Asian Cardiovasc Thorac Ann 2001;9:59-61
© 2001 Asia Publishing EXchange Pte Ltd
Excision of Aortic Vegetation in Brucella Endocarditis
Enver Duran, MD,
Hasan Sunar, MD,
Turan Ege, MD,
Suat Canbaz, MD,
Filiz Akata, MD,1,
Gültaç Özbay, MD,2
Department of Cardiovascular Surgery
1 Department of Microbiology and Infectious Disease
2 Department of Cardiology Medical Faculty, Trakya University Edirne, Turkey
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For reprint information contact: Hasan Sunar, MD Tel: 90 284 235 9594 Fax: 90 284 235 0665 email: hasansunar{at}trakya.edu.tr Department of Cardiovascular Surgery, Medical Faculty, Trakya University, E-80 Yani, Edirne 22030, Turkey.
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Abstract
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A 19-year-old man with brucella endocarditis was treated by antimicrobial therapy and surgical excision of vegetation with preservation of the native aortic valve.
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Introduction
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Brucellosis, a zoonotic disease, occurs most frequently in areas of the Middle East and Mediterranean countries. Endocarditis develops in less than 2% of cases but despite its low rate of occurrence, this complication is the leading cause of mortality.1 Aortic valve involvement and embolic phenomena are common features of brucella endocarditis and aortic valve destruction, perivalvular abscesses, and congestive heart failure may result.2 Although a few cases have been treated with antimicrobial therapy alone, surgical intervention combined with antimicrobial agents is advised.3 Valve replacement is usually preferred, however, in a small number of cases of endocarditis due to other microorganisms, simple excision of the vegetation ("vegetectomy") has been reported as an alternative conservative approach.4
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Case Report
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A 19-year-old dairyman was admitted with night sweating, arthralgia, myalgia, and weight loss. He and his family were employed in stock breeding. On physical examina-tion, a left parasternal systolic murmur and hepatospleno-megaly were found. Transthoracic echocardiography revealed moderate aortic regurgitation and a vegetation of 1 cm in diameter on the right coronary cusp of the aortic valve (Figures lA and 1B
). Left ventricular end-diastolic and end-systolic diameters were measured as 48 and 28 mm, respectively, and the septum was 11 mm in thickness. Ejection fraction was 79%. A diagnosis of brucellosis was established serologically; the patient had a positive rose bengal reaction, a positive Wright's tube agglutination test with a titer of 1/640, a positive 2-mercaptoethanol agglutination test with a titer of 1/160, and negative blood cultures. Specific antibiotic therapy with doxycycline, rifampicin, and trimethoprim plus sulfamethoxazole was started. After 4 weeks, surgery revealed a single vegetation on an otherwise normal aortic valve. There was no perivalvular abscess. The vegetation was carefully excised; the aortic valve was competent after excision. Fibrin and rare leucocytes were found on light microscopic examination of the resected vegetation. No pathogen was isolated from the vegetation. Antimicrobial therapy was continued for 9 months after the operation. Four months postoperatively, a positive Wright's tube agglutination test (titer, 1/160) was obtained. The patient's weight had increased by 6 kg. Echocardio-graphic examination revealed mild aortic regurgitation but there was no vegetation on the aortic cusps.
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Figure 1. (A & B). Echocardiographic demonstration of the vegetation (veg) in apical and parasternal windows.
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Discussion
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Brucella endocarditis is a destructive process pre-dominantly involving the aortic valve and perivalvular tissues. The valvular lesions have been described as bulky and ulcerative with gross abscesses within the cusps, destruction of commissures, and calcification. Myocardial abscesses have been found in 43% of patients on postmortem examination, and aortic root abscess seems to be a common complication of aortic valve involvement. The mortality rate exceeded 80% before the era of open heart surgery and combined antibiotic treatment.5
Although medical therapy is thought to be insufficient to eradicate this infection, there are a few reported cases of cure by antimicrobial treatment alone.3 Most patients require valve replacement in combination with anti-microbial agents. The optimal regimen or duration of antimicrobial therapy for brucella endocarditis has not been established. Doxycycline plus either streptomycin or gentamicin or doxycycline plus trimethoprim, sulfa-methoxazole, or rifampin have been recommended for more than 8 weeks and up to 10 months after valve replacement.5 Valve replacement surgery has drawbacks such as potential reinfection of the prosthetic valve and the need for lifelong anticoagulation. The most significant predictor of prosthetic valve endocarditis is the presence of active endocarditis at the time of valve replacement. No difference was found in the risk of early or late postoperative prosthetic valve endocarditis between patients receiving mechanical versus bioprosthetic valves.6 Allograft aortic valve replacement was shown to be associated with a low and constant risk of recurrent endocarditis, whereas other valve types were associated with a high early risk.7 Unfortunately, allograft aortic prostheses are difficult to come by in our country.
If no valvular destruction or root abscesses exist, simple excision of the vegetation may be used as an alternative conservative surgical treatment for bacterial endocarditis. Vegetectomy was originally described for the tricuspid valve and subsequently used as a valve-sparing therapeutic approach, especially for right-sided bacterial endo-carditis.4,5 Hughes and Noble8 reported excision of vegetation on the mitral valve of an intravenous drug abuser with staphylococcal endocarditis, with repeated vegetectomies on the tricuspid valve of the same patient. In our patient, aortic vegetectomy was performed 4 weeks after starting antibiotic treatment. This surgical approach was chosen because of the well-preserved state of the aortic valve with a single vegetation that was easily excised. To our knowledge, this is the first reported case of vegetectomy on the aortic valve. We recommend preserving the native valve in selected cases of brucella endocarditis where vegetectomy may be an effective alternative approach that avoids the disadvantages of implanting a prosthetic valve.
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References
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Guerrero MLF. Zoonotic endocarditis. Infect Dis Clin North Am 1993;3:135–52.
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Grover FL, Cohen DJ, Oprian C, Henderson WG, Sethi G, Hammermeister KE. Determinants of the occurrence of and survival from prosthetic valve endocarditis. J Thorac Cardiovasc Surg 1994;108:207–14.[Abstract/Free Full Text]
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McGiffin DC, Galbraith AJ, McLachlan GJ, Stower RE, Wong ML, Stafford EG, et al. Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg 1992; 104:511–20.[Abstract]
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Hughes CF, Noble N. Vegetectomy: an alternative surgical treatment for infective endocarditis of the atrioventricular valves in drug addicts. J Thorac Cardiovasc Surg 1988; 95:857–61.[Abstract]
This article has been cited by other articles:
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H. Sunar and E. Duran
Vegetectomy in brucella endocarditis
Ann. Thorac. Surg.,
June 1, 2002;
73(6):
2036 - 2036.
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Abstract
Introduction
