Ann Thorac Surg 2003;78:687-689
© 2003 The Society of Thoracic Surgeons
Case report
Pulmonary homograft endocarditis after ross procedure
Jean-Michel Grinda, MDa*,
Patricia Brazille, MDb,
Marie-Odile Bricourt, MDa,
Jean-Luc Mainardi, MDc,
Gustavo Gonzales-Canali, MDb,
Christophe Piketti, MDb,
Alain Deloche, MDa
a Department of Cardiovascular Surgery, European Hospital Georges Pompidou, Paris, France
b Department of Immunology, European Hospital Georges Pompidou, Paris, France
c Department of Microbiology, European Hospital Georges Pompidou, Paris, France
Accepted for publication June 23, 2003.
* Address reprint requests to Dr Grinda, Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, 20 rue Leblanc 75015, Paris, France
e-mail: jean-michel.grinda{at}hop.egp.ap-hop-paris.fr
 |
Abstract
|
|---|
We report the case of a 36-year-old patient who experienced an isolated acute pulmonary homograft endocarditis two years after a Ross procedure for aortic valve infective endocarditis.
|
Introduction
|
|---|
Right-sided endocarditis is uncommon, usually involving the tricuspid valve. Endocarditis of the pulmonary valve is rarely seen. The reconstruction of the right outflow tract using a pulmonary homograft during the Ross procedure may create an area predisposed to infection.
A 36-year-old human presented with a fever of unknown origin that lasted 2 weeks. During this time there was a weight loss of 7 kg and pain in the right hypochondrium.
The patient had a history of intravenous drug addiction and was positive for human immunodeficiency virus and Hepatitis C virus. He had undergone a Ross procedure for aortic endocarditis 2 years ago due to aortic homograft unavailability. At that time, three different Enterococcus faecalis phenotypes were found. A targeted antibiotic therapy was instituted for a total of 6 weeks. Since the time of the Ross procedure the intravenous addiction had stopped and the patient was placed on methadone. After the Ross procedure the patient had four satisfactory transthoracic echocardiograms (TTE) of the pulmonary autograft. On the last TTE performed 3 months before the current episode, an increased mean gradient of 28 mm Hg was noted at the right outflow pulmonary homograft. No signs of either endocarditis or homograft calcifications were found to explain this gradient. TEE was not realized.
On admission, the patient was tachycardic but had a normal blood pressure, temperature was 39°C. A 3 of 6 diastolic murmur was heard in the left parasternal region. Abdominal examination and chest auscultation were unremarkable. Leukocyte count was 8600x109 with 91% neutrophilia. C-reactive protein was 93 mg/L, and all blood cultures were positive for Enterococcus faecalis. Antibiotic treatment was initiated. Chest roentgenograms were normal. Abdominal ultrasound and computed tomography (CT) scan revealed splenomegaly. A first transeosophagal echocardiogram (TEE) was not demonstrative for either left- or right-sided valvular endocarditis. The mitral valve and the pulmonary autograft exhibited no signs of dysfunction or endocarditis, the tricuspid valve was normal, the pulmonary valve was not well visualized.
Additionally dorsolumbar roentgenogram and bone scintigraphy were normal. Six days after admission, the patient experienced right basithoracic pain, dyspnea, and recurrent fever. Chest roentgenogram indicated right basal opacity with right pleural effusion. Arterial blood gases were 68 mm Hg PO2, 37 mm Hg PCO2 with 93% of saturation without oxygen supplement. Thoracic CT scan showed right basal pulmonary infarction with pleural effusion, and a thrombus floating in the right pulmonary artery. Because of septic pulmonary embolism diagnosis, the patient underwent a second TEE which revealed large vegetations on the pulmonary valve prolapsing into the pulmonary trunk and obstructing the right pulmonary branch.
The patient was operated under cardiopulmonary bypass with cardioplegic arrest through pulmonary arteriotomy. The previously inserted pulmonary homograft was completely destroyed by large vegetations prolapsing into the pulmonary bifurcation (Fig 1). After removal of all vegetations, infected tissues, and right pulmonary branch thrombus aspiration, a new pulmonary homograft was inserted (Fig 2). Vegetations were later found to be positive for Enterococcus faecalis. The Enterococcus faecalis, however, was identified as being different from the three types of enterococcus faecalis encountered during the initial aortic endocarditis 2 years ago. The patient had an uneventful recovery following 6 weeks of targeted antibiotics: 2 weeks intravenously (Ampicilline associated with Gentamicine), 4 weeks with Ampicilline associated with Rifampicine. At 1-year follow-up the patient is well. Transthoracic echocardiography illustrated no abnormalities of either the aortic or the pulmonic orifices with a mean gradient of 15 and 12 mm Hg, respectively.
View larger version (145K):
[in this window]
[in a new window]
|
Fig 1. The pulmonary homograft completely destroyed by large vegetations prolapsing in the pulmonary bifurcation.
|
|
View larger version (178K):
[in this window]
[in a new window]
|
Fig 2. New pulmonary homograft insertion after removal of all vegetations and infected tissues and right pulmonary branch thrombus aspiration.
|
|
|
Comment
|
|---|
Right-sided endocarditis is an uncommon disease and usually involves the tricuspid valve such that pulmonary valve endocarditis is often overlooked being qualified as a "forgotten disease." However, pulmonic endocarditis is a well-recognized entity and should be consistently investigated as the other more frequent implicated valve [1, 2]. Considering the size of the vegetation found, it should have been discovered before causing a pulmonary embolism. This report strongly emphasizes that all four cardiac valves must be explored during echocardiography in order to rule out the presence of detectable valvular endocarditis [1–4]. Preexisting anatomic lesions are traditionally predisposing factors for valvular bacterial attack [3]. This situation is rare for noncongenital pulmonary valve disease. In a normal heart, right-sided endocarditis is now seen more often because of the prevalence of intravenous drug abuse, chronic intravenous catheters, notably the central catheters and the flow directed pulmonary artery catheters, and the use of pacemakers [2–4].
Ross is an increasingly performed double valvular orifice procedure. Concerning its indication, it has been proposed that the Ross procedure is illogical at the acute stage of aortic endocarditis because of the opening of the non infected pulmonary orifice in an infected area [5–9]. The implicated organisms of the two successive cases of endocarditis in our patient were Enterrococci faecalis (three different strains of Enterrococci faecalis for the first endocarditis and one entirely different strain from the second). All the Enterrococci faecalis isolated were of different phenotypes. Thus, in this patient, we cannot attribute a perioperative contamination of the pulmonary homograft during the Ross procedure. After the Ross procedure, echocardiographic studies should not be focused solely on the pulmonary autograft. Pulmonary homografts can also manifest signs of deterioration and may be affected by endocarditis. Reconstruction of the right outflow tract with a pulmonary homograft during the Ross procedure should also be considered as a risk factor for pulmonic endocarditis.
|
References
|
|---|
- Shapiro S.M., Young E., Ginzton L.E., Bayer A.S. Pulmonic valve endocarditis as an underdiagnosed disease: role of transesophageal echocardiography. J Am Soc Echocardiogr 1992;5:41-48.[Medline]
- Schaefer A., Meyer G.P., Waldow A., Weiss T., Hausmann D., Drexler H. Pulmonic valve endocarditis. Circulation 2001;103:53-54.
- Edmond J.J., Eykyn S.J., Smith L.D.R. Community acquired staphylococcal pulmonary valve endocarditis in non-drug users: case report and review of the literature. Heart 2001;86:17.[Free Full Text]
- Levitt M.A., Snoey E.R., Tamkin G.W., Gee G. Prevalence of cardiac valve abnormalities in afebrile injection drug users. Acad Emerg Med 1999;6:911-915.[Medline]
- Prat A., Saez de Ibarra J.I., Vincentelli A., et al. Ross operation for active culture-positive aortic valve endocarditis with extensive paravalvular involvement. Ann Thorac Surg 2001;72:1492-1495.[Abstract/Free Full Text]
- Bohm J.O., Botha C.A., Hemmer W., et al. The Ross operation as a combined procedure and in complicated cases is there an increased risk?. Thorac Cardiovasc Surg 2001;49:300-305.[Medline]
- Daenen W., Jalali H., Eyskens B., Gewillig M. Mid-term results of the Ross procedure. Eur J Cardiothorac Surg 1998;13:673-677.[Medline]
- Stelzer P, Weinrauch S, Tranbaugh RF. Ten years of experience with the modified Ross procedure. J Thorac Cardiovasc Surg 1998;115:1091–1100
- Erek E, Yalcinbas YK, Salihoglu E. Fate of stentless bioprostheses on right side of the heart. Asian Cardiovasc Thorac Ann 2003;Mar;11:58–62
Top
Abstract
Introduction
