Asian Cardiovasc Thorac Ann 2001;9:318-319
© 2001 Asia Publishing EXchange Pte Ltd
Repeat Tricuspid and Mitral Valve Replacement for Enterococcal Endocarditis
Yoshiharu Hamanaka, MD,
Norimasa Mitsui, MD,
Shinji Hirai, MD
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Department of Thoracic and Cardiovascular Surgery Hiroshima Prefectural Hospital Hiroshima, Japan
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For reprint information contact: Yoshiharu Hamanaka, MD Tel: 81 82 254 1818 Fax: 81 82 253 8274 email: yhamanaka-circ{at}umin.ac.jp Department of Thoracic and Cardiovascular Surgery, Hiroshima Prefectural Hospital, 1-5-54 Ujina-kanda, Minami-ku, Hiroshima 734-8530, Japan.
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ABSTRACT
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A man who underwent tricuspid and mitral valve replacement with bioprostheses at 45 years of age required a second double valve replacement at 50, a third tricuspid valve replacement for enterococcal endocarditis at 57, and a third mitral valve replacement for relapsing enterococcal endocarditis at the age of 60. Recurrent Enterococcus faecalis prosthetic valve endocarditis was thought to be due to colon polyps causing intermittent infection.
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INTRODUCTION
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Repeat prosthetic valve replacement, especially for prosthetic valve endocarditis, remains a challenging situation. We report an unusual case of relapsing enterococcal prosthetic valve endocarditis associated with bleeding colon polyps.
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CASE REPORT
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A man who had undergone closed mitral commissurotomy for rheumatic mitral stenosis at 24 years of age, required mitral and tricuspid valve replacement with bioprostheses at the age of 45. When he was 50 years old, he underwent a second double valve replacement because of structural valve deterioration, with implantation of a mechanical valve in the mitral position and a biological valve in the tricuspid position. At 54 years of age, he was admitted with infective endocarditis. Blood cultures grew Entero-coccus faecalis and became negative after extended antibiotic treatment (piperacillin 8 g daily for 4 weeks, fosfomycin 8 g daily for 6 weeks increasing to 12 g daily for 3 weeks). Two years later, he suffered a similar episode of infective endocarditis. At 57 years of age, he suffered a 3rd episode of infective endocarditis, which was successfully treated, but subsequently, malfunction of the tricuspid bioprosthesis was diagnosed by echocardio-graphy. He underwent a 3rd tricuspid valve replacement (with a mechanical valve) and implantation of a permanent pacemaker with an epicardial pacing lead for atrial fibrillation with bradycardia. The explanted valve showed overgrowth of neointima extending to the valve cusps, which markedly reduced their mobility (Figure 1
). Blood and neointimal tissue cultures were negative. There were 4 further admissions for treatment of Enterococcus faecalis endocarditis in the next 3 years. Tarry stool was noted on one occasion and colon fiberscopy showed bleeding polyps that were resected successfully. Pathology of the polyps revealed tubular adenoma.
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Figure 1. Right ventricular aspect of the removed valve. Neointima extended to the valve cusps markedly reducing their mobility. Neointimal tissue cultures grew no microorganisms.
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When the patient was 60 years old, perivalvular leakage of the mitral prosthesis was detected, so he was referred for a 3rd mitral valve replacement. On admission, he had normal prosthetic valve sounds and a grade 2/6 systolic regurgitant murmur at the apex. Chest radiography showed moderate cardiomegaly (cardiothoracic ratio, 62%). A transesophageal echocardiogram revealed moderate mitral perivalvular regurgitation. The left ventricle was not dilated and maintained normal function with an estimated ejection fraction of 63%. Mitral valve replacement was carried out under cardiopulmonary bypass with moderate hypothermia (30°C) after a median sternotomy and dissection of pericardial adhesions. Antegrade warm blood cardioplegia was infused every 15 minutes and cardiac arrest was maintained. The left atrium was entered by an atrial septum incision, and the mitral valve prosthesis was exposed. There was a perivalvular tissue defect involving the posterior one-third of the annulus. After removing the mitral valve prosthesis, all visibly infected annular tissue was excised, and a new mechanical valve was implanted. The aortic crossclamp time was 243 minutes and the total aortopulmonary bypass time was 332 minutes. Weaning from cardiopulmonary bypass was uneventful and the postoperative course was smooth. The patient was dis-charged with negative postoperative blood cultures. He was doing well with no fever at 10 months postoperatively.
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DISCUSSION
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Morishita and colleagues1 reported that advanced New York Heart Association functional class and low left ventricular ejection fraction were independent predictors of late death in patients having repeat prosthetic valve replacements. In patients having redo bioprosthetic valve replacement, Akins and colleagues2 found that predictors of hospital death were age greater than 65 years, male sex, renal insufficiency, and non-elective operation. In those reoperated for prosthetic valve endocarditis, Lytle and colleagues3 noted that the only variables significantly associated with increased hospital mortality were impaired left ventricular function, preoperative heart block, coronary artery disease, and culture of organisms from the surgical specimen.
This case of a 60-year-old man who successfully under-went multiple elective prosthetic valve replacements for treatment of prosthetic valve endocarditis with normal left ventricular function indicates that redo valve replacement should be performed before the patient's condition deteriorates. Enterococci, most often Entero-coccus faecalis, causes 5% to 20% of cases of infective endocarditis.4–6 Enterococcal endocarditis is usually a disease of older men, and the most frequent source of infection is the genitourinary tract.6 Hoen and colleagues7 concluded that colon tumors (especially malignant tumors) are a risk factor for the development of Streptococcus bovis endocarditis. Other gut organisms have been reported to infect heart valves when colorectal pathology was present, but far less frequently than Streptococcus bovis.8 This report concerns Enterococcus faecalis prosthetic valve endocarditis from an unusual source: a colon polyp that was thought to cause intermittent infection. A patient with relapsing enterococcal endocarditis in the absence of another infectious source should be carefully examined for a colon tumor.
Presented at the 8th Annual Meeting of The Asian Society for Cardiovascular Surgery, Fukuoka, Japan, September 6–8, 2000.
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REFERENCES
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Morishita K, Mawatari T, Baba T, Fukada J, Abe T. Re-replacement for prosthetic valve dysfunction: analysis of long-term results and risk factors. Ann Thorac Surg
1998;65:696–9.[Abstract/Free Full Text]
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Akins CW, Buckley MJ, Daggett WM, Hilgenberg AD, Vlahakes GJ, Torchiana DF, et al. Risk of reoperative valve replacement for failed mitral and aortic bioprostheses. Ann Thorac Surg
1998;65:1545–52.[Abstract/Free Full Text]
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Lytle BW, Priest BP, Taylor PC, Loop FD, Sapp SK, Stewart RW, et al. Surgical treatment of prosthetic valve endocarditis. J Thorac Cardiovasc Surg
1996;111: 198–210.[Abstract/Free Full Text]
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Gordon SM, Serkey JM, Longworth DL, Lytle BW, Cosgrove DM III. Early onset prosthetic valve endocarditis: the Cleveland Clinic experience l992–1997. Ann Thorac Surg
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Dossche KM, Defauw JJ, Ernst SM, Craenen TW, De-Jongh BM, de-la-Riviere AB. Allograft aortic root replacement in prosthetic aortic valve endocarditis: a review of 32 patients. Ann Thorac Surg
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Megran DW. Enterococcal endocarditis. Clin Infect Dis
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Hoen B, Briancon S, Delahaye F, Terhe V, Etienne J, Bigard MA, et al. Tumors of the colon increase the risk of developing Streptococcus bovis endocarditis: case-control study. Clin Infect Dis
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Milbrandt E. A novel source of enterococcal endocarditis. Clin Cardiol
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ABSTRACT
INTRODUCTION
