Ecocardiografia Tridimensional na avaliação de endocardite de válvula nativa: um relato de caso e semelhança entre achados ecocardiográficos e cirúrgicos / Three-Dimensional transesophageal echocardiography in native valve endocarditis: a case report and similarities between echocardiography and surgical findings

A endocardite de valva nativa é uma doença incomum, complexa, e de alta morbimortalidade. Requer tratamento clínico prolongado, com várias complicações possíveis, e o seu tratamento cirúrgico é complexo e tecnicamente difícil. O ecocardiograma transtorácico e transesofágico são fundamentais na avaliação da doença, inclusive seus achados são parte dos critérios diagnósticos de endocardite. Adicionalmente, o ecocardiograma tridimensional (3D) contribui com detalhamento anatômico na avaliação das estruturas cardíacas acometidas pela doença. Mostramos um caso em que é ilustrado o papel da ecocardiografia no diagnóstico e avaliação de complicações da endocardite, comparando as imagens do ecocardiograma 3D pré-operatórias, com os achados durante o ato cirúrgico. (AU)

Native valve bacterial endocarditis is an uncommon, complex, and highly morbid disease that requires prolonged clinical treatment and challenging surgical interventions. Transthoracic and transesophageal echocardiography are paramount assessment tools whose findings are included in the diagnostic criteria. Three-dimensional echocardiography shows further realistic imaging details. Here we present a case demonstrating the role of echocardiography in the diagnosis of endocarditis and the identification of its complications to show how advanced imaging techniques may have a remarkable resemblance with in vivo surgical findings. (AU)

Heterogeneidad del tratamiento para cándida parapsilosis en endocarditis micótica de válvula nativa / Types of treatments for native-valve endocarditis due to candida parapsilosis

Introducción: las infecciones por cándida en el ámbito intrahospitalario han ido en ascenso en las últimas décadas en especial en las unidades de cuidado intensivo (UCI), dado el uso cada vez más frecuente de antibióticos de amplio espectro y de procedimientos invasivos tanto diagnósticos como terapéuticos. Hoy se consideran las especies de cándida como la cuarta causa de infección del torrente sanguíneo en los Estados Unidos de Norteamérica, con alto riesgo de complicaciones que incluyen endocarditis, trombosis y embolismo séptico al sistema nervioso central (SNC) entre otros. En relación con la endocarditis por especies de cándida, se ha considerado de mal pronóstico por el alto riesgo de afectación al SNC, por lo que se ha recomendado el manejo quirúrgico como piedra angular de su tratamiento. Presentación del caso: se describe el caso clínico de un paciente con endocarditis y con candidemia por Candida parapsilosis a quien se le realizó manejo médico.

Nosocomial Candida infections have increased in the last decades particularly in the intensive care units (ICU) due to the rise in broad-spectrum antibiotics usage and invasive diagnostic and therapeutic procedures usage. Today, Candida species are recognized as the fourth causative organisms of endovascular infection in the United States of America posing a high risk of endocarditis, thrombosis and septic embolization to the central nervous system (CNS). Endocarditis due to Candida species is associated with a poor prognosis because of the increased risk of CNS involvement for which surgical approach has been recommended as the cornerstone of therapy. We hereby report a patient with endocarditis and candidemia due to Candida parapsilosis, who received medical management.

Endocarditis de Libman-Sacks de válvulas nativas derechas en contexto de síndrome antifosfolípido y lupus eritematoso sistémico: ¡cuando el tratamiento marca la diferencia! / Libman-Sacks endocarditis of right native valves in the context of antiphospholipid syndrome and systemic lupus erythematosus: when treatment makes a difference!

We report the case of a 54 years old woman with antiphospholipid syndrome in irregular therapy, admitted due to exertional dyspnea and orthopnea. The transthoracic echocardiogram showed dilated cardiomyopathy with biventricular systolic dysfunction, pulmonary hypertension and masses related to the pulmonary and tricuspid valve without autonomic movement. The crops and white count were normal, with alteration of the SAF test, in addition, SLE was diagnosed. It was started therapy for heart failure, steroids, rituximab and anticoagulation, with improving of the symptoms. The echocardiographic control showed remission of the tricuspid masses and similar dimensions of the pulmonary mass.

Presentamos el caso de una mujer de 54años con síndrome antifosfolípido en terapia irregular, quien ingresa por disnea de esfuerzo que progresó a ortopnea. El ecocardiograma transtorácico evidenció cardiopatía dilatada con disfunción sistólica biventricular, hipertensión pulmonar y masas relacionadas con válvula pulmonar y tricúspide sin movimiento autonómico. Los cultivos y cuenta blanca estaban normales, con alteración de las pruebas del SAF, haciéndose, además, diagnóstico de lupus eritematoso sistémico. Se inició terapia para insuficiencia cardiaca, esteroides, rituximab y anticoagulantes, mejorando la clínica. El ecocardiograma control mostró remisión de las masas tricuspídeas y similares dimensiones de la masa pulmonar.

Caso Clínico: Endocarditis Bacteriana de Válvula Aórtica Nativa / Case Report: Native Aortic Valve Bacterial Endocarditis

INTRODUCCIÓN: La Endocarditis Bacteriana es una enfermedad grave de difícil diagnóstico, debido al cuadro clínico inespecífico. Se caracteriza por la formación de vegetaciones infectadas por microorganismos en las válvulas y cámaras cardiacas o en el endotelio de los grandes vasos. Las valvulopatías congénitas y las enfermedades reumáticas son los principales factores de riesgo asociados con el padecimiento en válvulas nativas. Desde hace un siglo, la cavidad bucal ha sido reconocida como una fuente potencial de bacteriemia. CASO CLÍNICO: Paciente masculino de 40 años de edad, presentó disnea de inicio súbito, debilidad muscular, pérdida del estado de conciencia, posteriormente afasia y hemiplejia derecha. Se realizó una tomografía simple de cráneo evidenciando una zona isquémica, presentó alza térmica ≥ 38ºC. En el ecocardiograma con presencia de imagen sugestiva de vegetación adherida a la válvula aórtica y protrusión hacia tracto de salida del ventrículo izquierdo. EVOLUCIÓN: Se realizó cirugía de cambio valvular aórtico mecánico, con tratamiento antibiótico presentado evolución favorable y recuperando la fuerza muscular en hemicuerpo derecho. En hospitalización se instauró anticoagulación oral durante el cual luego varios días presentó cuadro convulsivo, se evidencia en la tomografía zona hemorrágica y se remplazó medicación por heparina de bajo peso molecular. CONCLUSIÓN: La endocarditis bacteriana se sospecha en todo paciente que presenta clínica de fiebre y criterios de DUKE positivos. Siendo la piedra angular del diagnóstico el ecocardiograma y el hemocultivo positivo, para establecer su etiología requiriendo un manejo adecuado, precoz para brindar una terapéutica oportuna. (ua)

BACKGROUND: Bacterial endocarditis is a critical disease of difficult diagnosis due to the non-specific of his clinical presentation; characterized by the formation of vegetations infected by microorganisms in the valves and chambers cardiacs or in the endothelium of the large vessels. Congenital valvulopathies and rheumatic diseases are the main risk factors associated with the disease in native valves and, one century ago, the oral cavity has been recognized as a potential source of bacteremia. CASE REPORT: A 40 ­ year-old male patient who had sudden onset dyspnea, muscle weakness, loss of consciousness and subsequently right aphasia and hemiplegia. A tomography was performed evidencing an ischemic zone, presented thermal rise above 38ºC and an echocardiogram was performed with presence of suggestive image of vegetation adhered to the aortic valve with protrusion towards exit tract. EVOLUTION: Mechanical aortic valve replacement surgery was performed, with antibiotic treatment that presented favorable evolution and recovery of muscle strength in the right hemisphere. During hospitalization, oral anticoagulation was established. Several days later, the patient presented convulsive symptoms, evidenced the hemorrhagic area at the tomography and replaced the medication with molecular weight heparin. CONCLUSION: Bacterial endocarditis is suspected in all patients presenting with fever and positive DUKE criteria. The cornerstone of the diagnosis is the echocardiogram and the positive blood culture, in order to establish the etiology, requiring an adequate, early management to provide a timely treatment.(au)

Fungal endocarditis

ABSTRACT Fungal endocarditis is a rare and fatal condition. The Candida and Aspergillus species are the two most common etiologic fungi found responsible for fungal endocarditis. Fever and changing heart murmur are the most common clinical manifestations. Some patients may have a fever of unknown origin as the onset symptom. The diagnosis of fungal endocarditis is challenging, and diagnosis of prosthetic valve fungal endocarditis is extremely difficult. The optimum antifungal therapy still remains debatable. Treating Candida endocarditis can be difficult because the Candida species can form biofilms on native and prosthetic heart valves. Combined treatment appears superior to monotherapy. Combination of antifungal therapy and surgical debridement might bring about better prognosis.

Endocardite em valva aórtica bivalvular com extensão e perfuração da cúspide anterior mitral / Endocarditis in bicuspid aortic valve with extension and perforation of the anterior leaflet mitral / Endocarditis en Válvula Aórtica Bivalva con Extensión y Perforación de la Cúspide anterior Mitral

Paciente jovem, internado por endocardite em valva aórtica bivalvular, com extensão perianular da infecção (abscesso mitral com perfuração de cúspide), apresentando insuficiência aórtica e mitral importantes. Evoluiu com choque misto, baixo débito cardíaco efetivo, acidose metabólica, insuficiência respiratória e insuficiência renal aguda dialítica secundária a glomerulonefrite por deposição de imunocomplexos. Instituído tratamento para insuficiência cardíaca, antibioticoterapia de amplo espectro, suporte ventilatório não invasivo e hemodiálise, apresentando melhora do quadro clínico. Submetido à troca valvar aórtica por prótese biológica e plastia mitral, com bom resultado cirúrgico. Não havia relato de procedimento dentário prévio, outras portas de entrada para microrganismos nem uso de drogas ilícitas por via intravenosa. Bacteremias espontâneas podem ser implicadas, certamente, nesses casos. Parece não haver redução da incidência de infecções valvares com uso de profilaxia antibiótica em portadores de valvas nativas alteradas, segundo as atuais recomendações.

Young patient, hospitalized for infective endocarditis in bicuspid aortic valve with extension periannular infection (abscess with perforation of mitral leaflet) presenting significant aortic and mitral insufficiency. Evolved with mixed shock, low cardiac output effective, metabolic acidosis, respiratory failure and acute renal failure requiring dialysis secondary to glomerulonephritis by immune complex deposition. Established treatment for heart failure, broad-spectrum antibiotic therapy, noninvasive ventilatory support and hemodialysis, with clinical improvement. Underwent to aortic valve replacement and mitral valve bioprosthesis with good outcome. There was no report of previous dental procedure, other ports of entry for microorganisms and drug addiction. Spontaneous bacteremia can be certainly involved in these cases. There seems no reduction in the incidence of valvular infections with use of antibiotic prophylaxis in patients with native valves changed, according to current recommendations.

Paciente joven, internado por endocarditis en válvula aórtica bivalva, con extensión perianular de la infección (absceso mitral con perforación de cúspide), presentando insuficiencias aórtica y mitral importantes. Evolucionó con choque mixto, bajo débito cardíaco efectivo, acidosis metabólica, insuficiencia respiratoria e insuficiencia renal aguda dialítica secundaria a glomerulonefritis por deposición de inmunocomplejos. Establecido tratamiento para insuficiencia cardíaca, antibioticoterapia de amplio espectro, soporte ventilatorio no invasivo y hemodiálisis, presentando una mejora del cuadro clínico. Sometido a un trasplante de la válvula aórtica por una prótesis biológica y una plastia mitral, con buen resultado quirúrgico. No había antecedentes de procedimientos previos, otras puertas de entrada para microorganismos ni uso de drogas ilícitas por vía intravenosa. Las bacteriemias espontáneas pueden ser implicadas, ciertamente, en esos casos. Parece no haber reducción de la incidencia de infecciones valvulares con uso de profilaxis antibiótica en portadores de válvulas nativas alteradas, conforme a las actuales recomendaciones

Endocardite infecciosa: definição diagnóstica e terapêutica pela ecocardiografia / Infective endocarditis: definition diagnosis and treatment by echocardiography

A endocardite infecciosa (EI) é o processo infeccioso do endotélio cardíaco e caracteriza-se por uma vegetação, um coágulo de plaquetas e fibrina infectado, contendo ainda leucócitos e hemácias¹. A vegetação pode estar localizada em qualquer sítio do endotélio, mas frequentemente ocorre nas superfícies endoteliais das válvulas cardíacas e próteses valvares¹. A EI apresenta elevada incidência e alto risco de morbimortalidade¹. Seu diagnóstico se faz por meio de critérios clínicos, laboratoriais e ecocardiográficos, sendo este último acrescentando alta sensibilidade e especificidade nos critérios diagnósticos. O prognóstico desta síndrome infecciosa depende de um diagnóstico rápido, tratamento efetivo e um pronto reconhecimento de suas complicações². A antiobioticoterapia específica para o agente infectante, usualmente, é o tratamento da endocardite infecciosa, porém, em determinados casos, há necessidade de cirurgia². O tratamento cirúrgico apresenta grande desafio devido a sua forma de apresentação variada, podendo acometer valvas, próteses, lesões congênitas ou fios de marca-passos previamente colocados². A indicação cirúrgica está direcionada para os casos de urgência ou emergência, como na insuficiência cardíaca aguda secundária às doenças das valvas cardíacas, nos casos de abcessos perivalvares e na presença de grandes vegetações com risco elevado de embolização sistêmica¹-². Neste relato, documentamos um caso incomum de endocardite infecciosa, na qual uma grande vegetação móvel aderida à parede ventricular foi ressecada, cirurgicamente, pelo alto risco de embolização sistêmica.

The infective endocarditis (EI) is the infectious process of the heart and endothelium characterized by a vegetation, a clot of platelets and fibrin infected, further containing leukocytes and erythrocytes¹.The vegetation can be located anywhere on the endothelium, but often occurs in the endothelial surfaces of heart valves and prosthetic valves¹. EI has a high incidence and high risk of morbidity and mortality¹. The diagnosis is made through clinical, laboratory and echocardiographic findings, the latter adding a high sensitivity and specificity in diagnostic criteria². The prognosis of this infectious syndrome depends on rapid diagnosis, effective treatment and prompt recognition of complications². The specific therapy to the infecting agent is usually the treatment of infectious endocarditis, but in some cases surgery is needed². Surgical treatment presents a great challenge due to their form of presentation varied and can involve valves, prosthesis, congenital lesions or previously placed pacemaker wires². Surgical indication is directed to cases of emergency or in emergencies such as acute heart failure secondary to diseases of the heart valves in cases of perivalvular abscesses and in the presence of large vegetations with high risk of systemic embolization¹,². In this report, we documentan unusual case of infective endocarditis where a large mobile vegetation attached to the ventricular wall was surgically resected athigh risk of systemic embolization.

Endocarditis infecciosa: una revisión bibliográfica necesaria / Infectious endocarditis: a necessary literature survey

Se revisaron diversas fuentes bibliográficas sobre endocarditis infecciosa, especialmente las que trataban aspectos clinicoepidemiológicos, diagnósticos y terapéuticos, a fin de confeccionar un trabajo que constituya un material para el estudio y la actualización de este tema; no obstante, se consideró la necesidad de continuar dicha investigación sobre otras determinadas características de esta infección para ampliar los conocimientos al respecto.

Diverse literature sources on infectious endocarditis were reviewed, especially those that dealt with clinical epidemiological, diagnostic and therapeutic aspects, in order to make an investigation that constitutes a material for the study and the update of this topic; nevertheless, it was considered the necessity to continue this investigation on other certain characteristics of this infection to widen the knowledge in this respect.

Infective endocarditis at a hospital in Saudi Arabia: epidemiology, bacterial pathogens and outcome

Data on infective endocarditis prevalence, epidemiology and etiology from Saudi Arabia and the Gulf region are sparse. We undertook this study to describe the pattern and the causative agents of endocarditis at a hospital in Saudi Arabia. We conducted a retrospective analysis of all reported endocarditis cases at the Dhahran Health Center from January 1995 to December 2008. Of the 83 cases of endocarditis, 54 [65%] were definite endocarditis and the remaining 29 [35%] were possible endocarditis based on the Duke criteria. Patients with definite endocarditis included 39 males and 15 females [ratio of 2.6:1] with a mean age [SD] of 59.7 [18.2] years. Of the definite endocarditis cases, native valve endocarditis occurred in 44 [81.5%] cases of and prosthetic valve endocarditis was observed in 10 [18.5%]. The most commonly involved valves were mitral [n=24; 44.4%] and aortic [n=20; 39.2%]. The most common organisms were S aureus [n=23; 42.6%], Enterococcus faecalis [n=12; 22.2%] and viridans streptococci [n=9; 16.7%]. Surgical intervention was required in 17 [31.4%] cases and the in-hospital mortality rate was 29.4% [n=15]. Of all the patients, 3 [5.5%] had embolic stroke as a complication. Native valve endocarditis is the predominant type of endocarditis. The patients were older adults and the most common organisms were S aureus, E faecalis and viridans streptococci

Surgery for Infective Endocarditis

The last decade has seen many changes in the landscape of infective endocarditis (IE) - ranging from the epidemiology; microbiology; diagnostic techniques and indication for antibiotic prophylaxis. Unfortunately; the role of surgery in the patient with endocarditis; including the indication; timing and type of surgery continues to be plagued by controversy. Although surgery has an important and established role in critically ill patients with endocarditis; the choice between medical therapy and surgery is often less clear cut and poses a major challenge to the physician treating this condition. The following article summarises some of these controversies including indications for surgery in native and prosthetic valve endocarditis; the timing of surgery; the choice of prostheses and issues surrounding anti-coagulation

Papel do tratamento farmacológico na evolução e nas complicações das valvopatias mitrais / Pharmacological management influence on the natural history and complications of mitral disease

As valvulopatias mitrais de etiologia reumática ainda são muito prevalentes em nosso meio...

Endocarditis relacionada a cables de marcapasos o cardiodesfibriladores implantables / Endocarditis of pacemaker or implantable cardioverter-defibrillator leads

Antecedentes: Dentro del síndrome de endocarditis infecciosa, se incluyen la infección de dispositivos endovasculares. el objetivo de la presentación fue avaluar las características clínicas y la evolución de la endocarditis relacionada a dispositivos electrónicos endovasculares. Casos clínicos: entre 2002 - 2007 fueron identificados 7 pacientes con edad promedio de 56,5 años. La presentación clínica fue en el 85,7% fiebre de origen desconocido, con un promedio de 28 días de evolución del cuadro. Los germenes aislados fueron estafilococo coagulasa negativo en 6 pacientes y estafilococo aureus en 1 paciente. El tratamiento se baso en la extracción del sistema y terapia antibiótica, salvo 1 caso que solo recibió tratamiento antibiótico. Hubo 2 (28,5%) muertes intrahospitalarias durante el seguimiento. Conclusión: La endocarditis relacionada a dispositivos es una entidad con elevada mortalidad. el diagnóstico temprano y la extracción del sistema son de vital importancia para el tratamiento y pronóstico.

BACKGROUND: Infective endocarditis includes the endovascular devices infection. The main objective was to evaluate the clinical characteristics and evolution of the endocarditis related to electronics devices. CASE REPORTS: Between 2002 - 2007 periods were identified 7 patients, age average of 56.5 years. The clinical presentation was fever of unknown origin in 85.7%, with a mean of 28 days of evolution. The microbiology isolated was coagulase-negative staphylococci in 6 patients and staphylococcus aureus in 1 patient. The treatment was complete system extraction and antibiotic therapy, except in 1 case that only received antibiotics. There were 2 deaths (28,5%) during in hospital follow-up. CONCLUSION: The endocarditis related to devices is a disease with high mortality. Early diagnosis and system extraction are very important for the treatment and prognosis.

Endocardite valvar mitral causada por Chlamydia psittaci: apresentação de um caso raro / Chlamydia psittaci as a cause of mitral valve endocarditis: presentation of a rare case

Relatamos o caso de um criador de pássaros que desenvolveu um quadro consuntivo, febril, com mialgia e hemoculturas negativas. Internado por três ocasiões, foi tratado empiricamente com antibióticos, sem melhora. Após quatro meses, apresentou piora com sinais de infecção sistêmica. Ecocardiograma demonstrou insuficiência mitral moderada, com vegetações, não presentes em exame prévio. Sorologia positiva para Chlamydia psittaci (imunofluorescência indireta). Na cirurgia, identificou-se grande destruição da valva mitral, com cúspide anterior rota e vegetações. Após a cirurgia, apresentou melhora clínica, recebendo alta em treze dias, com antibioticoterapia específica. Apesar de pouco freqüente, a Chlamydia psittaci deve ser lembrada em casos de endocardite com hemoculturas negativas, quando houver história de exposição a pássaros.

The authors report a clinical case of bird breeder who evolved with fever, myalgia, weight lost and negative blood cultures. On three occasions he was treated with different antibiotics, without improvement. He became progressively worse and after four months a diagnosis of endocarditis was made. An echocardiogram showed mitral valve dysfunction with vegetation that had not been seen previously. A blood test proved positive for Chlamydia psittaci (indirect immunofluorescence). In surgery the mitral valve was seen to have severe lesions with anterior cuspid rupture and large areas with vegetation. After surgery, he presented with a clinical improvement and was discharged on the thirteenth post-operative day on specific antibiotic therapy. Although rare, Chlamydia psittaci must be considered in cases of endocarditis with negative blood cultures, when there is a possibility of contact with birds.