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Background: Only 4.1% of tricuspid valve IE cases require surgical intervention. The complication after tricuspid valve IE with lung abscess and empyema is rare., Case Presentation: We report the case of a 38-year-old male (an intravenous drug abuser) diagnosed with tricuspid valve IE who underwent tricuspid valve replacement. The case was complicated by multiple lung abscesses and thoracic empyema. The pathogens causing the lung abscesses and empyema were Acinetobacter baumannii complex and Candida albicans, which were different from those causing the endocarditis. After 4 weeks of antibiotic treatment, chest X-ray revealed bilateral clear lung markings with only mild blunting of the right costophrenic angle., Conclusion: The pathogen causing the lung abscess is not always compatible with that causing the endocarditis. Thoracoscopic incision of the abscess with 4 to 6 weeks of broad-spectrum antibiotic treatment is effective and safe.

Symptomatic paravalvular leaks (PVL) are a relatively uncommon, but potentially significant postoperative complication of valve replacement surgery. Percutaneous repair of PVLs has become an increasingly utilized approach in patients whose comorbidities obviate surgical repair. We present an interesting case of a gentleman who underwent successful repair of a mitral PVL with Amplatzer devices following initial aortic and mitral valve replacements for bacterial endocarditis. He later developed fungal endocarditis that ultimately required re-operation to remove the devices and replace his mitral and aortic valves. This complication of closure devices, although reportedly rare, should be considered when contemplating a percutaneous approach. © 2012 Wiley Periodicals, Inc., (Copyright © 2012 Wiley Periodicals, Inc.)

The case is reported of multiple valve surgery using as little prosthetic material as possible in a drug addict with recurrent right and left bacterial endocarditis. The patient underwent aortic valve replacement with a cryopreserved aortic homograft, mitral repair and tricuspid valve replacement with a mitral homograft, using a modified technique. The indications and surgical options for tricuspid valve endocarditis in this patient group are discussed, with particular focus on technical aspects of using mitral homografts in the tricuspid position.

Mycotic aneurysms of the aorta and the visceral arteries are life-threatening diseases, due to potential rupture and organ or limb ischemia. They occur in endocarditis, immunodeficiency, bacteremia and fungemia, and have a poor prognosis. We report on a case of a 54-year-old male patient suffering from abdominal angina after mitral valve replacement for septic mycotic endocarditis. In presence of a mycotic-embolic occlusion of the left popliteal artery and multiple septic organ infarctions a mycotic aneurysm of the superior mesenteric artery was found in abdominal spiral-CT. Based on sequential spiral-CT examinations, this case demonstrates the development of a septic aneurysm of the superior mesenteric artery.

A 35 year old woman, cocaine addict, suffered Candida albicans aortic valve endocarditis complicated with embolisation of infected vegetations in the distal abdominal aorta. She underwent successful staged aortic valve replacement followed by transaortic and transfemoral thrombectomy. One month later an arteriogram disclosed partial occlusion of the left iliac artery, bilateral aneurysmal degeneration of both iliac arteries and right iliac artery-right iliac vein fistula. She was operated again, performing re-laparotomy and re-exploration. A composite bifurcated cryopreserved homograft was implanted end-to-side between the infrarenal abdominal aorta, right external iliac artery and left common femoral artery. The right iliac artery-iliac vein fistula was obliterated with suture. The patient had an uneventful recovery but a relapsing arterio-venous fistula was diagnosed by arteriography. Three months later she underwent percutaneous transluminal closure of the reopened fistula. At present, 17 months after the implantation of the homograft, the patient is symptom-free, on antifungal agents and with arteriographic and clinical evidence of a well-functioning arterial homograft.

During the past 25 years the authors have performed the following operations in the surgical treatment of intractable right-sided endocarditis in drug addicted patients: 1) Excision of the infected tricuspid valve and replacement with a mechanical or bioprosthetic valve during the same operation. In these patients the overall mortality was 100% due to: (a) inability to control the endocarditis in 80%; (b) re-infection due to a return to drug abuse and (c) fatal complications due to non-compliance with anticoagulant therapy. 2) Tricuspid valvulectomy in 53 patients, tricuspid and pulmonary valvulectomy without replacement in two patients. Six patients (11%) died within six weeks. Five due to the endocarditis and one due to low cardiac output. Ten patients (18%) died six months to 13 years later. In nine of these patients, death was related to continued drug abuse. At 22 years the actuarial survival is 64%. This experience supports the authors conclusion that among drug addicts with intractable right-sided endocarditis, tricuspid valvulectomy or tricuspid and pulmonary valvulectomy without replacement is/are the operation(s) of choice.

We describe in detail 14 children (age, less than or equal to 19 years) who underwent operative intervention during active infection of the heart and/or great vessels. The series included five children less than 6 years old, who constitute 10% of all such cases reported in this age group to date. We also review the 132 published reports in which children underwent operative intervention during active endocarditis. We found the following: (1) The survival rate for all cases was 77%. (2) Persistent infection, embolic phenomena, and increasing congestive heart failure were the most frequent indications for operative intervention. (3) Survival rates were independent of the duration of preoperative antibiotic treatment. (4) Survival rates were independent of positive results of cultures of blood or tissue obtained at operation. (5) The perioperative mortality in our series was 14%. (6) Only 67% of patients had conditions thought to predispose to endocarditis. (7) Except for removal of catheter-associated cardiac masses from neonates, operative intervention in active endocarditis was uncommon among children less than 4 years old. (8) Staphylococcus aureus and viridans streptococci were the etiologic agents in the majority of cases of endocarditis requiring operation during active infection in children.

Objective: to assess the experience of both departments in the surgical therapy of infective endocarditis--indications and results., Design: retrospective analysis on clinical data, surgery and follow up., Setting: patients (pts) studied in the Cardiology Department and Cardiothoracic Surgery Department of the Santa Marta Hospital in Lisbon., Patients and Interventions: sequential sample of 28 patients (11 females, 17 males, mean age 39 years) submitted to surgery between 1978 and 1987 for infective endocarditis., Measurements and Results: the indications for surgery were: heart failure (15 pts), "resistant" infection (8 pts), emboli (4 pts) and "large" vegetations shown by echocardiography (2 pts). Surgical mortality -27.5%. Four patients developed periprosthetic leaks. There was an improvement in functional class of the survivals., Conclusion: the indications for surgery were heart failure, "resistant" infection, emboli and "large" vegetations. There was a high surgical mortality, namely in the patients with resistant infection, severe heart failure and periprosthetic leaks. In the follow up there was a net improvement of functional class. The morbidity is due to the periprosthetic leaks, which induced most of the reoperations.

The study makes an assessment of the results of surgical treatment of infectious endocarditis in 25 patients operated in 1982-1988 at the Institute of Experimental and Clinical Medicine. At the active stage of the disease, surgery was performed on 15 patients (60%), while prior to the operation, 16 persons' condition (64%) corresponded to the IIIrd and IVth degree of the NYHA functional classification. In infectious endocarditis, early mortality after valve replacement was 8%, late mortality--9% with an average of two-year post operative follow-up. Re-infection occurred in 12% patients, paravalvular regurgitation was found in 20 percento, out of whom 8% were haemodynamically significant and associated with the infection. Clinical post-operative improvement was observed in 76% patients, out of whom one half was totally asymptomatic and one third resumed their jobs. The results show that early surgical treatment of infectious endocarditis helps to reduce mortality. The post-operative risk of re-infection or of other complications was not high and the long-term post-operative functional effect was favourable in most patients.

Seventy-five surgically treated patients with prosthetic valve endocarditis were treated at the Stanford University Medical Center. This was a multivariate analysis analyzing both patient related factors, bacteriology, and surgical findings. The conclusions among 10 patients with allograft valves, 20% had an annular abscess; this occurred in 36% of 29 patients with porcine valves, and 65% of these with mechanical prosthesis. Though prevention, again, is key in this especially devastating disease, once infection has been established and an aggressive approach is indicated, it would appear that a homograft re-replacement or free aortic homograft valve replacement can deal with severe tissue destruction to prevent recurrence.

The presentation and course of infective endocarditis is changing because there is an increasing number of resistant organisms which are causative agents. At present, resistant organisms are isolated in more than one-half of the cases; Streptococcus viridans is found in only 40 percent. The increased use of antimicrobial agents, the frequent use of intravenous heroin and the increased amount of cardiac surgery have been important in increasing the number of resistant organisms and providing convenient access routes to the circulation.

Among 32 patients with late prosthetic valve endocarditis selected from two cooperative retrospective studies, ten had valve replacement: six men and four women, mean age being 48 years, ranging from 23 to 65 years old. An emergency reoperation was undertaken for refractory heart failure in seven out of ten cases, with an average delay of 6.6 days after the beginning of antibiotic therapy. In the other three cases, the operation was carried out at the end of 40 days of antibiotic therapy, once for recurrent endocarditis and twice for severe aortic insufficiency. The most common causative micro organism was the staphylococcus (7 out of 10 cases). The infected prosthetic valves were, in 8 out of the 10 cases, in the aortic position. The outcome was poor as the mortality rate was 60% (6 out of the 7 patients operated on in an emergency). Death was attributed to heart failure with conduction disturbances and severe aortic regurgitation (2 cases), cerebral emboli (2 cases), septicopyemia (2 cases). Four patients of the ten, after a mean follow up of 10 months, are cured without prosthetic valve dysfunction. The extreme gravity of prognosis seems related to the microorganism (staphylococcus), to the delay between the beginning of antibiotic therapy and the onset of the fever, and finally to the extension of destructive lesions under the prosthetic valve implantation base; the reimplantation of the prosthesis on frail and abscessed tissue implies a substantial risk of disinsertion. The indications for systematic early reoperation in cases of severe acute heart failure are discussed.