Ann Thorac Surg 2000;70:2158-2159
© 2000 The Society of Thoracic Surgeons
Case report
Isolated right ventricular outflow tract mass presenting as hemoptysis
Kanti M. Uppal, MDa,
Ismael N. Nuño, MDa,
Daniel S. Schwartz, MDa,
Kenneth A. Ashton, MDa,
Vaughn A. Starnes, MDa
a Department of Cardiothoracic Surgery, University of Southern California School of Medicine, Los Angeles, California, USA
Accepted for publication March 16, 2000.
Address reprint requests to Dr Schwartz, Department of Cardiothoracic Surgery, USC School of Medicine, 1510 San Pablo St, Suite 415, Los Angeles, CA 90033
e-mail: dschwartz{at}surgery.usc.edu
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Abstract
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Infective endocarditis presenting as an isolated right ventricular outflow tract mass is rare. We report a 34-year-old man with no history of congenital heart defect or intravenous drug abuse who presented with hemoptysis and fevers. Diagnostic workup revealed isolated right ventricular outflow tract vegetation. Despite aggressive antibiotic treatment for endocarditis, he developed septic emboli and acute respiratory distress. He was taken to the operating room for successful resection of the ventricular mass.
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Introduction
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Despite the improvements in antimicrobial therapy, infective endocarditis (IE) continues to result in substantial morbidity and mortality. Rapid diagnosis and effective treatment of its complications are essential for patient survival. Suspicion for IE is necessary, even in the absence of typical symptoms such as peripheral emboli and immunologic vascular phenomena, due to the variability of clinical presentation. Patients with right-sided IE lesions may not have these typical symptoms.
A 34-year-old man with no medical or social history presented with a 2-week history of productive cough that progressed from blood-tinged sputum to teaspoon quantities of dark red mucus three to four times per day. In addition, he also complained of worsening fevers, chills, and night sweats. On examination he was dyspneic and had a new II/VI holosystolic heart murmur heard over the left sternal border. His white blood cell count (WBC) was 38,000. Chest roentgenogram revealed infiltrates of both lower lobes. He was started empirically on antibiotics for suspected pneumonia. His hemoptysis worsened, requiring ventilatory support. Blood cultures revealed Staphylococcus aureus and bronchoscopy was nondiagnostic. A transesophageal echocardiogram was performed, which revealed a pedunculated mobile mass in the right ventricle, approximately 1 x 1.5 cm, which had prolapsed into the right ventricular outflow tract (RVOT) (Fig 1). Normal ventricular function was observed and no evidence of valvular regurgitation was apparent.
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Fig 1. Transesophageal echocardiogram demonstrating the pedunculated mass (arrows) partially obstructing the right ventricular outflow tract (LV = left ventricle; RV = right ventricle).
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Despite intravenous antibiotics, the patient continued to have daily fevers, an elevated WBC, and bilateral pulmonary infiltrates over the next 6 days. In addition, his pulmonary status worsened, requiring increased FiO2 and pressure support. A repeat echocardiogram revealed no change in the RVOT mass. The patient was taken to the operating room for surgical resection of the ventricular mass.
At operation, the tricuspid and pulmonary valves appeared normal. However, there was a pedunculated grayish mass measuring 1.5 x 3.0 cm attached by a thin stalk to the right posterior ventricular wall. There was no evidence of a ventricular septal defect or other cardiac defect. The mass was excised and histologic evaluation revealed a formed clot along with fibrous tissue with no evidence of infective organisms.
Computed tomography of the chest, abdomen, and pelvis was performed but was unable to detect the source of infection. The patient’s postoperative course was unremarkable; results of his chest roentgenogram were normal and he was discharged on antibiotics.
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Comment
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Previous reports have demonstrated various forms of IE which commonly affect the heart valves. In addition, there have been isolated cases of IE which involve the interventricular septum of individuals diagnosed with ventral septal defect. We report a unique case of isolated RVOT vegetation not adherent to the tricuspid or pulmonic valve in an individual with no history of congenital heart defect or intravenous drug abuse.
Endothelial surface damage and exposure of underlying collagen initiate the process of IE. This process provides a thrombogenic and receptive surface for bacterial colonization during episodes of bacteremia. The lesions of IE tend to form just beyond the narrowed orifice through which the high velocity jet stream passes. Lesions typically occur on the ventricular surfaces of aortic valves, the atrial surfaces of mitral or tricuspid valves, and the walls of the pulmonary artery at the orifice of the patent ductus arteriosus. Cure of IE requires sterilization of the vegetations that develop on the cardiac endothelial surfaces with appropriate antibiotics.
Infective endocarditis that involves the right side of the heart has been estimated previously to account for approximately 5% of all cases of IE [1]. These studies have shown that 73% of right-sided heart IE cases have preexisting congenital heart disease or acquired valvular lesion [2]. Our patient represents the subset of individuals without history of drug use and without evidence of underlying cardiac abnormality.
The complications of IE have been well studied. The most frequent cause of death in IE patients remains congestive heart failure due to valvular damage and subsequent insufficiency [3]. Previous case studies of individuals with right-sided heart IE and septic pulmonary emboli have examined their experience of associated hemoptysis [4]. The septic pulmonary emboli are the result of dislodgment or seeding from the vegetations which leads to subsequent necrosis and cavitations in the pulmonary parenchyma, which can result in abscess formation [5]. Continued infection of the pulmonary tissue erodes into the surrounding blood vessels and bronchial airways, resulting in hemoptysis. Hemoptysis in an individual with known right-sided IE should be addressed early with careful monitoring in an intensive care facility. Careful monitoring with aggressive medical management is the primary mode of treatment for these patients. Worsening cardiac hemodynamics due to progression of infection and destruction of valvular or other endocardial structures warrant surgical intervention. Attempts to stabilize and treat the underlying infection should be made, but patients who do not respond to medical therapy also become surgical candidates.
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References
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Bain R.C., Edwards J.E., Scheifley C.H., Geroci J.E. Right sided bacterial endocarditis and endarteritis. Am J Med 1958;24:98-102.[Medline]
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Cassling R.S., Rogler W.C., McManus B.M. Isolated pulmonic valve infective endocarditis: a diagnostically elusive entity. Am Heart J 1984;109:558-567.
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Weinstein L., Rubin R. Infective endocarditis—1973. Prog Cardiovasc Dis 1973;16:239-242.[Medline]
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Webb D.W., Thadepalli H. Hemoptysis in patients with septic pulmonary infarcts from tricuspid endocarditis. Chest 1979;76:99-100.[Abstract/Free Full Text]
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Roberts W.C., Buchbinder N.A. Right sided valvular infective endocarditis. A clinicopathological study of twelve necropsy patients. Am J Med 1972;53:7-12.[Medline]
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Abstract
Introduction
