Asian Cardiovasc Thorac Ann 2004;12:86-88
© 2004 Asia Publishing EXchange Ltd
Staphylococcus aureus Pancarditis Complicated by a Left Ventricular Pseudoaneurysm
Ahmed A Arifi, MD,
Alwin Koehler, MD,
Thomas MT Hwong, FRCS,
Song Wan, MD,
Innes YP Wan, FRCS,
Anthony PC Yim, MD
Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, People’s Republic of China
For reprint information contact: Ahmed A Arifi, MD Tel: 852 2632 2629 Fax: 852 2645 9544 Email: arifiahmed{at}hotmail.com Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Territories, Hong Kong, People’s Republic of China.
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ABSTRACT
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Acute septic pancarditis is a life threatening but fortunately rare condition. We report a case of this condition in a young 20-year-old female patient with an early complication of mitral valve destruction and a late complication of a left ventricular pseudoaneurysm formation.
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INTRODUCTION
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Although bacterial endocarditis is not a new disease, acute septic pancarditis due to Staphylococcus aureus is not commonly seen. The course of this condition is unpredicted and complications may arise either early in the acute phase or delayed as seen in this case. We report our experience in treating a patient with this condition who had developed an early complication of mitral valve destruction and a late complication of a left ventricular pseudoaneurysm.
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CASE REPORT
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A 20-year-old woman was hospitalized due to septic shock and was found to have a harsh systolic murmur at the apex of the heart. An urgent trans-thoracic echocardiography (TTE) was preformed on the day of admission and this showed a large vegetation on the anterior mitral leaflet with severe mitral regurgitation. Furthermore, the gram stain of the shoulder joint aspirate showed a large amount of gram positive cocci and the blood cultures taken at the time revealed significant growth of Methicillin-sensitive Staphylococcus aureus. The diagnosis of acute infective endocarditis in the context of gram positive septicemia was made. High dosages of intravenous antibiotics were given (Gentamycin and Cloxacillin) immediately and the patient was transferred to the intensive care unit for inotropic support and mechanical ventilation. Emergency surgery was performed on the next day due to failure of the medical treatments to control her sepsis. During the operation, a large amount of pus was drained from the pericardial sac and the myocardium was found to be edematous with multiple tiny pockets of abscesses together with areas of hemorrhage. The mitral valve was grossly destroyed where a large vegetation was seen on the anterior leaflet and an abscess collection over the antero-lateral commissure (Figure 1
). Severe inflammation involving the full thickness of the myocardium including the epicardium and the endocardium was seen indicating the presence of a Staphylococcus aureus pancarditis (Figure 2). The damaged valve was excised with preservation of the subvalvular apparatus. Mitral valve was replaced with a size 27 mm bileaflet St. Jude mechanical Prosthesis (St. Jude Medical, Inc. USA).
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Figure 1. Surgeon view of the mitral valve showing a large vegetation on the anterior mitral leaflet. (Arrow)
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Figure 2. Surgeon view of the anterior surface of the right ventricle showing the severity of the pancarditis.
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Postoperatively, a 4-week course of intravenous antibiotics was given. Prior to discharge, the patient suddenly developed shortness of breath and signs of hemodynamic shock. Echocardiogram was performed showing a cystic structure compressing the right atrium and ventricle. Contrast-enhanced computed tomography (CT) showed that there was a large pseudoaneurysm arising from the left ventricle compressing the right atrium (Figure 3). The patient was brought to theatre and cardio-pulmonary bypass was achieved by femoral cannulation. The pseudoaneurysm was incised (Figure 4) and the tear at the inferior surface of the left ventricle was repaired with pledged sutures and tissue glue. The patient had a slow but complete recovery and remains well six months after the second operation on follow-up.
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Figure 3. CT scan showing contrast emerging from the left ventricle to the pseudoaneurysm (PSEUDO). RA = right atrium; LA = left atrium.
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DISCUSSION
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Staphylococcus aureus has become the most common cause of acute bacterial endocarditis of native valves and is associated with high mortality rates.1 Whereas pseudoaneurysm formation with underlying infective pericarditis and endocarditis has been reported in the literature,2,3 a pancarditis originating from Staphylococcus aureus septicemia is extremely rare. To the best of our knowledge, this is the first report of the successful treatment of such a condition. Previously, only one case of staphylococcal pancarditis, when the patient died of toxic shock syndrome, was reported.4 The present case was also unusual in that the patient was young, with no evidence of intravenous drug abuse and had no history of previous disease or signs suggestive of immune dysfunction.
Our case also illustrates the fact that life threatening complications can occur after the initial disease of pancarditis. It is well known that septic abscesses in the myocardium and other organs can occur with Staphylococcus aureus septicemia5 and in very rare circumstances, ventricular rupture may occur with a pancarditis as the structural integrity of the heart muscle is weakened at multiple sites.
In conclusion, despite early surgical interventions to remove all infective sources from the body and aggressive antibiotic therapy, Staphylococcus aureus pancarditis may still lead to late complications of ventricular rupture and pseudoaneurysm formation. CT imaging is very useful in demonstrating the pseudoaneurysm and thus can provide important information for perioperative planning.6,7
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R. Vijayvergiya, Dhanaraj Singh Chongtham, Shyam Kumar Thingnam, A. Grover, and A. Lal
Left Ventricular Pseudoaneurysm With Infective Pericarditis: A Rare Cause of Intractable Hemoptysis
Angiology,
August 1, 2008;
59(4):
507 - 509.
[Abstract]
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