Download Left Ventricular Pseudoaneurysm Caused by Infective Endocarditis

Case Report
Acta Cardiol Sin 2014;30:346-349
Left Ventricular Pseudoaneurysm Caused by
Infective Endocarditis
Tung-Chen Yeh,1,2,5 Chun-Peng Liu,1 Ching-Jiunn Tseng,4,5,6,7 Pa-Rum Can3 and Jau-Cheng Liou2
A 32-year-old male presented with infective endocarditis and left ventricular pseudoaneurysm (PA). The patient
was treated with oxacillin but remained intermittently febrile for the next 3 weeks. Blood culture revealed
Staphylococcus aureus. Treatment with oxacillin 2 g every 4 hours gradually reduced the fever. Echocardiography
then showed an aneurysm-like structure communicating with the left ventricle. However, the patient refused
further examinations and insisted on discharge. After 4 days, he was readmitted to our ward with severe dyspnea.
Chest computed tomography showed the heart was behind a huge PA. The selected treatments for this rare case of
multiple medical conditions were surgical resection of the PA and mitral valve replacement surgery, which
achieved a gradual recovery. In this case, early diagnosis and timely surgical intervention resulted in an excellent
prognosis.
Key Words:
Infective endocarditis · Pseudoaneurysm · Staphylococcus aureus
INTRODUCTION
tients with infective endocarditis complicated with LV PA
have high mortality and morbidity, especially those who
do not receive surgical intervention.
Most reported cases of left ventricular (LV) pseudoaneurysm (PA) are typically related to myocardial infarction (particularly inferior wall myocardial infarction) and
cardiac surgery.1,2 Diagnosing LV PA is often difficult due
to its atypical presentations. The standard noninvasive
techniques for diagnosing LV PA are chest computed
tomography (CT) and, alternatively, noninvasive thoracic echocardiography. However, chest CT is impractical
for patients with unstable hemodynamic conditions. Pa-
CASE REPORT
A 32-year-old male with a 3-year history of diabetes mellitus and a 10-year history of cocaine use presented at our emergent care unit with intermittent fever 21 days after receiving treatment with oxacillin 2 g
every 4 h at a local regional hospital. The patient’s
blood culture revealed Staphylococcus aureus. Chest
X-ray (Figure 1A) revealed cardiomegaly, and echocardiography (Figure 1C) showed an aneurysm-like
structure (4 ´ 4 ´ 5 cm 3 ) communicating with the LV
and moderate-to-severe eccentric mitral regurgitation
but no obvious valvular vegetation. Laboratory data
showed leukocytosis (white blood cell counts: 13010/
cumm, Seg.: 82%) and normocytic anemia (Hemoglobin: 9.0 g/dL). Electrocardiography (Figure 1D) showed
sinus tachycardia and no significant ST-T change. However, the patient’s troponin I level (3.7 ng/mL) was
Received: June 23, 2013
Accepted: November 13, 2013
1
Department of Internal Medicine, Division of Cardiology, Kaohsiung
Veterans General Hospital; 2Department of Biological Sciences,
National Sun Yat-sen University; 3Department of Surgery, Division of
Cardiovascular Surgery; 4Department of Medical Education and
Research, Kaohsiung Veterans General Hospital, Kaohsiung; 5Institute of
Clinical Medicine, National Yang-Ming University; 6Department of
Pharmacology, National Defense Medical Center, Taipei; 7Institute of
Biomedical Science, National Sun Yat-sen University, Kaohsiung, Taiwan.
Address correspondence and reprint requests to: Dr. Jau-Cheng Liou,
Department of Biological Sciences, National Sun Yat-sen University,
No. 70, Lien-Hai Rd., Kaohsiung 80424, Taiwan. Tel: 886-7-525-2000
ext. 3628; Fax: 886-7-345-5045 ; E-mail: [email protected]
Acta Cardiol Sin 2014;30:346-349
346
Left Ventricular Pseudoaneurysm
over the left cardiac border (Figure 1B). After his conditions had been stabilized, a CT (Figure 2A) revealed a PA
over the inferoposterior aspect of the heart. Coronary
angiorgaphy showed no significant coronary stenosis.
However, mild compression of the left circumflex artery
by the PA was observed and confirmed by LV angiography (Figure 2B). During surgery, a huge LV PA caused
by a ruptured posterior wall was noted (Figure 2C). The
PA was confirmed on pathology, and the mitral valve pathology showed valvulitis. After mitral valve (MV) replacement and wide resection, patch closure of the defect markedly improved the symptoms. An echocardio-
high. Blood pressure and pulse rate were 109/72 mmHg
and 109 bpm, respectively. The fever gradually receded
after a 4-day treatment with oxacillin 2 g every 4 hours.
He refused to undergo non-invasive cardiac CT, magnetic resonance imaging or invasive coronary catheterization. Against our medical advice, he requested discharge 9 days after admission.
Four days after his discharge, the patient was again
admitted at our emergency department with dyspnea,
orthopnea, and bilateral lower leg edema, but no severe
chest pain or chest tightness was noted. Chest X-ray
showed cardiomegaly and an abnormal bulging shadow
A
C
B
D
Figure 1. (A) Cardiomegaly revealed by chest x-ray taken on day of admission. (B) Chest x-ray taken 13 days after admission showing increased
cardiomegaly and an abnormal and progressively expanding shadow over the left cardiac border (white arrow). (C) Two-dimensional
echocardiograph in apical two-chamber view showing: (1) a discontinuous site below the anterior leaflet of the mitral valve, (2) a saccular contour of
the pseudoaneurysm chamber, and (3) a narrow orifice relative to the diameter of the pseudoaneurysm. The jet flow from the left ventricle to the
pseudoaneurysm was visualized by color echocardiography. (D) Electrocardiography showing sinus tachycardia without ST-T change. LA, left atrium;
LV, left ventricle; PA, pseudoaneurysm; RV, right ventricle.
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Acta Cardiol Sin 2014;30:346-349
Tung-Chen Yeh et al.
A
rysm3 or coronary artery spasm associated with cocaine
usage.4 Pericarditis and myocarditis were suspected initially due to the elevated troponin I level. Since electrocardiography showed no diffuse ST-T change or ventricular tachycardia, echocardiography further showed no
general LV dysfunction or obvious pericardial effusion,
pericarditis or myocarditis were also excluded. We hypothesized that the PA resulted from a local septic embolism. Recent studies indicate that patients diagnosed
with staphylococcal endocarditis tend to increase serum
troponin levels.5,6 Chest CT can exclude very rare cases
of PA of the innominate artery.7
Infective endocarditis complicated by LV PA is a
catastrophic cardiovascular disease with a high mortality rate, especially in the absence of surgical intervention. Frances et al. (1998) reported that the risk of rupture in LV PA is 30-45% and that most cases are related
to myocardial infarction or cardiac surgery.1 Of the 290
cases of LV PA analyzed in that study, the etiology was
related to MV infective endocarditis in only two (1%)
cases.
Infective endocarditis has a high mortality rate and
is difficult to treat. Symptoms include persistent fever
and unstable hemodynamic condition. In the acute
stage, unstable hemodynamic conditions are often combined with pulmonary edema and respiratory failure. In
emergent care patients in unstable hemodynamic condition, heart condition is usually assessed by portable
2-dimensional echocardiography instead of by cardiac
CT examination. Three PA characteristics that can be revealed by 2-dimensional echocardiography include: (1) a
sharp discontinuity of the endocardial image at the site
of communication between the PA and the LV cavity; (2)
a saccular or globular contour of the PA chamber; (3) a
relatively smaller diameter of the orifice in comparison
with the PA.8
Infective endocarditis complicated by a huge PA is
very rare and is more difficult to treat compared to classic infective endocarditis. The recent American Heart
Association Scientific Statement reported that congestive heart failure increases mortality risk in infective
endocarditis. 9 The case of infective endocarditis reported here was complicated by both CHF and a huge
PA. In LV PA with severe MV regurgitation, mortality risk
is substantially increased by MV replacement, wide resection and patch closure of the defect.1 The patient re-
B
C
Figure 2. (A) Chest computed tomography image showing a pseudoaneurysm over the inferior posterior aspect of the heart and a narrow
orifice relative to the diameter of the pseudoaneurysm. (B) Left ventricular catheter angiogram showing a huge pseudoaneurysm over the
posterior aspect of the left ventricle and one narrow base. (C) Surgical
treatment revealed the rupture site over the posterior wall of the left
ventricle. Mitral annuli with chordae (white arrow) and without chordae
(black arrow) were also noted. LA, left atrium; LV, left ventricle; PA,
pseudoaneurysm.
graphy performed 6 months after discharge confirmed
preserved LV function.
DISCUSSION
This 32-year-old male, a drug abuser, was discharged
against our advice after undergoing a one-month oxacillin treatment for Staphylococcus aureus bacteremia,
severe mitral regurgitation and a LV PA. He presented 4
days later with symptoms of acute decompensated
heart failure and finally consented to surgery. Diagnoses
of a PA and infective endocarditis were confirmed on
pathology.
Possible causes of PA can include myocardial infarction, cardiac surgery, infective endocarditis and coronary spasm. The patient had no complaint of severe
chest pain or chest tightness, and electrocardiography
showed no significant ST-T change. Coronary angiography revealed no significant stenosis and excluded
myocardial infarction, infected coronary artery aneuActa Cardiol Sin 2014;30:346-349
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Left Ventricular Pseudoaneurysm
ported in this case required emergent replacement of
the MV and resection of the PA. Surgical treatment of
the LV PA by MV replacement with wide resection and
patch closure of the defect obtained a good outcome
and prognosis. An echocardiography taken 6 months after discharge revealed normal LV function.
3.
4.
5.
CONCLUSIONS
6.
Cases involving infective endocarditis complicated
by a huge PA are rarely reported in the literature. This
case demonstrated the good outcomes that can be
achieved by early surgical intervention, continuous antibiotic treatment for 4 months after surgery, and regular
post-procedural echocardiography for 3-4 months thereafter.
7.
8.
9.
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