Ann Thorac Surg 1997;63:829-830
© 1997 The Society of Thoracic Surgeons
Case Reports
Endaortitis of Coarctation of the Aorta After Invasive Diagnostics
Jürgen O. Böhm, MD,
Cornelius A. Botha, FCS(SA),
Joachim-Gerd Rein, MD,
Wolfgang Rupp, MD
Cardiac Surgical Clinic, "Sana Herzchirurgische Klinik," Stuttgart, Germany
Accepted for publication September 28, 1996.
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Abstract
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We report the case of a young woman in whom endaortitis developed at the site of a coarctation of the aorta after the invasive investigation of right fossa iliac pain. The organism responsible suggests a causal relationship to the investigations without antibiotic prophylaxis, and we emphasize the need for antibiotic prophylaxis in these cases. Invasive investigation of isolated coarctation in a young adult or adolescent is probably superfluous.
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Introduction
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Patients with congenital cardiovascular anomalies are known to be at increased risk of contracting infective endocarditis. An incidence of infective endocarditis during their lifetime as high as 5% for all patients with congenital heart defects was cited in a 1978 study [1]. On this premise, various recommendations have been made with regard to prevention and prophylaxis of endocarditis in these patients [2–4].
Infective endocarditis complicating coarctation is more commonly situated on an accompanying bicuspid aortic valve, or rarely arises from either the mitral valve or an accompanying ventricular septal defect [5]. Bacterial endarteritis of an isolated coarctation of the aorta is a seldom-described phenomenon [2, 5, 6].
A 21-year-old woman with a systolic heart murmur known since childhood presented to her physician with right iliac fossa pain. From March to May 1995 she underwent various investigations including urologic and gastrointestinal endoscopy, without endocarditis prophylaxis, and also without any positive findings. During this hospitalization upper body hypertension was noted with barely palpable pulses in her lower extremities. She had no symptoms consistent with coarctation. The difference in blood pressure was 40 mm Hg between her upper and lower extremities. Further noninvasive echocardiographic studies confirmed the presence of coarctation of the aorta, and a gradient of 40 mm Hg was also calculated by Doppler ultrasound. No other cardiac defects were discovered. Due to the persisting undiagnosed abdominal pain she also underwent mesenteric arteriography, which included direct measurement and confirmation of the gradient across the coarctation. Magnetic resonance imaging confirmed the coarctation 3 cm distal to the origin of the left subclavian artery and also showed unremarkable poststenotic dilatation. Abdominal arteriography did not contribute to the diagnosis of her iliac pain. She was discharged on a regimen of antispasmodic medication and oral nitrates for her abdominal pain and was to be electively referred to the cardiothoracic surgeons for operation of the coarctation.
A few days afterwards she was readmitted with fever spikes of up to 39.7°C. A 2-cm abscess with a mobile vegetation of 1 cm attached was seen on transoesophageal echocardiography and magnetic resonance imaging immediately downstream to the coarctation in the dorsal aspect of the aorta (Fig 1
). Blood cultures grew Enterococcus faecalis. Appropriate intravenous antibiotics over a period of 4 weeks failed to cure the fever, although subsequent blood cultures remained negative, and she was eventually referred to the Stuttgart Sana Cardiac Clinic for an operation.
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Fig 1. . Magnetic resonance image of aorta (sagittal section) showing coarctation of the aorta with the dorsally situated abscess cavity immediately downstream of the coarctation.
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The chest was entered via a left posterolateral thoracotomy, and an hourglass deformity of the aorta was noted 3 cm distal to the left subclavian artery. After the aorta was clamped above and below the coarctation, the aorta was opened and the typical finding of an extremely stenotic ridge in the region of the ligamentum arteriosum was seen. Immediately downstream of this was a perforation into a thimble-sized, smooth-walled, nonthrombosed cavity. The region was excised and aortic continuity achieved by interposition of a Hemashield prosthesis (Meadox Medicals, Inc, Oakland, NJ). The postoperative course was uneventful, and the appropriate antibiotic course was completed. She experienced no further fever, and the iliac pain did not recur. Histologic examination of the tissue confirmed an acute granulomatous inflammatory process. The tissue culture was sterile.
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Comment
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We suspect that the cause of the endocarditis in our patient was the invasive diagnostic endoscopy or possibly the angiographic measures performed without the appropriate endocarditis prophylaxis. The specific organism isolated supports origin from the gastrointestinal tract [3].
The precise situation of the abscess was at the typical "locus resistentiae minoris." Abdominal symptoms associated with coarctation of the aorta are not unusual [5], although this is not generally described as a cause of right iliac fossa pain.
As we have stated, endaortitis of coarctation of the aorta is extremely rare [2, 5, 6]. Publications by Reifenstein and associates [7] and Abbott [8] from the preoperative era looked at autopsies of, respectively, 104 and 200 patients who died of coarctation and described 6 and 14 cases, respectively, where the cause of death was ascribed to the presence of mycotic aneurysm formation, bacterial endocarditis, or aortitis. Skinner and associates [6] described a single case of Staphylococcus aureus causing a mycotic aneurysm. In 5 cases Gross and associates [9] isolated Salmonella enteritidis, Staphylococcus aureus and Brucella abortus in aortitis at various sites. In our case, Enterococcus faecalis was the infecting organism.
As a practical consequence of this case study we reach two conclusions: First, in isolated coarctation in an adolescent or young adult, as suggested by the usual clinical findings, as diagnosed by noninvasive means, and where the gradient is confirmed by Doppler ultrasound measurement and where concomitant cardiac conditions have been excluded by cardiac echocardiography, further invasive investigation before operation is unnecessary [5]. Second, we emphasize that due consideration should still be given to antibiotic prophylaxis during invasive diagnostic measures in patients of all ages with congenital heart defects including coarctation of the aorta, in line with the recommendations for other congenital cardiac conditions [2–4].
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Addendum
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The further clinical course of this patient was uneventful. Transthoracic echocardiography performed after 6 months was unremarkable, and a pressure gradient of 6 mm Hg (mean) was calculated across the prosthesis by Doppler ultrasound. Although the patient remained symptom free, a magnetic resonance imaging control study was requested by her physician 10 months later and confirmed a smooth contour of the descending thoracic aorta. Her right iliac fossa pain has not reappeared, and neither has any fever. She has returned to her normal lifestyle.
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Footnotes
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Address reprint requests to Dr Böhm, Sana Herzchirurgische Klinik, Herdweg 2, D-70174 Stuttgart, Germany.
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References
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- Rose AG. Infective endocarditis complicating congenital heart disease. S Afr Med J 1978;53:739–43.[Medline]
- Miner PD. Infective endocarditis. Implications for care of the adult with congenital heart disease. Nurs Clin North Am 1994;29:269–83.[Medline]
- Dajani AS, Bisno AL, Chung KJ, et al. Prevention of bacterial endocarditis. JAMA 1990;264:2919–22.[Abstract/Free Full Text]
- Durack DT. Prevention of infective endocarditis. N Engl J Med 1995;332:38–44.[Free Full Text]
- Kirklin JW, Barratt-Boyes BG, Blackstone EH, Jonas RA, Kouchoukos NT. Coarctation of the aorta and interrupted aortic arch. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery. 2nd ed. New York: Churchill Livingstone, 1993:1263–303.
- Skinner JR, Bexton R, Wren C. Aortic coarctation endarteritis and aneurysm: diagnosis by transoesophageal echocardiography. Int J Cardiol 1992;34:216–8.[Medline]
- Reifenstein GH, Levine SA, Gross RE. Coarctation of the aorta. A review of 104 autopsied cases of the "adult type," 2 years of age or older. Am Heart J 1947;33:146–68.
- Abbott ME. Coarctation of the aorta of the adult type. A statistical study and historical retrospect of 200 recorded cases with autopsy of stenosis or obliteration of the descending arch in subjects above the age of 2 years. Am Heart J 1928;3:574–618.
- Gross C, Harringer W, Mair R, Wimmer-Greinecker G, Klima U, Brücke P. Mycotic aneurysms of the thoracic aorta. Eur J Cardiothorac Surg 1994;8:135–8.[Abstract]
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Abstract
Introduction
