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Ann Thorac Surg 2003;75:1635-1637
© 2003 The Society of Thoracic Surgeons

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Case report

Staged laparoscopic splenectomy and valve replacement in splenic abscess and infective endocarditis

^a Division of Cardiac Surgery, Department of Surgery, University of Massachusetts Medical School, UMass Memorial Healthcare, Worcester, Massachusetts, USA,
^b Division of Infectious Diseases, Department of Medicine, University of Massachusetts Medical School, UMass Memorial Healthcare, Worcester, Massachusetts, USA
^c Cardiac Surgery, Mary Imogene Bassett Hospital, Cooperstown, New York, USA
^d Cardiac Surgery, Saint Vincent’s Hospital at Worcester Medical Center, Worcester, Massachusetts, USA
^e Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA

Accepted for publication November 1, 2002.

^* Address reprint requests to Dr Gammie, Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center N4W94, 22 South Greene St, Baltimore, MD 21201, USA (Email: jgammie{at}smail.umaryland.edu).

	Abstract

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Splenic abscess is a rare clinical entity that is most commonly associated with infective endocarditis. Valve replacement in the setting of an unaddressed splenic abscess is associated with a high incidence of prosthetic valve infection and death. We describe 2 patients with infective endocarditis and splenic abscess treated by laparoscopic splenectomy followed by valve replacement.

	Introduction

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Controversy exists regarding the proper selection, timing, and order of surgical procedures offered to the patient with concomitant infective endocarditis and splenic abscess. Eradication of all noncardiac infectious sources before valve replacement is of paramount importance. Valve replacement in the setting of an unaddressed splenic abscess is associated with a high incidence of prosthetic valve infection and death [1]. Laparoscopic splenectomy and a staged cardiac valve procedure may be the optimal management strategy for this clinical situation. We describe 2 patients with infective endocarditis and splenic abscess who were treated with this approach.

	Case reports

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Patient 1
A 78-year-old man presented with fatigue, left-sided abdominal pain, fever, and chills. Multiple blood cultures grew Staphylococcus aureus. Computed tomography (CT) of the abdomen showed a 3-cm abscess in the hilum of the spleen with multiple satellite lesions. Transesophageal echocardiogram (TEE) demonstrated a myxomatous mitral valve with a prolapsed posterior leaflet and a small vegetation on the atrial side of the anterior leaflet. There was mild to moderate mitral regurgitation. The patient was treated with nafcillin intravenously. He defervesced and subsequent blood cultures were sterile. Deemed in good clinical and functional condition 9 days after admission with no evidence of heart failure, he was discharged on a regimen of intravenous nafcillin. He presented to the emergency room 5 days later with recurrent fever and new onset atrial fibrillation. CT showed no change in the status of the splenic lesions.

An uneventful laparoscopic splenectomy was performed. Pathologic examination of the spleen confirmed the presence of multiple abscesses. He remained febrile during the postoperative period. A TEE showed moderate to severe mitral regurgitation with a perforation of the anterior leaflet. Cardiac catheterization revealed a 90% stenosis of the proximal left anterior descending artery (LAD). While waiting for a staged heart operation, the patient had an acute episode of heart failure and hypotension that necessitated urgent operation. Multiple vegetations and a perforation were observed on the anterior leaflet of the mitral valve. A mitral valve replacement with a Carpentier-Edwards porcine bioprosthesis and an aortocoronary bypass to the LAD with reversed greater saphenous vein was performed. Pneumococcal, Haemophilus influenzae type B, and meningococcal vaccines were administered. The patient was discharged on the 14th postoperative day and remains alive and in good health 1 year and 9 months postoperatively.

Patient 2
A 42-year-old man presented with arthralgia, myalgia, abdominal pain, fever, and chills. He had experienced a temporary loss of vision in his right eye 2 weeks before admission, which was attributed to a retinal bleed. Multiple blood cultures grew Streptococcus mitis. A TEE showed a 9-mm vegetation on the noncoronary leaflet of the aortic valve and mild aortic insufficiency. A CT scan of the abdomen demonstrated a lesion in the spleen consistent with an abscess. The patient became afebrile and blood cultures were sterile after intravenous antibiotics were started.

Nine days later the patient developed a pulseless right leg. Angiography revealed embolic occlusions of the infrainguinal trifurcation vessels that were treated successfully with embolectomy. Pathology confirmed their septic origin. A repeat TEE showed that the vegetation on the noncoronary leaflet was no longer present. A new 5-mm vegetation on the right coronary leaflet was observed as well as moderate aortic regurgitation. Aortic valve replacement was planned in view of the embolic episode and worsening aortic insufficiency. Cardiac catheterization demonstrated an 80% proximal stenosis of a dominant right coronary artery (RCA). A repeat CT scan of the abdomen failed to show any improvement in the splenic lesion. CT-guided needle aspiration of the splenic lesion yielded 3 mL of purulent fluid. Gram stain showed polymorphonuclear leukocytes (3+).

A laparoscopic splenectomy was performed. Pathologic evaluation of the specimen confirmed suppuration. Five days later aortic valve replacement with a bileaflet mechanical prosthesis and a right internal mammary artery bypass to the RCA was performed. Vegetations were observed on the noncoronary and right coronary leaflets of the native aortic valve. The patient did well and was discharged home on the fifth postoperative day after vaccination. He is alive and in good health 2 years and 4 months postoperatively.

	Comment

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Splenic abscess is a rare clinical entity. The largest reported series rarely include more than 10 patients in periods spanning as many as 20 years [2]. Infective endocarditis is the most common clinical scenario in which splenic abscess is recognized [3]. Clinically recognized splenic abscess occurred in 3% to 5% of cases in retrospective reviews of infective endocarditis [1]. The pathogenesis of splenic abscess in infective endocarditis is likely a septic embolism that produces a splenic infarct, which in turn evolves into a frank abscess.

In the largest reported series of patients with infective endocarditis and splenic abscess, Robinson and colleagues [1] identified 27 patients with splenic abscess among 564 (4.8%) patients diagnosed with infective endocarditis during a 20-year period. Among the 10 patients treated without splenectomy (5 of whom also had valve replacement), the mortality was 100%. In contrast, 17 patients were treated with splenectomy and 14 (82%) survived. Among the patients who underwent splenectomy, mortality was 9% with and 33% without valve replacement [1]. In a literature review of 37 patients with infective endocarditis and splenic abscess, mortality for 17 not treated with splenectomy was 100% whereas 19 of 20 treated with splenectomy survived [4]. These series provide compelling evidence that among patients with infective endocarditis and splenic abscess, splenectomy is essential to eradicate the extracardiac focus of infection as a prerequisite to successful treatment of infective endocarditis with either antibiotics alone or in concert with heart valve surgery.

Given the variable and often subtle clinical manifestations of splenic abscess, a high index of suspicion is necessary to make the diagnosis in a patient with infective endocarditis. Computed tomography is the most sensitive and specific imaging technique to diagnose splenic abscess [5]. The typical appearance of a splenic abscess on CT is a focal lesion of low attenuation with peripheral enhancement after intravenous contrast injection. The differentiation between common splenic infarcts and much rarer abscesses can be challenging. Generally, splenic infarcts appear to be well-defined, peripheral, wedge-shaped defects with the apex toward the hilum and the base extending to the capsule. Percutaneous CT-guided needle aspiration may play a role in differentiating an infarct from an abscess in equivocal cases [2].

Treatment of a splenic abscess by antibiotics alone is universally unsuccessful [2]. Percutaneous CT-guided drainage may be initially effective in 75% of patients with splenic abscess but fails to be definitive for a patient who may acquire a prosthetic heart valve. Furthermore percutaneous drainage is ineffective for treating multifocal abscesses (which occur in 40% of cases) and is dangerous for abscesses located near the hilum [2]. Splenectomy is indicated as soon as the diagnosis of splenic abscess is confirmed. Laparoscopic splenectomy is an attractive approach for patients requiring splenectomy before heart valve operation. It provides faster recovery and significantly lower morbidity compared with open splenectomy [6]. Vaccination against pneumococci, meningococci, and Hemophilus influenzae type B is indicated postoperatively to reduce the risk of overwhelming postsplenectomy sepsis.

In conclusion we believe that every patient with infective endocarditis should be evaluated for splenic lesions with routine abdominal CT scanning. The presence of a splenic abscess mandates splenectomy. If the patient is clinically stable, the optimal approach is laparoscopic splenectomy, which permits definitive resolution of the extracardiac focus of infection with least physiologic perturbation, followed by staged heart valve repair/replacement during the same hospitalization.

	References

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1. Robinson SL, Saxe JM, Lucas CE, Arbulu A, Ledgerwood AM, Lucas WF. Splenic abscess associated with endocarditis Surgery 1992;112:781-787.[Medline]
2. Allan JD. Splenic abscess. pathogenesis, clinical features, diagnosis and treatment. Curr Clin Top Infect Dis 1994;14:23-51.[Medline]
3. Alonso-Cohen MA, Galera MJ, Ruiz M, et al. Splenic abscess World J Surg 1990;14:513-517.[Medline]
4. Johnson JD, Raff MJ, Barnwell PA, Chun CH. Splenic abscess complicating infectious endocarditis Arch Intern Med 1983;143:906-912.[Abstract/Free Full Text]
5. Caslowitz PL, Labs JD, Fishman EK, Siegelman SS. The changing spectrum of splenic abscess Clin Imaging 1989;13:201-207.[Medline]
6. Park A, Targarona EM, Trias M. Laparoscopic surgery of the spleen. state of the art. Arch Surg 2001;386:230-239.

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This Article Abstract Full Text (PDF) 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): Sinan A Simsir Robert A Lancey Thomas J Vander Salm James S Gammie Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Simsir, S. A. Articles by Gammie, J. S. Search for Related Content PubMed PubMed Citation Articles by Simsir, S. A. Articles by Gammie, J. S.