

Síndrome de Austrian en endocarditis infecciosa: reporte de un caso y manejo médico quirúrgico exitoso / Austrian syndrome in infective endocarditis

Resumen: El Síndrome de Austrian, corresponde al cuadro clínico descrito por Robert Austrian en 1957, definido por la triada de Neumonía, Endocarditis Infecciosa (EI) y Meningitis, causado por Streptococcus pneumoniae. En la mayoría de los casos el vicio valvular presente, es la insuficiencia valvular aórtica, cuyo tratamiento médico y resolución quirúrgica de acuerdo con su gravedad, deben ser realizados precoz y oportunamente. Un paciente de 51 años, sin antecedentes de valvulopatía, con historia de poli consumo de alcohol y cocaína comenzó dos semanas previo a su ingreso hospitalario con síndrome febril, neumonía, y meningitis bacteriana por Streptococcus pneumoniae. Sus hemocultivos fueron negativos. El ecocardiograma transesofágico (ETE) fue compatible con EI valvular aórtica con insuficiencia moderada a severa. Se trató como EI a microorganismo desconocido y se efectuó un reemplazo valvular aórtico electivo con prótesis biológica a la 5° semana después de terminado el tratamiento médico antibiótico, cuyo resultado fue exitoso.

Abstract: A syndrome including Infective endocarditis, pneumonia and Meningitis caused by S pneumoniae was described by Robert Austrian in 1957. The aortic valve is affected in most cases. Medical followed by surgical treatment should be promptly implemented. The clinical case of a 51 year old man with a history of multiple drug consumption developing fever, pneumonia, and meningitis caused by S pneumoniae is presented. Blood cultures were negative and trans esophageal echocardiography showed aortic valve vegetations and moderate regurgitation. After multiple antibiotic treatment the patient underwent aortic valve replacement and recovered satisfactorily. Clinical and epidemiological characteristics of this syndrome are discussed.

Microbiota periodontal y microorganismos aislados de válvulas cardiacas en pacientes sometidos a cirugía de reemplazo de válvulas en una clínica de Cali, Colombia / Periodontal microbiota and microorganisms isolated from heart valves in patients undergoing valve replacement surgery in a clinic in Cali, Colombia

Resumen Introducción. La periodontitis es una enfermedad infecciosa que afecta los tejidos de soporte del diente y se asocia con diferentes enfermedades sistémicas, incluida la enfermedad cardiovascular. Los estudios microbiológicos permiten detectar microorganismos a partir de muestras subgingivales y cardiovasculares. Objetivo. Describir la microbiota periodontal cultivable y la presencia de microorganismos en válvulas cardiacas de pacientes sometidos a cirugía de reemplazo valvular en una clínica de Cali. Materiales y métodos. Se analizaron 30 muestras subgingivales y de tejidos valvulares mediante cultivo en medio bifásico, agar de sangre con suplemento y agar tripticasa de soya con antibiótico. Las muestras de las válvulas se analizaron mediante reacción en cadena de la polimerasa (PCR) convencional. Resultados. Los patógenos periodontales aislados de bolsas periodontales fueron Fusobacterium ( 50 % ), Prevotella intermedia/nigrescens (40 %), Campilobacter rectus (40 %), Eikenella corrodens (36,7 %), bacilos entéricos Gram negativos (36,7 %), Porphyromonas gingivalis (33,3 %) y Eubacterium (33,3 %). Los agentes patógenos aislados de la válvula aórtica fueron Propionibacterium acnes (12 %), bacilos entéricos Gram negativos (8 %), Bacteroides merdae (4 %) y Clostridium bifermentans (4 %), y de la válvula mitral, P. acnes y Clostridium beijerinckii. La PCR convencional no arrojó resultados positivos para agentes patógenos orales y solo se detectó ADN bacteriano en dos muestras. Conclusiones. La microbiota periodontal de pacientes sometidos a cirugía de reemplazo valvular estaba conformada por especies Gram negativas que han sido relacionadas con infecciones en tejidos extraorales; sin embargo, no se encontraron agentes patógenos periodontales en los tejidos de las válvulas. Aunque hubo muestras de estos tejidos y subgingivales, positivas para bacilos entéricos Gram negativos, no es posible asegurar que tuvieran el mismo origen filogenético.

Abstract Introduction: Periodontitis is an infectious disease that affects the support tissue of the teeth and it is associated with different systemic diseases, including cardiovascular disease. Microbiological studies facilitate the detection of microorganisms from subgingival and cardiovascular samples. Objective: To describe the cultivable periodontal microbiota and the presence of microorganisms in heart valves from patients undergoing valve replacement surgery in a clinic in Cali. Materials and methods: We analyzed 30 subgingival and valvular tissue samples by means of twophase culture medium, supplemented blood agar and trypticase soy agar with antibiotics. Conventional PCR was performed on samples of valve tissue. Results: The periodontal pathogens isolated from periodontal pockets were: Fusobacterium nucleatum (50%), Prevotella intermedia/ nigrescens (40%), Campylobacter rectus (40%), Eikenella corrodens (36.7%), Gram negative enteric bacilli (36.7%), Porphyromonas gingivalis (33.3%), and Eubacterium spp. (33.3%). The pathogens isolated from the aortic valve were Propionibacterium acnes (12%), Gram negative enteric bacilli (8%), Bacteroides merdae (4%), and Clostridium bifermentans (4%), and from the mitral valve we isolated P. acnes and Clostridium beijerinckii. Conventional PCR did not return positive results for oral pathogens and bacterial DNA was detected only in two samples. Conclusions: Periodontal microbiota of patients undergoing surgery for heart valve replacement consisted of species of Gram-negative bacteria that have been associated with infections in extraoral tissues. However, there is no evidence of the presence of periodontal pathogens in valve tissue, because even though there were valve and subgingival samples positive for Gram-negative enteric bacilli, it is not possible to maintain they corresponded to the same phylogenetic origin.

Síndrome de Austrian: reporte de caso / Austrian syndrome: report of one case

Austrian syndrome is a triad characterized by pneumonia, meningitis and endocarditis, as a result of a Streptococcus pneumoniae bacteremia. We report a previously healthy 49 year-old male, who consulted at the emergency care unit with a history of one week of pleuritic pain, fever leading to an altered level of consciousness and seizures. A diagnosis of community-acquired pneumonia and meningitis was reached, isolating Streptococcus pneumoniae in the cerebrospinal fluid and blood cultures. Antibiotic treatment was started but the patient had an unsatisfactory response. During hospitalization a new heart murmur was found in the physical examination. An echocardiography was performed and a massive aortic valve insufficiency was found along with vegetations and a perforation of the same valve. The valve was replaced by a prosthetic one and the patient responded satisfactorily to the surgical and antibiotic treatment, without complications.

Anesthetic and hemodynamic management of a rare case of Brucella multivalvular endocarditis in cardiogenic shock undergoing emergency aortic valve replacement and mitral valve repair.

We describe a very rare case of human brucella multivalvular endocarditis. Patient presented in a state of cardiogenic shock with low urine output and a history of breathlessness. Patient was diagnosed to have brucellosis 2 months back by blood cultures and agglutination tests and was receiving doxycycline and rifampicin therapy. Echocardiography showed severe aortic regurgitation, moderate mitral regurgitation, severe left ventricular dysfunction and a mobile vegetation attached to the aortic valve. Patient was scheduled for emergency surgery; while preparing for surgery hemodynamic monitoring, non‑invasive ventilation and inotropic supports were started. During surgery, the aortic valve was found perforated and the aortomitral continuity was disrupted. Aortic valve replacement and mitral valve repair were performed. Hemofiltration was used during cardiopulmonary bypass. Weaning from bypass was achieved with the help of inodilators, dual chamber pacing and intra‑aortic balloon pump.