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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 25-28

Periaortic abscess forming pulsatile sac around graft in a patient with prosthetic valve endocarditis after bentall operation


1 Department of Cardiology, Bagcilar Training and Research Hospital, Health Sciences University, Istanbul, Turkey
2 Department of Cardiology, Okmeydanı Training and Research Hospital, Health Sciences University, Istanbul, Turkey

Date of Submission26-May-2018
Date of Acceptance26-Nov-2018
Date of Web Publication21-Feb-2019

Correspondence Address:
Dr. Sinan Varol
Department of Cardiology, Bagcilar Training and Research Hospital, Health Sciences University, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCA.IJCA_22_18

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  Abstract 

A 62-year-old man with high fever, general fatigue, and history of transient ischemic attack was transferred to our cardiology clinic with high clinic suspicious of endocarditis. He had a history of mitral ring annuloplasty and coronary artery bypass grafting operation before many years ago and reoperation for aortic dissection as Bentall procedure about 3 months ago. Blood tests showed leukocytosis with massive elevation of C-reactive protein, modest elevation of troponin, marked elevation of International Normalized Ratio, mild anemia, and hypoalbuminemia. Transesophageal echocardiogram (TEE) revealed a 4-mm × 15-mm round mobile mass originating from the anterior part of the mitral annular ring. In addition, there were a sac surrounding aortic graft and surrounding aneurismal aorta suggests a separation of graft because of possible aortic perivalvular abscess. There was blood flow into the sac and extensive thrombus with mobile component was seen in it. Blood cultures were positive for Streptococcus pneumoniae. Vancomycin, gentamicin, and rifampicin were chosen as antibiotic regimen. Early surgery planned for endocarditis and drained abscess cavity. However, the patient was persistently refused the third heart surgery operation. Repeat TEE showed the absence of vegetation on mitral valve and evident shrinkage of thrombus. Chest X-ray showed large left pleural effusion. Computed tomography with contrast enhancement confirmed this finding and revealed that contrast leak to the periaortic area and spreading a path under pulmonary artery to adjacent of the anterior wall of left ventricle. Thoracentesis was performed. Fistula to left pleura was suspected but not clearly confirmed. At 6 weeks of hospitalization, he clinically deteriorated. Due to confusional state, informed consent was obtained from attending relatives. The patient was transferred to the operating room. Cardiopulmonary resuscitation was initiated and thoracotomy was performed. Dehiscence of the aortic valve was seen. Infected tissues were extracted and repair with new prosthesis aortic valve was performed. Despite all resuscitation efforts, the patient died.

Keywords: Abscess, aortic valve, Bentall, dehiscence, pulsatile sac


How to cite this article:
Varol S, Özcan S, Kum G, Sahin I, Okuyan E. Periaortic abscess forming pulsatile sac around graft in a patient with prosthetic valve endocarditis after bentall operation. Int J Cardiovasc Acad 2019;5:25-8

How to cite this URL:
Varol S, Özcan S, Kum G, Sahin I, Okuyan E. Periaortic abscess forming pulsatile sac around graft in a patient with prosthetic valve endocarditis after bentall operation. Int J Cardiovasc Acad [serial online] 2019 [cited 2019 May 19];5:25-8. Available from: http://www.ijcva.com/text.asp?2019/5/1/25/250798


  Introduction Top


The Bentall procedure was first described by Bentall and De Bono in 1968. Since then, composite replacement of the aortic valve and ascending aorta has been considered the gold standard for treating ascending aortic dissection complicated by aortic regurgitation.[1] Cardiac surgery is usually required for infections of the mechanical valved conduit because of the high likelihood of resistant organism, and the possibilities of heart failure and embolization. Here, we report a case of early infective endocarditis complicated by periaortic abscess.


  Case Report Top


A 62-year-old man with high fever, general fatigue, and history of transient ischemic attack was transferred to our cardiology clinic with high clinic suspicious of endocarditis. He had a history of mitral ring annuloplasty and coronary artery bypass grafting (CABG) and mitral ring annuloplasty operation 12 years ago and reoperation for aortic dissection as Bentall procedure about 3 months ago. He has diabetes, moderate chronic obstructive pulmonary disease, and right nephrectomy for several years ago. His medication was warfarin, spironolactone plus hydrochlorothiazide, gliclazide, metformin, digoxin, furosemide, and tiotropium. The patient has tachycardia with 2/6 systolic aortic murmur. Bilateral lung sounds were normal. The embolic and rheumatic phenomenon of endocarditis were absent and other findings were normal. Electrocardiogram showed that sinus rhythm with 120 BPM. Blood tests showed leukocytosis with massive elevation of C-reactive protein (CRP), modest elevation of troponin, marked elevation of International Normalized Ratio (INR) value, mild anemia, and hypoalbuminemia [Table 1]. Minimal left pleural effusion was seen on chest X-ray. Transesophageal echocardiogram (TEE) revealed a 4-mm × 15-mm round mobile mass originating from the anterior part of mitral annular ring [Figure 1]. In addition, there were a sac surrounding aortic graft and surrounding aneurismal aorta suggests a separation of graft because of possible aortic perivalvular abscess [Figure 2] and [Video 1a] and [Video 1b]. There was blood flow into the sac and extensive thrombus with mobile component was seen in it. Blood cultures were positive for Streptococcus pneumoniae. Vancomycin, gentamicin, and rifampicin were chosen as antibiotic regimen. INR values were high during the 1st week (>5) despite K-vitamin replacement. Leukocytosis and CRP values are gradually decreased with antibiotic regimen and subsequent blood cultures were negative. After clinical stabilization and the fall of INR value to therapeutic range, early surgery planned for endocarditis and drained abscess cavity. The patient informed about his clinical status and requirement of surgical operation. However, the patient was persistently refused third heart surgery operation. At 3rd week of treatment, repeat transesophageal echocardiogram.
Table 1: Blood tests on admission

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Figure 1: Transesophageal echocardiogram revealed a 4-mm × 15-mm round mobile mass originating from the anterior part of the mitral annular ring

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Figure 2: There was a sac surrounding aortic graft and surrounding aneurismal aorta suggests a separation of graft because of possible aortic perivalvular abscess

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TEE showed absence of vegetation on mitral valve and evident shrinkage of thrombus [Figure 3] and [Video 2a] and [Video 2b]. The leukocyte count was 10900/mm3 and CRP was 108 mg/L. However, mild-to-moderate dyspnea was developed after a few days. Chest X-ray showed large left pleural effusion. Computed tomography with contrast enhancement confirmed this finding and revealed that contrast leak to the periaortic area and spreading a path under pulmonary artery to adjacent of the anterior wall of left ventricle [Figure 4]. Thoracentesis were performed. Fistula to left pleura was suspected, but not clearly confirmed by noninvasive tests. The patient was continued to refuse a heart operation. At 6 weeks of hospitalization, he suddenly gets hypotensive and clinically deteriorated. Because the patient was in a confusional state, informed consent was obtained from attending relatives. The patient was transferred to the operation room for emergency surgery. Cardiopulmonary resuscitation was initiated and thoracotomy was performed. Dehiscence of the aortic valve was seen. Infected tissues were extracted and repair with new prosthesis aortic valve was performed. However, postoperative myocardial functional recovery could not be achieved. Despite all resuscitation efforts, the patient died.
Figure 3: Repeat transesophageal echocardiogram showed the absence of vegetation on mitral valve and evident shrinkage of thrombus

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Figure 4: Computed tomography with contrast enhancement confirmed this finding and revealed that contrast leak to the periaortic area and spreading a path under pulmonary artery to adjacent of the anterior wall of the left ventricle

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  Discussion Top


Complications due infection after Bentall procedure are rare (1.4%)[2] but severe and not well documented. Staphylococci, alpha-hemolytic streptococci, and enterococci are the common causative organisms.[3] In a study consists ascending aorta prosthetic graft infections, most common organisms were coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas aeruginosa, and Candida albicans.[4] Our patient developed infective endocarditis caused by S. pneumoniae at 3 months after the procedure. Native valve endocarditis due to S. pneumoniae has become rare since the introduction of antibiotics.[5],[6],[7] Illicit drug use, altered mental status, and alcohol intake were found as risk factors for endocarditis. For prosthetic valves and graft infections, S. pneumoniae is very rare as causative organism.[8]

Austrian syndrome, the combination of meningitis, pneumonia, and infective endocarditis due to S. pneumoniae infection, is a rare entity.[9] Given its acute presentation and rapid course, patients should be closely monitored for any complications.

Treatment of pneumococcal endocarditis (PE) includes a prolonged course of intravenous antibiotics and if needed, surgery.[9] Our patient was treated conservatively, and surgical operation cannot be performed because of the refusal by the patient. However, he subsequently developed hemodynamic failure. Surgical evaluation must be pursued in any PE patients with suspicion for complication such as abscess, large vegetation, and valve perforation. The combined medical and surgical approach has improved outcomes, as compared to medical treatment alone in this group of patients.[9]


  Conclusion Top


This case illustrates the need for closer monitoring after surgery. A redo-operation for active prosthetic valve endocarditis after Bentall operation rare in published series is a serious possible complication during follow-up. Its treatment comprises early complete removal of prosthetic material under suitable antibiotic therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23:338-9.  Back to cited text no. 1
    
2.
Joo HC, Chang BC, Youn YN, Yoo KJ, Lee S. Clinical experience with the bentall procedure: 28 years. Yonsei Med J 2012;53:915-23.  Back to cited text no. 2
    
3.
Wang A, Athan E, Pappas PA, Fowler VG Jr., Olaison L, Paré C, et al. Contemporary clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007;297:1354-61.  Back to cited text no. 3
    
4.
Ramos A, García-Montero C, Moreno A, Muñoz P, Ruiz-Morales J, Sánchez-Espín G, et al. Endocarditis in patients with ascending aortic prosthetic graft: A case series from a national multicentre registry. Eur J Cardiothorac Surg 2016;50:1149-57.  Back to cited text no. 4
    
5.
Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. 2015 ESC guidelines for the management of infective endocarditis: The task force for the management of infective endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36:3075-128.  Back to cited text no. 5
    
6.
du Cheyron D, Lesage A, Le Page O, Flais F, Leclercq R, Charbonneau P, et al. Corticosteroids as adjunctive treatment in Austrian's syndrome (pneumococcal endocarditis, meningitis, and pneumonia): Report of two cases and review of the literature. J Clin Pathol 2003;56:879-81.  Back to cited text no. 6
    
7.
Henriques-Normark B, Tuomanen EI. The pneumococcus: Epidemiology, microbiology, and pathogenesis. Cold Spring Harb Perspect Med 2013;3. pii: a010215.  Back to cited text no. 7
    
8.
Marrie TJ, Tyrrell GJ, Majumdar SR, Eurich DT. Risk factors for pneumococcal endocarditis. Eur J Clin Microbiol Infect Dis 2018;37:277-80.  Back to cited text no. 8
    
9.
Martínez E, Miró JM, Almirante B, Aguado JM, Fernandez-Viladrich P, Fernandez-Guerrero ML, et al. Effect of penicillin resistance of Streptococcus pneumoniae on the presentation, prognosis, and treatment of pneumococcal endocarditis in adults. Clin Infect Dis 2002;35:130-9.  Back to cited text no. 9
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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