Kaohsiung J Med Sci August 2006 • Vol 22 • No 8 398
The clinical manifestations of infective endocarditis complicated with either ruptured sinus of Valsalva or complete atrioventricular (AV) block have been sepa-rately reported [1,2]. These two manifestations often indicate the rapid and devastating course of bacteria invasion with tissue destruction. However, both com-plications occurring simultaneously in a single patient with infective endocarditis is rare. The timing of surgi-cal intervention is important for eradicating the vege-tation and for tissue repair, but the comorbidities,
unstable hemodynamic status, and overwhelming sepsis make the risk of operation even higher. Here, we report a 54-year-old man with a previous history of alcoholic cirrhosis and chronic renal failure, devel-oping a fulminant course of infective endocarditis and complicated with both ruptured sinus of Valsalva and complete AV block.
C
ASEP
RESENTATIONA 54-year-old man with a previous history of alcoholic cirrhosis with esophageal varices bleeding and chronic renal failure visited our emergency room with the major complaint of tarry stool passage and general weakness. Severe anemia with hemoglobin 5.6 g/dL was found and the patient was admitted into the
Received: February 27, 2006 Accepted: March 31, 2006 Address correspondence and reprint requests to: Dr Wen-Ter Lai, Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, 100 Tzyou 1stRoad,
Kaohsiung 807, Taiwan. E-mail: [email protected]
R
UPTURED
S
INUS OF
V
ALSALVA AND
C
OMPLETE
A
TRIOVENTRICULAR
B
LOCK
C
OMPLICATING
F
ULMINANT
C
OURSE OF
I
NFECTIVE
E
NDOCARDITIS
:
A C
ASE
R
EPORT AND
L
ITERATURE
R
EVIEW
Chih-Sheng Chu, Chau-Chyun Sheu,1Kun-Tai Lee, Shuo-Tsan Lee, Kai-Hung Cheng, Wen-Chol Voon, Sheng-Hsiung Sheu, and Wen-Ter Lai
Divisions of Cardiology and 1Pulmonary Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
Patients with infective endocarditis usually developed persistent fever and heart failure, espe-cially when the valve structures are invaded and destroyed. Persistent bacteremia often leads to severe sepsis or overwhelming septic shock. Septic emboli from the vegetation will possibly result in systemic thromboembolism with multiple organ infarction. Patients with infective endocarditis have been reported to present with either ruptured sinus of Valsalva or complete atrioventricular block. However, both of these serious complications occurring in a single patient is rare. In this case report, we present a 54-year-old man with a previous history of alcoholic cirrhosis and chronic renal failure who suffered from a fulminant course of infective endocarditis. Simultaneously, rup-tured sinus of Valsalva and complete atrioventricular block further complicated the preexisting septic shock and multiple organ failure.
Key Words: complete atrioventricular block, infective endocarditis, multiple organ failure, sinus of Valsalva rupture
general ward under the impression of upper gastro-intestinal bleeding. Routine surface 12-lead electro-cardiogram after admission revealed high-degree AV block (2:1–3:1 AV conduction) and intermittent com-plete AV block with a heart rate of 40–45 bpm (Figure 1). The patient was then sent to the intensive care unit (ICU) after a temporary pacing wire was inserted for hemodynamic support. Serum potassium was 5.4 mmol/L at that time. Gastrointestinal bleeding and complete AV block were recovered after blood transfu-sion and temporary pacing backup, and the temporary pacing wire was removed on the 5th day after ICU
admission. Normal sinus rhythm with normal PR interval was noted. However, high fever and chills with renal function deterioration developed in the fol-lowing 4 days, and the patient received hemodialysis on the 9thday after ICU admission. The wound over the
previous arteriovenous shunt was found to have pus formation. Culture from the infective wound revealed oxacillin-sensitive Staphylococcus epidermidis. Blood cul-tures also revealed a resistant strain of S. epidermidis; intravenous antibiotics vancomycin and meropenem were administered for persistent bacteremia.
On the 12thday after ICU admission, sinus
tachy-cardia, a heart rate of 120 bpm, and dyspnea with respiration rate of 36/minute developed. Chest auscul-tation revealed a new-onset grade IV/VI continuous
murmur with thrill over the aortic area and a grade IV/VI systolic and diastolic murmur over the left lower sternal border and apical area. RV heave was palpable. Bedside Doppler echocardiography showed severe grade III aortic regurgitation jet through the destroyed aortic valves with moderate mitral regur-gitation. A ruptured sinus of Valsalva with turbulent blood flow from the aorta into the right atrium was demonstrated (Figure 2). No obvious vegetation could be identified. Hemodynamic monitoring with pulmonary arterial catheterization showed high car-diac output of 7.0–8.0 L/minute and low systemic vascular resistance of 578 dyn.s/cm5. Volume
expan-sion was performed under the impresexpan-sion of septic shock. Unfortunately, liver function deteriorated gradually and gastrointestinal bleeding reoccurred with coagulopathy. The prothrombin time was pro-longed, with international normalized ratio of 3.5. Hepatic coma and jaundice developed and over-whelming septic shock worsened in spite of aggres-sive medical care. Surgical intervention was suggested but the patient’s family refused due to the risk of high surgical mortality in the setting of multiple organ failure. On the 21st day after ICU admission,
cardiac arrest preceded by sudden complete AV block occurred (Figure 3). Serum potassium was 4.9 mmol/L and pH was 7.31 at that time. The patient passed
I aVR aVL aVF V1 V2 V3 V4 V5 V6 II III II 25 mm/s 10 mm/mV 0.15 Hz–40 Hz HP709 02205 Figure 1.Surface 12-lead electrocardiogram on admission reveals second-degree Mobitz type II with intermittent complete atrioven-tricular block. High tent T wave was noted.
away eventually even under extensive cardiac pul-monary resuscitation.
D
ISCUSSIONWe described a case of infective endocarditis compli-cated with ruptured sinus of Valsalva and complete AV block. The diagnosis of infective endocarditis was suspected immediately when the patient developed
persistent high fever and new onset of cardiac murmur. The mycotic aneurysm and ruptured sinus of Valsalva were documented with bedside color Doppler echocardiography. The turbulence of blood flow detected on parasternal short-axis view was initially misdiagnosed as tricuspid regurgitation flow. The velocity of turbulent flow measured by continuous Doppler was up to 4.79 m/second, with an estimated pressure gradient up to 91.8 mmHg. The result was completely incompatible with the
A B
Figure 2.(A) Parasternal short-axis view at the aortic valve plane on 2-D echocardiography. Prolapse of mycotic aneurysm with a small disruption in the aortoseptal continuity are demonstrated. Also note that the orifice surrounded by three destroyed aortic semi-lunar valves remained open during diastole. (B) Color Doppler echocardiography reveals turbulent flow through the ruptured non-coronary sinus of Valsalva, with blood flowing from the aortic root into the right atrium.
Cardiac arrest 6:57:23 6:57:29 0.02 M B N N N N N N N P P P P Complete AV block 6:15:45 6:15:51 A
Figure 3.Sudden onset of cardiac arrest preceded by complete atrioventricular block on continuous monitoring in the intensive care unit. No high tent T wave was noted.
value of pulmonary artery systolic pressure obtained by right heart catheterization, where the pulmonary artery systolic pressure was only 53 mmHg. This discrepancy prompted us to repeat the echocardio-graphic examination, and to make the diagnosis of mycotic aneurysm with rupture of sinus of Valsalva into the right atrium. Because both the resolution of the echocardiography machine and the acoustic win-dow of the patients could be impaired, especially in an intubated patient in the ICU setting, special atten-tion should be paid to the unexpected interpretaatten-tion.
Infective endocarditis complicated with sinus of Valsalva rupture or complete AV block have been reported earlier [1,2]. However, both complications occurring in a single patient with infective endo-carditis has rarely been reported. Abe et al described a patient with infective endocarditis who presented with vegetation on the aortic valves [3]. The non-coronary sinus of Valsalva was ruptured and exten-ded into the right atrium, and the electrocardiogram revealed first-degree AV block during the initial admission. Postoperative complete AV block devel-oped after manipulating the mycotic aneurysm; sur-gical closure of the ruptured sinus of Valsalva was done and a permanent pacemaker was implanted. Another case report by Hayashi et al described a rap-idly changing clinical course in a patient with infec-tive endocarditis with rupture of the right sinus of Valsalva [4]. The patient developed transient Adams-Stokes attack with cardiac arrest up to 30 seconds after coughing. The surgical course was completed smoothly. However, the patient died 10 days after the operation due to severe sepsis and disseminated intravascular coagulopathy.
In a series of 50 patients with infective endocarditis, Hayashi et al found that in addition to abnormalities in aortic or mitral valve structure, other predisposing factors including cachexia, chronic alcohol or intra-venous drug abuse that compromised host defense mechanism may enhance the susceptibility of infec-tive endocarditis [5]. Our patient was previously diagnosed with alcoholic cirrhosis and chronic renal insufficiency. The complicating and fulminant course of the infective endocarditis might be related to reduced host immunity.
Conduction disturbance found in a case of infective endocarditis should raise the possibility of septal inva-sion and destruction [2]. However, in our case, another possible factor contributing to complete AV block
could be hyperkalemia. Although the initial potas-sium level was only 5.4 mmol/L, the patient exhibited intermittent complete AV block. After the initiation of hemodialysis, the potassium level was maintained at 4.0–5.0 mmol/L and the temporary pacing wire was removed because normal sinus rhythm resumed and remained stable for 5 days. The massive blood trans-fusion and multiple organ failure might raise serum potassium in a short period. In addition, the rapid invasion of septal tissue near the atrioventricular conduction system by the progression of infective endocarditis might also cause conduction failure. Complete AV block with sudden cardiac arrest was found without evidence of any preceding hyper-kalemia or metabolic acidosis in this patient. Pro-longed temporary pacing could be of value in this setting of unexpected course of such overwhelming infective endocarditis before surgical intervention.
The rare presentation of two serious complica-tions in this case of infective endocarditis necessi-tated applying greater and serious attention to learn from it. The role of Doppler color flow imaging is paramount in the correct diagnosis and detection of complications from infective endocarditis [6]. Oxygen step-up or aortography might provide direct evidence of diagnosis of sinus rupture of Valsalva but neither was performed in this case because of the patient’s critical condition and the risk associated with trans-portation to the catheterization room. Surgical inter-vention is the only way to repair the damage of ruptured sinus of Valsalva in a case of infective endo-carditis and to restore the hemodynamic status of the patient [7]. In a case with unstable hemodynamic status due to severely ruptured sinus of Valsalva, high-degree AV block and uncontrollable infective status, the decision of an earlier surgical intervention should be kept in mind.
R
EFERENCES1. Yoshihara K, Komatsu H, Koyama N, et al. A case of
ruptured aneurysm of the sinus of Valsalva compli-cated by aortic regurgitation due to infectious endo-carditis. Kyobu Geka 1985;38:917–20. [In Japanese]
2. Braud J, Vergne M, Fontaine G, et al. Complete
auriculoventricular block due to septal invasion by an oslerian infection of the aortic valve (apropos of 2 cases). Ann Med Interne (Paris) 1969;120:445–8. [In French]
3. Abe M, Hamada M, Fujiwara Y, et al. Mycotic aneurysm of the sinus of Valsalva and complete atrioventricular block complicating infectious endocarditis with aortic regurgitation: a case report. J Cardiol Suppl 1991;25: 187–94.
4. Hayashi M, Nishinomiya T, Kunimoto S, et al. Case
of active infectious endocarditis taking a rapidly changing clinical course and exhibiting accentuated atrioventricular block and perforation of the right Valsalva’s sinus. Nippon Naika Gakkai Zasshi 1993;82: 2061–3. [In Japanese]
5. Rudolph W, Kraus F. Detection and evaluation
of infectious endocarditis. Herz 1983;8:241–70. [In German]
6. Torres S, Pereira LS, Martins L, et al. Ruptured
aneu-rysm of the sinus of Valsalva into the right ventricle— apropos of a case. Rev Port Cardiol 1990;9:51–5.
7. Okada K, Sueda T, Orihashi K, et al. Ruptured sinus
valsalva with infectious endocarditis: a technique of defect closure with an autologous-xenologous pericar-dial sandwich patch. Ann Thorac Cardiovasc Surg 2000;6:271–4.
!"VR==O==OT= !"VR==P==PN= !"#$%&' !"!#$ %&'() UMT !"#$NMM
