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Query: UMLS:C0014118 (endocarditis)
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Cocaine abuse is widespread in North America. It is estimated that almost one in every four Americans has used cocaine at least once in his/her lifetime. In the past two decades, cocaine related cardiovascular complications have mushroomed because cocaine has become cheaper and more readily available. The fundamental effects of cocaine on cardiovascular system are similar to those observed following an intense, sympathetic stimulation. Cocaine intake results in marked increase in blood pressure, myocardial oxygen demand and heart rate. Coronary blood flow, which increases in response to exercise (endogenous sympathetic stimulation) however, is decreased by cocaine intake. Increased demand of oxygen by the myocardium in the face of decreased supply in subjects with cocaine use, leads to myocardial ischemia, which in turn forms a substrate for most of the cardiovascular complications, namely, myocardial infarction, cardiac arrhythmias and acute pulmonary edema. Hypertension related complications, dissection and rupture of aortic aneurysm, hemorrhagic stroke, in addition to infective endocarditis, myocarditis, cardiomyopathy all occur more frequently in cocaine addicts. In this review, pertinent clinical pharmacology and cardiovascular risks associated with cocaine abuse are presented.
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PMID:Cardiovascular effects of cocaine abuse. 829 63

Pregnancy carries substantial maternal and fetal risks in patients with uncorrected or palliatively corrected cyanotic congenital heart disease (CHD). In tricuspid valve Ebstein's anomaly, pregnancy is well tolerated. Maternal mortality in tetralogy of Fallot seems to be less than 10%, but it exceeds 50% in Eisenmenger's syndrome and primary pulmonary hypertension (PPH). Maternal hematocrit greater than 60%, arterial oxygen saturation lower than 80%, right ventricular hypertension, and syncopal episodes are poor prognostic signs. Maternal risk could be reduced by vaginal delivery. Continuous monitoring of arterial and central venous pressure, electrocardiography, and pulse oximetry are recommended for every anesthetic procedure. The use of a pulmonary artery catheter is controversial and probably should be avoided in parturients with cyanotic CHD or PPH. The choice of anesthetic technique and drugs per se is of secondary importance and should be governed by individual preferences. Titration of anesthetic drugs, general anesthesia with controlled ventilation, or, preferably, regional anesthesia with spontaneous breathing should be used cautiously to avoid worsening of the preexisting condition. Prevention of excessive erythrocytosis, volume and blood loss substitution, cardiocirculatory pharmacologic support, prophylaxis of infective endocarditis, and judicious use of anticoagulant drugs should be applied as indicated by the type and presentation of CHD. Poor outcome of pregnancy in PPH requires an early consideration of heart-lung or lung transplantation. Multidisciplinary team effort and prolonged monitoring in the intensive care unit are mandatory to ensure a favorable outcome for cyanotic CHD and PPH parturients.
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PMID:Cyanotic congenital heart disease and pregnancy: natural selection, pulmonary hypertension, and anesthesia. 837 15

The number of patients with congenital cyanotic heart disease who reach child-bearing age is increasing. This is partly a consequence of the high long-term survival and the haemodynamic benefits resulting from the Fontan procedure, which is used for the definitive palliation of such cyanotic heart disease as tricuspid atresia and single ventricle. However, so far little experience has been recorded with pregnant patients who have undergone right ventricular exclusion procedures. The particular physiology of a univentricular heart and a passive, non-pulsatile blood flow through the lungs has significant implications for the anaesthetic obstetric management of these patients. We report a case of successful pregnancy and caesarean delivery after a modified Fontan procedure. CASE REPORT. The patient was a 30-year-old pregnant woman with a singleton pregnancy. At the age of 20, after four palliative shunt operations, she had undergone a modified Fontan operation due to tricuspid atresia with a single ventricle, d-transposition of the great arteries, pulmonary atresia and a single atrium. Following the Fontan repair, she initially suffered from intermittent Wolff-Parkinson-White syndrome and isorhythmic AV dissociation. The pregnancy was uneventful, and caesarean section was scheduled for 32 weeks' gestation. Because of the increased risk of thrombosis, the patient was treated with s.c. heparin preoperatively; for this reason, epidural anaesthesia was excluded, though it may otherwise be preferred for such patients. Amoxicilline was used to prevent endocarditis. At the date of caesarean delivery her body weight was 54 kg and boy height, 155 cm. Before induction of anaesthesia, a central venous and a radial artery catheter were placed for invasive pressure monitoring. An exaggerated left lateral tilt position was used to avoid aortocaval compression. After careful preoxygenation, anaesthesia was induced with 24 mg etomidate, 1.5 mg norcuronium, and 75 mg succinylcholine. Halothane 0.5-0.7% in oxygen was used during the first few minutes of surgery. Central venous pressure under mechanical ventilation was 20 mmHg, while the heart rate varied between 70 and 90 bpm. Delivery was accomplished 8 min after the induction of anaesthesia. The Apgar scores after 1 and 5 min were 9 and 10, respectively. Anaesthesia was continued with fentanyl, midazolam and nitrous oxide 50%. The remainder of surgery was unevenful. The child is now 5 years old and healthy. The mother has a near-normal activity level and does not need any help to care for her child. DISCUSSION. After a modified Fontan repair, i.e. atriopulmonary or total cavopulmonary anastomosis, the pulsatile pulmonary blood flow is converted to a passive, non-pulsatile blood flow that depends critically both on the pressure gradient between right (RAP) and left atrial pressure (LAP) and on pulmonary vascular resistance (PVR). Thus, the maintenance of an adequate transpulmonary pressure gradient and avoidance of an increase in PVR are of major importance for the obstetric anaesthetic management in patients who have undergone right ventricular exclusion procedures. Impairment of venous return caused by slight caval compression or high airway pressure may reduce cardiac output more critically than in patients with a normal circulation. CONCLUSION. This case demonstrates that the haemodynamic consequences of pregnancy and of caesarean delivery under general anaesthesia can be tolerated in post-Fontan patients despite the absence of a contractile pulmonary ventricle.
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PMID:[Anesthesiologic aspects of pregnancy and delivery in a patient following a modified Fontan procedure ]. 876 69

A 23-year-old man, diagnosed as ventricular septal defect in childhood, was hospitalized with right-sided infective endocarditis. He developed acute respiratory failure following septic pulmonary emboli and underwent urgent surgical treatment, because vigorous medical treatment was ineffective. Extracorporeal membrane oxygenation was performed to maintain arterial blood oxygen tension after cardiopulmonary bypass and the patient was weaned from ECMO after 36 hours. Postoperatively, mechanical ventilation for respiratory failure was needed continuously and pleural leaks due to lung injuries were increased. The reduction of pleural leaks by surgical closure of fistula and plication of the cyst decreased gas exchange impairment. To our knowledge, application of extracorporeal membrane oxygenation for septic pulmonary emboli is unprecedented.
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PMID:[Application of extracorporeal membrane oxygenation for respiratory failure following septic pulmonary emboli]. 894 Aug 49

Cirrhosis is associated with several circulatory abnormalities. These include hyperkinetic systemic and splanchnic circulation, hepatopulmonary syndromes including pulmonary hypertension, and cirrhotic cardiomyopathy. Hepatopulmonary syndrome generally refers to hypoxaemia seen in patients with chronic liver disease and appears to be relatively common, although often subclinical. However, significant pulmonary hypertension occurs in 0.2-0.7% of cirrhotic patients. Nitric oxide and/or other vasodilators appear to be involved in the pathogenesis of hepatopulmonary syndrome through induction of pulmonary capillary dilatation which increases the alveolar-arterial oxygen gradient. Cirrhotic cardiomyopathy refers to abnormal left ventricular function which is manifested under conditions of physiological or pharmacological stress. The emergence of liver transplantation as an effective treatment for end-stage liver disease has led to recognition of previously subclinical cardiomyopathy and congestive heart failure accounts for significant morbidity and mortality after this procedure. Diminished myocardial beta-adrenergic receptor function has been shown to play an important role in the pathogenesis of this condition. The contributions of other factors including nitric oxide, catecholamines and membrane fluidity changes are under investigation. Cirrhotic patients also have an increased incidence of other cardiac abnormalities, such as endocarditis and pericardial effusions.
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PMID:Cardiopulmonary dysfunction in cirrhosis. 1038 72

In Pseudomonas aeruginosa, pvdS, a key oxygen (O2)-dependent locus, regulates expression of a number of virulence genes, including toxA (which encodes exotoxin A production). To define the in vivo role of differing O2 tensions on pseudomonal virulence, 2 knockout mutants, DeltapvdS and DeltatoxA, were compared with their parental strain, PA01, in rabbit aortic and tricuspid endocarditis models (representing aerobic vs. microaerobic conditions in vivo, respectively). In aortic endocarditis, DeltapvdS densities were significantly less than those of PA01 in vegetations, kidneys, and spleen (P<.01). In contrast, in tricuspid endocarditis, there were no significant differences between DeltapvdS and PA01 tissue densities in these same target tissues. The DeltatoxA mutant proliferated within target tissues to the same extent as the parental strain. Thus, pvdS (but not toxA) appears to be required for optimal virulence of P. aeruginosa, particularly in tissues preferentially exposed to high O2 tensions (e.g., aortic vegetations).
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PMID:The oxygen- and iron-dependent sigma factor pvdS of Pseudomonas aeruginosa is an important virulence factor in experimental infective endocarditis. 1072 May 26

In 25 patients, 13 boys and 12 girls, median age 5.5 years, in 1990-2000, surgical reparation of their heart defects were performed. Median age of diagnostic Tetralogy of Fallot was 3.2 months, range 1 day-2 years. Anoxic spells were present in three patients. Ten patients (median age 3 years, range 3 months-10 years) initially palliated with a modified Blalock-Taussig shunt, underwent a reparation at a median of 4.5 years after palliation. Median follow up was 4.2 years, range 3 months-10 years. The 30-day mortality rate was 16%. Mean right ventricular outflow tract gradient on echocardiography was 20.20 +/- 4.78, and mean oxygen saturation was 96% +/- 1.3. Two patients had non significant residual ventricular septal defect with left to right shunt, 7 right ventricular enlargement and almost all mild pulmonary regurgitation. Also two patients had Blalock-Taussig shunt's thrombosis. Before surgical reparation, one boy showed pulmonary valve's endocarditis. Complete atrioventricular block has been developed on one girl. No patient required reintervention during follow up and there was no late mortality. Almost all of our patients were asymptomatic, had normal activity, regularly exercised and some of them participated in school sport programs. Complete correction of Tetralogy of Fallot showed good results with normal life expectancy for the patients.
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PMID:[Tetralogy of Fallot: postoperative monitoring of patients]. 1121 6

Effect of nimotope on cerebral metabolism and incidence of mental disorders in patients operated on under forced ventilation of the lungs (FVL) was studied in 32 patients subjected to replacement of mitral and aortic valves for infective endocarditis. Nimotope was used for preventing hypoxic disorders of the CNS. The drug was injected starting from the stage of operation before FVL. Cerebral hypoxia was diagnosed using lactate-oxygen index (LOI) and other cerebral metabolic coefficients. LOI increased in all patients immediately after FVL, being much higher in the patients without cerebral protection. Moreover, numerous neurotic and mental disorders were observed in this group of patients during the early postoperative period. By contrast, no mental disorders, disorders of memory or attention were detected in the patients treated with nimotope. These data indicate that nimotope decreases the unfavorable effect of FVL on the CNS function in patients with infective endocarditis. The difference of lactate content in arterial blood and in the internal jugular vein bulb and LOI can be used for the diagnosis of brain ischemia in heart surgery with FVL.
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PMID:[Brain protection in open heart surgery in patients with infective endocarditis]. 1158 21

Workers in our laboratory have previously identified the staphylococcal respiratory response AB (SrrAB), a Staphylococcus aureus two-component system that acts in the global regulation of virulence factors. This system down-regulates production of agr RNAIII, protein A, and toxic shock syndrome toxin 1 (TSST-1), particularly under low-oxygen conditions. In this study we investigated the localization and membrane orientation of SrrA and SrrB, transcription of the srrAB operon, the DNA-binding properties of SrrA, and the effect of SrrAB expression on S. aureus virulence. We found that SrrA is localized to the S. aureus cytoplasm, while SrrB is localized to the membrane and is properly oriented to function as a histidine kinase. srrAB has one transcriptional start site which results in either an srrA transcript or a full-length srrAB transcript; srrB must be cotranscribed with srrA. Gel shift assays of the agr P2, agr P3, protein A (spa), TSST-1 (tst), and srr promoters revealed SrrA binding at each of these promoters. Analysis of SrrAB-overexpressing strains by using the rabbit model of bacterial endocarditis demonstrated that overexpression of SrrAB decreased the virulence of the organisms compared to the virulence of isogenic strains that do not overexpress SrrAB. We concluded that SrrAB is properly localized and oriented to function as a two-component system. Overexpression of SrrAB, which represses agr RNAIII, TSST-1, and protein A in vitro, decreases virulence in the rabbit endocarditis model. Repression of these virulence factors is likely due to a direct interaction between SrrA and the agr, tst, and spa promoters.
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PMID:Characterization of virulence factor regulation by SrrAB, a two-component system in Staphylococcus aureus. 1506 46

A 37-year-old man was suffering from pneumonia and severe aortic regurgitation due to acute aortic valve endocarditis with the annular abscess with Staphylococcus aureus. Preoperative serum brain natriuretic peptide was over 2,000 pg/ml. Preoperative arterial oxygen saturation was 82% on mechanical ventilation (Fio2: 1.0) with nitric oxide inhalation. Under a full median sternotomy, total normothermic cardiopulmonary bypass was established. Using the normothermic retrograde continuous coronary sinus perfusion of oxygenated blood, on-pump beating aortic valve replacement (AVR) was performed. Veno arterial bypass was required for 72 hours postoperatively. Postoperative course was otherwise uneventful. On-pump beating AVR seemed to be one of the useful procedures for a high-risk patient.
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PMID:[On-pump beating aortic valve replacement for severe aortic regurgitation due to infective endocarditis]. 1520 62


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