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Query: UMLS:C0036690 (sepsis)
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We report a case of successful mitral valve replacement performed on the patient who is an infective endocarditis due to MRSA. She was 27-year-old female and treated by antibiotics medication because of remittent fever two years ago. On August 1995, cerebral infarction occurred and she was pointed out endocarditis. After high fever continued, blood cultures demonstrated MRSA. Furthermore, echocardiography showed vegetation on posterior mitral valve leaflet and moderate mitral regurgitation so, mitral valve replacement with a S.J.M. 25 mm performed to control MRSA sepsis condition. During operation, we used VCM 2 g into the extracorporeal circulation and after operation 0.5 g intravenously every 6 hours. Two weeks later we changed antibiotics to FOM, Viccillin and ABK according to the result of minimum inhibitory concentration (MIC) obtained through blood culture. The patient was discharged on the 44 th postoperative day because of her uneventful postoperative course.
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PMID:[A case report of an infective endocarditis caused by methicillin-resistant Staphylococcus aureus with successful mitral valve replacement]. 874 44

Sepsis from an infected cardiac valve can lead to bacterial seeding and destruction of the arterial wall with formation of a mycotic aneurysm. The natural history of these lesions is the rupture. We report the case of a 20 year old female who was admitted to our institution with massive mitral regurgitation and emboli of the central nervous system and both lower extremities. She underwent emergency valve replacement and then, staged treatment of her ischemic legs and multiple asymptomatic mycotic aneurysms: Superior mesenteric, right common iliac and left superficial femoral arteries. A splenectomy was required to treat a splenic abscess. An aneurysm of a peripheral branch of the middle cerebral artery was medically treated, demonstrating reduction in size on subsequent angiogram. She recovered uneventfully and remains asymptomatic after 20 months of follow up. The development of new diagnostic and therapeutic tools has led to a decrease of these complications during infectious endocarditis. However, in the patient with late diagnosis and symptoms in different territories, the mycotic aneurysm must be kept in mind to provide the patient with appropriate treatment.
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PMID:[Mycotic aneurysms and multiple peripheral embolisms in a patient with infectious endocarditis]. 951 90

Thirty-two intracardiac myxoma patients who underwent tumor excision in Srinagarind Hospital between January 1, 1983 and January 30, 1997 were retrospectively reviewed. Clinical presentations, diagnostic method, operative findings, and postoperative course were also analysed. There were 20 female and 12 male patients, age range 10 to 60 years (mean 37.9). Clinical presentations included congestive heart failure (56.2%), atypical chest pain (25.0%), syncope (18.9), and constitutional symptoms (9.3%). In six patients, there was clinical evidence of systemic embolism. One patient was essentially asymptomatic and incidentally detected during clinical check-up. Diagnosis was all made by two dimensional (2-D) echocardiographic study. There were 29 left atrial, 2 right atrial and 1 combined right atrial and right ventricular myxomas. There were 3 postoperative deaths, two due to septicemia and the other due to cerebral embolism. One patient developed postoperative severe mitral regurgitation and complete heart block needed mitral valve replacement and permanent pacemaker insertion. One patient developed localized seizure 6 years after resection and was suspected of brain metastasis. The other was found to have two high echogenic liver masses, 2 years after resection, suggestive of hepatic metastasis. Unfortunately, we could not obtain the histologic confirmation from any of those suspected lesions. Because of the non-specific and various manifestations of atrial myxoma, a high index of suspicion is needed. The diagnostic method of choice is 2D-echocardiography. Clinical follow-up for at least 10 years may be needed to rule out recurrence or metastasis.
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PMID:Atrial myxoma: a review of clinical experience at Srinagarind Hospital. 1008 16

Extracorporeal membrane oxygenation (ECMO) is used as circulatory support or bridge to transplantation in patients with severe left ventricular (LV) dysfunction. Left heart decompression is needed to reduce pulmonary edema, prevent pulmonary hemorrhage, and reduce ventricular distention that may aid in recovery of function. We reviewed our experience from November 1993 to December 1997 with 10 patients having severe LV dysfunction (7 myocarditis, 3 dilated cardiomyopathy) who required circulatory support with ECMO and who underwent left heart decompression with blade and balloon atrial septostomy (BBAS). Patients ranged in age from 1 to 24 years (median, 3 years). Indications for BBAS included left atrial/left ventricular distension (10), pulmonary edema/hemorrhage (9), or severe mitral regurgitation (2). BBAS was performed electively in eight patients and urgently in two patients. BBAS was performed while on ECMO in seven patients and pre-ECMO in three. A femoral venous approach was used in all patients. ECMO patients were fully heparinized. Transseptal puncture was required in nine patients while one patient had a patent foramen ovale. Blade septostomy was performed in all patients. Enlargement of the defect was then performed by stationary balloon dilation in nine and Rashkind balloon atrial septostomy in one. Balloon diameters ranged from 10 to 20 mm. Sequential balloon inflations were performed in some patients. Adequacy of the atrial septal defect (ASD) was confirmed by pressure measurement and echocardiography. Adequate left heart decompression was achieved in all patients. Pulmonary edema improved in nine of nine patients. Left atrial mean pressure fell from a mean of 30.5 mm Hg, (range, 12-50 mm Hg) to 16 mm Hg (range, 9-24 mm Hg). Left atrial to right atrial pressure gradient fell from a mean of 20 mm Hg pre-BBAS to 3 mm Hg post-BBAS. ASDs ranged in size from 2.5 to 8 mm (mean, 5.9 mm). Complications included needle perforation of the left atrium without hemodynamic compromise (one), ventricular fibrillation requiring defibrillation (one), and hypotension following BBAS which responded to volume infusion (two). Duration of ECMO ranged from 41 hr to 704 hr (mean, 294 hr). Seven patients survived and four patients had recovery of normal LV function. Of those who recovered, two had no ASD at follow-up while two ASDs are patent 14 days and 3 months post-BBAS. Three patients underwent successful cardiac transplantation. Three patients died, all of whom had multisystem organ failure with or without sepsis. A patent ASD was noted at transplant (three) or autopsy (two). No patient required a second BBAS. BBAS alleviates severe left atrial hypertension and pulmonary edema. In addition, BBAS avoids the potential bleeding complications of surgical left heart decompression. Stationary balloon dilation of the atrial septum is an effective alternative to Rashkind balloon septostomy in older patients. BBAS achieves left heart decompression that may permit recovery of LV function or allow extended ECMO support as a bridge to transplant.
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PMID:Blade and balloon atrial septostomy for left heart decompression in patients with severe ventricular dysfunction on extracorporeal membrane oxygenation. 1034 39

Acute heart failure in adults is the unfolding of heart failure in minutes, hours or a few days. Low output heart failure describes a form of heart failure in which the heart pumps blood at a rate at rest or with exertion that is below the physiological range and the metabolizing tissues extract their required oxygen from blood at a lower rate, causing a proportionately smaller oxygen amount remaining in the blood. Therefore, a widened arterial-venous oxygen difference occurs. High output heart failure is characterized by pumping blood with a rate above the physiological range at rest or during exertion, resulting in an arterial-venous oxygen difference, which is normal or low. This may be caused by peripheral vasodilatation during sepsis or thyrotoxicosis, blood shunting, or reduced blood oxygen content/viscosity (Fig. 1). The differentiation between low output heart failure versus high output heart failure is of highest importance for the choice of therapy and therefore the information and the monitoring of the systemic vascular resistance. Patients who present with acute heart failure suffer from a severe complication of different cardiac disorders. Most often they have an acute injury that affects their myocardial performance (eg, myocardial infarction) or valvular/chamber integrity (mitral regurgitation, ventricular septal rupture), which leads to an acute rise in left-ventricular filling pressures resulting in pulmonary edema.
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PMID:New strategies for the management of acute decompensated heart failure. 1135 11

Partial left ventriculectomy (PLV) is regarded as one of the alternatives to heart transplantation for idiopathic dilated cardiomyopathy (d-CMP). Between June 1996 and March 2000, 20 patients underwent left ventricular volume reduction surgery at five major cardiac centers in Korea. PLV was performed in 16 patients with d-CMP and in 1 patient with ischemic CMP. The modified Dor procedure was performed in three patients; two patients with d-CMP and one patient with ischemic CMP. Median age was 35 years (range 3-64 years). There were 13 male and 7 female patients; there were 4 patients in Class III and 16 patients in Class IV. Among the 16 patients in Class IV, 5 patients were inotropic dependent, 2 patients were resuscitated from cardiac arrest or shock in hospital, and 1 patient was treated with intra-aortic balloon pumping. Operative technique for PLV was the same as described by Batista and colleagues. For the modified Dor procedures, the apical left ventricle was opened and a circumferential pursestring suture was placed at the base of both papillary muscles to reduce the diameter of the left ventricle concomitant with mitral annuloplasty. Mitral valve repair was performed in 15 patients and mitral valve replacement was performed in 1 patient. Moderate-to-severe tricuspid regurgitation was noted in 12 patients (with tricuspid annuloplasty in 11 of these patients and replacement in 1 patient). Postoperatively, there were seven operative deaths after PLV and one death after the modified Dor procedure. Cause of death after PLV was right heart failure in four of the seven cases, sepsis in one case, and ventricular tachyarrhythmia in the remaining two cases. After the modified Dor procedure, there was one operative death with left ventricular failure. Postoperatively, mean ventricular end-diastolic dimension markedly decreased from 75.3 mm to 50.9 mm. However, this dimension had increased slightly to 58.2 mm, an average observed 22 months later. Mean left ventricular ejection fraction (LVEF) improved significantly from 20.6% to 33.5% (p < 0.0001), but decreased to 28.5% on average 22 months later (p = 0.058). Eleven patients were discharged from the hospital and followed-up for a mean of 20.2 months (range 1-41 months). During the early postoperative period, most were in good condition. However, heart failure progressed with mitral regurgitation in four patients, two of whom underwent heart transplantation. In conclusion, PLV for d-CMP seems to be an effective alternative surgical procedure to heart transplantation in Korea. The modified Dor procedure may be another alternative to transplantation for left ventricular volume reduction. However, in patients showing progression of heart failure, early intervention with ventricular assist or heart transplantation will be necessary. Also, further studies will be necessary for selection criteria and for prevention of ventricular tachyarrhythmia.
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PMID:Volume reduction surgery for end-stage heart failure: experience in Korea. 1176 35

The study evaluated the results of the tricuspid valve autograft technique, consisting of transferring the posterior tricuspid leaflet and subvalvular apparatus towards the mitral valve to reconstruct a destroyed commissure. Twenty patients entered the study. Etiology was degenerative in 12 patients (mean age, 55 +/- 21 years). Nine patients had endocarditis, 8 were rheumatic. Echocardiography results and secondary events were reviewed. Mean follow-up was 44 +/- 17 months. One patient died from sepsis. Survivors were in sinus rhythm. Predischarge echocardiography showed trivial or no mitral regurgitation in all but one patient (mild). Mean transmitral gradients were 3 to 6 mm Hg, and valvular surface was 4.3 +/- 2.1 cm(2). On the tricuspid valve, regurgitation was zero to mild, gradients 4 to 7 mm Hg. One patient developed recurrent endocarditis at 18 months with moderate regurgitation. Results were stable in all the other patients. The tricuspid autograft is an attractive technique for a selected group of patients with commissural destruction. The 6-year results are very encouraging.
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PMID:Tricuspid autograft for repair of a destroyed mitral commissure. 1180 48

The clinical and laboratory findings of eight (20%) cases of cardiac involvement of 39 patients with sepsis caused by S. aureus (Staphylococcus aureus) were reviewed retrospectively. Our purpose was to emphasize the importance of the cardiac findings in patients with sepsis caused by S. aureus in childhood. The ages of the patients ranged from 6 to 14 years. All patients had pericardial effusion which was confirmed by echocardiographic (ECHO) examination in all cases except the one in whom ECHO examination could not be performed because he died 2.5 days after admission to the hospital. This patient also had myocarditis and heart failure. Aside from these, mitral insufficiency was diagnosed in the other patient; it was accepted as a sequela of rheumatic fever acquired previously. Open pericardial drainage was conducted successfully in the case who had a progression to cardiac tamponade. In the other patients pericardial effusion completely resolved with supportive and antibiotic therapy one to two weeks. Two of eight patients died from sepsis and septic shock; the mortality rate was 25%. Our findings show that cardiac involvement was fairly high (20%) in S. aureus sepsis in childhood. Therefore, it is suggested that children with S. aureus sepsis should be carefully monitored for cardiac involvement.
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PMID:Cardiac findings in childhood staphylococcal sepsis. 1204 94

From January 1986 to January 1987, 116 Mitroflow pericardial valves were implanted in 98 patients at our center. Ages ranged from 10 to 83 years (mean, 64.9 years). Forty-three patients (44%) were in New York Heart Association Functional Class III or IV at the time of surgery. Twelve patients (12%) had undergone prior cardiac surgery. Ten hospital deaths (10%) (70% Confidence Limits, 7% to 14%) occurred. Incremental risk factors for hospital death included female gender (p = 0.08), higher functional class preoperatively (p = 0.04), and longer cardiopulmonary bypass time (p = 0.05). All 88 hospital survivors (100%) were followed for 6 to 13 months (mean, 9 months) after repair. Two late deaths (2.3%) occurred: 1 at 1.5 months from subacute cardiac failure, and another at 5 months from non-valve-related sepsis. Actuarial survival at 15 months was 87% +/- 5.5%. No late reoperations were performed. One patient who exhibited mild mitral incompetence 4 months postoperatively is being followed closely. Two patients (2.3%) who were not on anticoagulant therapy developed thromboembolic events in association with chronic atrial fibrillation. No patient has had hemolysis or infective endocarditis. All patients are now in Functional Class I or II. Our early-phase assessment of this valve reveals a low risk of valve-related events. Its low-profile frame and wide, flexible sewing ring make this prosthesis technically satisfactory for implantation. Continuing close follow-up will determine intermediate-and late-phase hazards.
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PMID:Early-phase events with the mitroflow pericardial valve. 1522 43

Acute prosthetic valve dysfunction is a critical condition for any patient, and is associated with a high mortality. A 24-year-old man who had undergone mitral valve replacement with a TRI bileaflet valve four months previously at another center was admitted with acute-onset left ventricular failure. Echocardiography showed massive mitral insufficiency which was suggestive of a stuck valve. Emergency surgery was carried out, at which the cranial leaflet was found to be stuck open. There was no tissue impingement and thrombosis, the caudal leaflet was absent, and there were no signs of endocarditis or pannus formation. The TRI valve was removed and a replacement 25 mm bileaflet mechanical valve inserted. The embolized leaflet was found in the terminal aorta, but the patient died on day 66 after surgery due to sepsis which had developed from aspiration pneumonia. This is the first report of leaflet escape and terminal aortic embolization with the TRI bileaflet rotatable mitral valve. Acute deterioration of a patient with a prosthetic heart valve should suggest valve dysfunction for which appropriate treatment is rapid relief of the failing left ventricle and replacement of the defective valve with a functioning prosthesis.
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PMID:Leaflet escape in a TRI bileaflet rotatable mitral valve. 1531 72


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