Ann Thorac Surg 2003;76:931-933
© 2003 The Society of Thoracic Surgeons
Infective aortitis associated with the nonpatent remnant of a ductus arteriosus
Walter J. Flapper, MBChBa,
Anand S. Dixit, FRACSa,
Mark M. Murton, FRACSa*
a Tasmanian Cardiothoracic Unit, Royal Hobart Hospital, Tasmania, Australia
Accepted for publication February 15, 2003.
* Address reprint requests to Dr Murton, Tasmanian Cardiothoracic Unit, GPO Box 623, Hobart, Tasmania 7001, Australia
Infective aortitis is a rare condition, which occurs most commonly in association with some form of structural abnormality of the heart or vessel wall. We describe the successful excision of an infected, nonpatent remnant of the ductus arteriosus.
Bacterial infections of the large elastic arteries, such as the aorta, are rare. In the preantibiotic era, Streptococcus pyogenes and syphilis were the most common causes of such infections [1,2], although in more recent times these bacteria have become increasingly uncommon. It is well recognized, however, that infection of the heart and large arteries occurs most commonly in association with some form of structural abnormality of the vessel or the vessel wall. Patent ductus arteriosus is a well-documented cause of bacterial endarteritis , as is coarctation of the aorta . The incidence of aortitis in patients with a patent ductus arteriosus has declined significantly since the introduction of ligation of the patent ductus in 1939 . We describe the successful excision of an infected remnant of the ductus arteriosus in a 57-year-old man.
A 57-year-old man was admitted to hospital with a 3-week history of ongoing lethargy, anorexia, persistent fever, and pain in both his right foot and his upper abdomen. Three weeks before admission he had been investigated for right upper quadrant abdominal pain. An ultrasound scan done at that time demonstrated a thickened gallbladder wall with no evidence of gallstones. His pain had resolved with a course of intravenous antibiotics. He was previously fit and well and his past medical and surgical history was unremarkable.
Physical examination revealed a low-grade fever of 37.8°C. His right foot was pale and cold with diminished pedal pulses. No further abnormalities were detected on physical examination. Laboratory investigations including a full blood count, serum biochemistry, and blood cultures were all normal. Electrocardiogram and chest roentgenogram results were normal. A V/Q scan showed a low probability for pulmonary embolus. A repeat ultrasound of the abdomen revealed a normal gallbladder and a 3.3-cm hypoechoic area in the spleen, suggesting a splenic infarct.
Because of suspicion that the patient may be having septic emboli from the heart, a transthoracic echocardiogram was carried out to exclude this possibility. These results were normal, however. A transesophageal echocardiogram demonstrated an intraaortic mass arising opposite the origin of the left subclavian artery. The heart valves were all normal. It was decided to take the patient to the operating room.
A left posterolateral thoracotomy was carried out, which revealed no evidence of any disease affecting the wall of the aorta. The aorta was mobilized and a Gott shunt was inserted superiorly at the level of the left common carotid artery and inferiorly at approximately the level of T5 vertebra. The aorta was cross-clamped and the midthoracic aorta opened by a longitudinal incision. A fibrinous structure attached to the remnant of the ductus arteriosus by a long pedicle was discovered (Fig 1),
with some adherence to the aortic wall distally. This mass was carefully removed in a piecemeal fashion. The area of the ductus (Fig 2) was then excised and a 26-mm Vascutek (Sulzer Australia Pty Ltd Lvl 1, 384 Eastern Valley Way, Chatswood, New South Wales 2067, Australia) graft inserted as an interposition graft using a continuous Prolene (Ethicon, Somerville, NJ) suture.
After the patients return to the recovery ward, he developed a cold, white, pulseless left foot. Angiography revealed this development to be related to an embolus at the popliteal trifurcation. This clot was removed successfully. The following day he was noted to have an expressive dysphasia. A computed tomography scan of the brain showed evidence of a left parietooccipital infarct. His dysphasia improved over the next few days. His upper abdominal pain slowly resolved more than 2 weeks after the operation. He continued to have spike fevers of 38°C despite intravenous antimicrobial therapy using gentamicin and vancomycin and his white cell count remained elevated at 27 x 106/L. A repeat ultrasound scan and computed tomography of the abdomen confirmed the diagnosis of acalculous cholecystitis and an infarcted spleen.
Two weeks after his surgery, the patient was discharged from hospital. Antibiotics were continued for a further 6 weeks. To date the patient remains fully independent despite a residual mild hemiparesis. He is well known to the staff at the Tasmanian cardiothoracic unit, whom he visits regularly and he continues to enjoy life.
The histology report from the specimen showed an intraluminal thrombus arising on an underlying ulcerated plaque, showing numerous degenerate neutrophils within the thrombus suggestive of bacterial endarteritis. At the external aspect of the aorta, a small, obliterated artery was noted, presumably the ligamentum arteriosum. Special stains showed no evidence of bacteria or fungi and no organisms were isolated on culture.
The large elastic arteries of the body are generally resistant to bacterial infection , and when infection does occur it is commonly associated with some form of structural anomaly of the vessel or its wall. Aortitis is also commonly associated with the vegetations in infective endocarditis. In a nontreated patent ductus arteriosus, subacute bacterial endarteritis is not an uncommon complication , occurring at any age but most commonly during childhood and early adulthood. In one series of postmortem examinations, endarteritis was found to be the cause of death in 30% of 92 cases of primary patent ductus arteriosus . However, the current literature does not recommend routine closure of clinically apparent patent ductus arteriosus for the sole purpose of eliminating the risk of infective endarteritis . A clinically silent patent ductus arteriosus can similarly become infected; however, such infection is extremely rare and to our knowledge has been reported only twice in the literature [10,11]. To our knowledge no reports to date in the literature have described endarteritis arising from a nonpatent remnant of the ductus arteriosus.
- Gomes M.N., et al. Infected aortic aneurysms, a changing entity. Ann Surg 1992;215:435-442.[Medline]
- Stengel A., Wolferth C.C. Mycotic (bacterial) aneurysms of intravascular origin. Arch Intern Med 1923;31:527-535.
- Thilén U., ström-Olsson K. Does the risk of infective endarteritis justify routine patent ductus arteriosus closure?. Eur Heart J 1997;18:503-506.[Abstract/Free Full Text]
- Idir M., Denisi R., Parrens M., Roudaut R., Deville C. Endarteritis and false aneurysm complicating aortic coarctation. Ann Thorac Surg 2000;70:966-969.[Abstract/Free Full Text]
- Johnson D., Rosenthal A., Nadas A. A forty-year review of bacterial endocarditis in infancy and childhood. Circulation 1975;51:581-588.[Abstract/Free Full Text]
- Parkhurst G.F., Decker J.P. Bacterial aortitis and mycotic aneurysm of the aorta. Am J Path 1955;31:821-825.[Medline]
- Touroff A.S., Vesell H. Experiences in the surgical treatment of subacute streptococcus viridans endarteritis complicating patent ductus arteriosus. J Thorac Surg 1940;59:83.
- Abbott M. Atlas of congenital heart disease. New York: American Heart Association, 1936.
- Sullivan I.D. Patent arterial duct: when should it be closed?. Arch Dis Child 1998;78:285-287.[Free Full Text]
- Balzer D.T., Thomas L.S., McMullin D., William C. Endarteritis associated with a clinically silent patent ductus arteriosus. Am Heart J 1993;125:1192-1193.[Medline]
- Parthenakis F.I., Kanakaraki M.K., Vardas P.E. Silent patent ductus arteriosus endarteritis. Heart 2000;84:619.[Free Full Text]