Asian Cardiovasc Thorac Ann 1999;7:65-67
© 1999 Asia Publishing EXchange Pte Ltd
Cardiac Rupture Due to Mitral Valve Endocarditis
Gennaro Ismeno, MD,
Attilio Renzulli, MD,
Renato Bellitti, MD,
Franco E Covino, MD,
Marisa De Feo, MD,
Maurizio Cotrufo, MD
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Institute of Cardiac Surgery Second University of Naples, V Monaldi Hospital Naples, Italy
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For reprint information contact: Attilio Renzulli, MD Tel: 39 81 553 9035 Fax: 39 81 553 6350 email: renzulliattilio{at}usa.net Via Aquila, 144, Naples 80143, Italy.
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Abstract
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A 66-year-old lady with a history of mitral valve endocarditis and recent onset of low-output syndrome, underwent successful emergency surgery for myocardial rupture with hemopericardium. Visualization of the abscess cavity was not possible with transthoracic echocardiography and a definitive diagnosis was made by transesophageal echocardiography. Diagnostic and therapeutic aspects of mitral valve abscess are reviewed.
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Introduction
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Abscesses formation is a common complication of infective endocarditis.1 However, abscess perforation leading to hemopericardium is rare. It has been almost exclusively reported as a complication of aortic valve endocarditis, with an incidence ranging from 0.022% to 0.035%.2,3 Penetrating mitral valve annular abscess leading to cardiac rupture and hemopericardium has been described rarely.3 We report a case of mitral valve annular abscess that perforated into the pericardium.
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Case Report
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A 66-year-old obese female with a previous history of chronic liver disease and insulin-dependent diabetes was admitted with a fever of 39°C, congestive heart failure, atypical chest pain, and leukocytosis. Transthoracic echocardiography showed mitral valve anterior leaflet prolapse with significant regurgitation and vegetation of 1.5 cm in diameter on the posterior leaflet. Blood cultures grew Staphylococcus epidermidis. Intravenous antibiotic therapy was started with 2 g per day of ceftriaxone together with a diuretic and digitalis. This gave temporary relief of symptoms but the clinical condition suddenly worsened on the 10th day after admission. The patient complained of shortness of breath at rest and there were clinical signs of congestive heart failure and pulmonary edema. On examination, a systolic (4/6) murmur was heard at the apex. Chest radiography showed cardiac enlargement, pulmonary edema, and right pleural effusion. Emergency transthoracic echocardiography showed a calcified mitral annulus, severe mitral valve regurgitation, vegetation on the posterior leaflet, and significant pericardial effusion (Figure 1
). Transesophageal echocardiography confirmed the previous findings and showed a myocardial abscess with a cavity on the posterior mitral valve annulus (Figure 2). Although no flow was seen between the heart and the abscess, the findings of an empty abscess and pericardial effusion were highly suggestive of rupture of the myocardial abscess into the pericardium.
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Figure 1. Transesophageal echocardiography showing vegetation on the posterior mitral leaflet and pericardial effusion. LA = left atrium, LV = left ventricle, PA = pulmonary artery.
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Figure 2. Transesophageal echocardiography showing a myocardial abscess on the posterior left ventricular wall. The cavity seems to be filled with blood although no flow between the cardiac cavities and the abscess was detected with color Doppler. LA = left atrium, LV = right ventricle, PML = posterior mitral leaflet.
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The patient underwent emergency surgery through a median sternotomy. The pericardium was opened and old fibrinous material and fresh clots were removed. A large hematoma was seen in the atrioventricular groove on the diaphragmatic surface of the heart. Hypothermic (28°C) cardiopulmonary bypass was started and the heart was protected with multiple doses of crystalloid cardioplegia. A longitudinal left atriotomy was performed. There was a significant prolapse of the mitral valve anterior leaflet with cordal rupture and a 2 x 1.8 cm area of vegetation. The posterior leaflet and the annulus were calcified. The mitral valve was excised and an abscess of 1.5 cm in diameter was identified at the level of the posterolateral commissure. The abscess communicated with the pericardial space. Annular debridement was performed, the abscess was closed with a pericardial patch, and a Sorin Bicarbon (Sorin Biomedica, Saluggia, VC, Italy) prosthesis was implanted with unpledgeted mattress sutures. The postoperative course was stormy and complicated by a low-output state and renal failure. The patient was treated with high doses of inotropic drugs (epinephrine, dopamine, isoprenaline), ultrafiltration, and hemodialysis. Her hemodynamic condition gradually improved and inotropic support was discontinued on the 7th postoperative day. However, the patient could not be weaned from the ventilator and a tracheotomy was performed on the 10th postoperative day. Mechanical ventilation was discontinued on the 20th postoperative day, renal function became normal on the 30th postoperative day, and the patient was discharged 7 days later. At follow-up one year later, the patient was asymptomatic, in New York Heart Association functional class I, and with no signs of a recurrence of endocarditis.
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Discussion
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Although there have been some reports of myocardial abscesses following myocardial infarction or angioplasty, the main cause of myocardial abscesses is bacterial endocarditis. Myocardial abscesses have been documented as complications in patients suffering from malignancy, hepatic disease, diabetes, endstage kidney failure, burns, and osteomyelitis.2,4 Progress in imaging techniques such as transesophageal echocardiography has improved the diagnosis of complications of bacterial endocarditis. However, occult abscesses may go undetected and the reported incidence in autopsy studies is approximately 1%.2,5
The location of the abscess varies from case to case. Native aortic valve involvement appears to be more frequent and a mitral annular abscess is an uncommon finding. Perforation of a mitral annular abscess into the pericardial space is a rare but life-threatening complication.3 Staphylococcus aureus has been implicated most often as the infecting organism. Polymicrobial etiology and candida abscess formation have become more frequent as a result of long-term antibiotic therapy but many other organisms have been isolated.1,3–5 Clinically, this infection may present acutely or silently. In most cases, the clinical signs of endocarditis precede abscess symptoms.5
Free perforation and hemopericardium due to abscess rupture are rare complications.3,6,7 Two mechanisms of myocardial rupture following mitral valve endocarditis have been described. Posterior left ventricular rupture has been reported following myocardial infarction caused by a septic embolism.6,7 As in the case reported here, myocardial rupture can be caused by a penetrating mitral annular abscess perforating into the pericardial space.3,8
Transesophageal echocardiography was found to have greater specificity than the transthoracic approach.9 Nevertheless, cases of myocardial abscess may be undetected in spite of accurate preoperative investigations.9,10 Therefore, a deterioration in the clinical condition of a patient with mitral valve endocarditis and pericardial effusion may lead to the diagnosis of a perforated abscess requiring emergency surgical treatment.
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References
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Abstract
Introduction
