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Ann Thorac Surg 1997;64:587-588
© 1997 The Society of Thoracic Surgeons

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Correspondence

Risk of Bacteremia Complicating Valve Replacement in the Presence of Colon Cancer

Section of Cardiothoracic Surgery, Department of Surgery, West Virginia University Health Science Center, Po Box 9238, Morgantown, Wv 26505

To the Editor:

Increasingly patients undergo operation at an older age. Associated with this comes increased incidence of coexisting diseases like cancer. We would like to share our recent experience of a patient referred for aortic valve and coronary arterial disease with concurrent carcinoma of the rectum that was not amenable to local resection.

A 72-year-old woman was admitted with a bleeding rectal carcinoma and was found on evaluation to have long-standing aortic valve stenosis and ischemic heart disease. Operation had been refused earlier as she declined to accept the risks of the procedure. On the present admission, a cardiac operation was considered a prerequisite for fitness to undergo colonic resection. After consenting to the operation she underwent echocardiography and cardiac catheterization, which showed calcified aortic stenosis and mild regurgitation with a mean gradient of 35 mm Hg and valve area of 0.8 cm². The left ventricular ejection fraction was 0.25 with significant lesions in the left anterior descending, first diagonal, and first obtuse marginal coronary arteries. Positron emission tomography showed reversible ischemia in the myocardium and no evidence of rectal carcinoma beyond the regional area. She underwent aortic valve replacement with a tissue prosthesis and three coronary artery bypass grafts. Her postoperative course was uneventful except for pyrexia of 39°C 6 days after the operation on the day of her planned discharge to home. In spite of preoperative and postoperative coverage with intravenous ampicillin and aminoglycoside in adequate dosage, the blood cultures grew Streptococcus faecalis. Continued antibiotic coverage resulted in negative blood cultures. Echocardiography confirmed a functioning valve with no evidence of leak. Five weeks after the cardiac operation she underwent colon resection with enteral and parenteral antibiotics.

The association between carcinoma and bacterial endocarditis has been recognized since 1951 [1]. The reason for this has been speculated to be due to entry of normal colonic flora into the bloodstream [2] or to impaired immunity [3]. The control of bacteremia is more vital in the presence of valve disease or a valve prosthesis. Streptococcus endocarditis has been specifically associated with colon cancer. We are aware of at least one report of Streptococcus faecalis endocarditis, and many reports exist of Streptococcus bovis bacteremia and endocarditis in conjunction with colon cancer [4]. That this complication developed in our patient in spite of appropriate intravenous antibiotic coverage brings to the fore that better control may require a reduction in the luminal as well as mucosal colonic microflora before valve replacement. The prevalence of Streptococcus bovis in the colon increases from 10% to 56% in the presence of a malignant lesion [4]. Reduction of luminal flora could be achieved with mechanical cleansing, whereas mucosal surface-associated bacteria would require oral antibiotics such as erythromycin and neomycin. The combination of mechanical washing with enteral and parenteral antibiotics could reduce the organism count to below the level necessary to produce infection [5].

We report our patient to say that during operation on patients with valve disease and associated colon cancer, bowel preparation as well as systemic antibiotic coverage may be required to prevent bacteremia, endocarditis, and reoperation. Cardiopulmonary bypass may facilitate bacterial entry to the systemic circulation by causing relative gut ischemia. Perhaps colon resection should be done early after valve replacement.

References

1. McCoy WC, Mason JM. Enterococcal endocarditis associated with carcinoma of sigmoid. J Med Assoc State Alabama 1951;21:162–6.
2. Murray HW, Roberts RB. Streptococcus bovis bacteremia and underlying gastrointestinal diseases. Arch Intern Med 1978;138:1097–9.[Abstract/Free Full Text]
3. Klein RS, Catalano MT, Edberg SC, Casey JI, Steigbel NH. Streptococcus bovis septicemia and carcinoma of the colon. Ann Intern Med 1979;91:560–2.[Abstract/Free Full Text]
4. Klein RS, Recco RA, Catalano MT, Edberg SC, Casey JI, Steigbigbel NH. Association of Streptococcus bovis with carcinoma of the colon. N Engl J Med 1977;297:800–2.[Abstract]
5. Smith MB, Goradia VK, Holmes JW, McCluggage SG, Smith JW, Nichols RL. Suppression of the human mucosal-related colonic microflora with prophylactic parenteral and/or oral antibiotics. World J Surg 1990;14:636–41.[Medline]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ganga Prabhakar Gregory J. England Jose L. Cruzzavala Gordon F. Murray Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Prabhakar, G. Articles by Murray, G. F. Search for Related Content PubMed PubMed Citation Articles by Prabhakar, G. Articles by Murray, G. F.