Download Left Ventricular-Right Atrial Shunt Due to Bacterial

Left
Ventricular-Right
Atrial
Bacterial
Endocarditis*
Stephen
M.D.,
Cantor,
Richard
Sanderson,
Shunt
M.D.,
Two
patients
resulting
are
Keith
reported
shock
and
the absence
C
ongestive
heart
failure
cause of death
in
merly,
mortality
from
uncontrolled
to
has
resulted
lems,
and
to
plays
only
seen
in these
heart
failure,
sequent,
a
in the
been
role
patients.
The
then,
first
that
in
the
describes
another
serious,
yet
may
lead
to life-saving
CASE
CASE
a
peripheral
pulses
and
the
the
referring
had
become
enlarged
surgery.
REPORTS
ciency,
man
developed
in
intravenous
from
1970,
20
came
dyspneic,
days
mild
after
institution
and
He
hospital
was
and
were
changed.
daily
of
therapy,
was
found
initially
for
17
relatively
on
he
to
suddenly
have
an
treated
over
lar
well.
Several
the
and
be-
sustained
with
isopro-
next
several
transfer
to our
institution,
he
#{176}Fromthe Cardiopulmonary
Unit and
cal Sciences,
Pacific
Medical
Center,
Cardiovascular
pital,
San
Supported
Grants
Surgery,
The
Veterans
Francisco,
California.
by grants
from
the Bay
HE-05498
of Health,
Maryland.
and
United
with
alert
Administration
A
had
a
or
There
was
modest
axis was
of
scan
suggesting
His
28,000
per
x-ray
with
which
defects.
again,
shock.
he
in
congestion
ventricu-
left
perfusion
of
a
notable
deteriorated
episodes
from
the
hemotocrit
was
vascular
with
no
more
mm3,
film
suddenly
transitory
significant-
been,
showed
he
not
became
pulmonary
enlargement
arrest
pattern;
abnormali-
infarction.
chest
admission
cardiac
slightly
depressions
formerly
slight
cardiac
recurrent,
was
hypertrophy
QRS
His
lung
louder
liver
conduction
count
left.
was
only
moderate
after
felt.
by
murmur
somewhat
The
ST-T
cell
the
was
believed
He
could
then
not
be
resuscitated.
Postmortem
heart
warm
examination
weighing
500
and
colored
cusp
On
Hos-
the
tions
Association
National
InService,
Be-
1 ).
just
foci
the
atrial
above
of
of necrosis;
did
not
aortic
examination
many
bacteria
552
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21525/ on 05/06/2017
were
the
seen
Graythe
portion
red
or cultured.
right
of
right
the
atrium.
polypoid
tricuspid
that
and
finger.
the
several
of
markedly
below
a
into
fibrin
were
one
and
enlarged
was
and
revealed
neutrophils,
no
admit
ruptured
leaflet
diffusely
valve
above
valve
there
septal
a
aortic
present
had
side
the
N’Iicroscopic
consisted
and
septum
right
The
were
of
intraventricular
revealed
grams.
calcified
vegetations
coronary
the Institute
of Mediand the Division
of
Area Heart
from the
Public
Health
HE-06311
States
was
to
hours
19.
tinob-
a white
1-Il/VI
diastolic
murmur
ischemia
shift
grade
It was
ventricular
had
coronary
V/VI
without
murmur
patient’s
frontal
they
prominence.
A
grade
apex,
diastolic
cm
intensity
of phlebitis.
occasion,
with
there
with
days.
January
of
the
a left
0.5
in
A
axilla.
was
and
thrill,
the
intraventricular
and
waves
to ausculta-
normal
border.
blood
venous
revealed
the
spleen
a left
one
v
clear
inside
systolic
no
than
increased.
evidence
or
just
collapse.
or
On
41
the
no
present
stenotic
After
stitutes
thesda,
revealed
ly
that
along
with
hours.
and
ECC
was
the
bounding
marked
heart
was
sternal
that
tender;
atrioventricular
ties
left
and
but
marked
bacte-
treated
doing
when
improved
insuffi-
subacute
been
failure,
and
was
units
had
heart
pressure.
at another
stenosis
and
million
he
collapsed
blood
terenol
1969,
and
some
aortic
Streptococcus
40
disappeared
apart
known
December
penicillin-C
fever
tamable
with
a Viridans
endocarditis
His
and
and
The
systolic
sound
to
cardiovascular
edema
the
immediate
lower
softer
pronounced
1
or
physician
the
of
palpable
noted
base
the
following
a
were
sound
was
not
was
lungs
first
high-pitch
along
small
100/mm.
prominent
easily
The
the
was
but
of
There
The
an
second
to
brisk
Examination
and
murmur
The
septum
edema.
Hg.
sign.
apex.
decrescendo,
no
ventricular
defect
rate
without
single
radiation
was
rial
the
the
output,
mm
percussion.
to
pitting
other
a heart
Kussmaul
pansystolic
poten-
the
to differential
diagnosis,
note is
venous
pressure
elevation
and
urine
1 10/80
heave
noted
of
pulmonary
and
elevation
a
possibility
A 70-year-old
good
was
and
tially
remediable,
disturbance
which
results
from
bacterial
endocarditis-a
left ventricular-right
atrial
shunt.
It is our belief
that
appreciation
of such
an
entity
extremities,
medial
con-
in the
of marked
ventricular
producing
with
while
With regard
the prominent
findings
tion
failure
factor
failure,
without
myocarditis
perforation
atrial
shunt,
as a complication
of bacterial
presented
with catastrophic
cardiac
deteriora-
pressure
prob-
cardiac
primary
developed
pressure
dys-
of these
valvular
damage
regurgitation.
is
valvular
report
valvular
appreciated
minimal
severe
This
common
myocarditis
with
myocardial
abMore
recently,
effective
therapy
in a decline
it has
most
emboli,
M.D.
significance.
murmur,
of radiographic
bacterial
endocarditis.
Forthis disease
was
attributed
infection,
function,
and
scess
formation.
the
is
who
biventricular
of little hemodynamic
made
of the pansystolic
to
Cohn,
in a left ventricular-right
One of these patients
endocarditis.
tion,
and
Due
valve
vegeta( Fig
the
vegetations
blood
cells
with
SHUNT
DUE
TO
BACTERIAL
553
ENDOCARDITIS
1
FIGuISE
la (tipper).
Right
atrium
and
tncllsI)id
valve
showing
fistula
( arrow ) sunrounded
by massive
vegetations.
FIGURE
lb (lower).
Aortic
valve
showing
thick
inregular
cusps
with
1)nolninent
vegetations.
Left
ventricular
aspect
of fistula
( arrow)
seen
i)clow
vegetations.
CAI:
2
ring
A 52-year-old
cause
of
lie
was
Ill/VI
the
dIld
congestive
was
aPParellt
and
a1)I)etrance
of
miirniiir
sud(Ien
neck
veins
Upon
I)roml)tecl
inspection
evident,
tile
its
CHEST,
VOL.
superior
60,
valve,
deep
of
the
NO.
left
No
lift
in
The
which
fistulous
inferior
6,
ridges
tract
surfaces
DECEMBER
to
l)all
and
x
2
fallen
was
to 7,000.
uncolltrolled
He
was
improvement
febnile
was
course
cultured
the
an(l
Postoi)erative
from
patient
resume(l
the
finally
on
sepsis,
tile
i)l(X)(l.
(lied
with
21st
1)ost-
closed.
tract
Tilere
the
was,
area
revealed
seate(l
of the
to
ill
right
tile
however,
a 1-mm
found
Pseudomona.s
tile
Starr-Edwards
without
was
the
aerugiizosa
on
and
to
fistulous
the
into
right
leak
found
diameter
al)scess
at
pros-
a valvular
ventricle
subannulan
vegetations,
grew
place
atnial
be
tract
nigilt
atrium.
aspect
of
the
culture.
DIsCussIoN
closed
the
tentil
clinical
his
atnial
cm
As
communicated
to
of
yellowish
a 3
was
firmly
fistiilous
tract,
variance
had
1)olYnlYxin,
exanlination
ie
Exuberant
marked
count
the
continuing
aerugiflosa
features
by
bleeding
clay.
froni
pulsating
By
however,
mg/day
clinical
the
cell
and
complicated
mediastillal
thereafter,
120
operative
was
injury.
white
hiniseif
Soon
tilesis
change
and
patients
Pseudoniona.s
tile
1)rOsthesis.
course
systelll
Postmortem
sternal
occurred.
prosthesis,
(liscovered
and
and
OPeration.
aortic
The
change
ventricular
showing
was
ventricle.
ilul)ricating
the
reiiioval
abscess
right
right
eniergency
ball
After
stll)annular
with
of
the
(liscoloration.
a
an
ECC
to feed
immediate
the
failure.
a
area
tile
able
Despite
included
aortic
day,
10 Starr-Edwards
tacilyarrhythmias,
flCVOUS
and
daily,
No.
postoperative
ventricular
evi(lent.
aurcu.s.
Il/VI
along
heart
no
the
gra(le
also
of
collsec-
inethicillin
it
a
Five
findings
I1ltlfll1l
border,
when
size
early
central
aortic
1968,
Staphylococcus
Physical
alld
ie-
valvular
August
malaise.
intravenous
IlltllllU
findings
and
gin
systolic
sternal
severe
until
for
12
(lecrescen(l()
I)Order,
was
long,
and
fever
in
replacement
prosthesis
positive
continued.
left
diastolic
the
vith
fever
along
chills,
were
treatluent
gra(le
failure
illiproved
for
valve
aortic
NlcCovern-Cromie
markedly
cultures
spiking
a
heart
was
hospitalized
1)100(1
I)espite
the
with
congestive
He
steilOsis.
LItRe
underwent
flldfl
1964,
\uve’mher
the
of
Tile
sewing
by
emphasized
in
the
introduction,
heart
failure
during
bacterial
endocarditis
usually
follows
valvular cusp perforation
or ruptured
chordae
tendineae;
1971
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21525/ on 05/06/2017
CANTOR,
554
the
development
of the
chambers
Surgical
has
therapy
by
apy
has
also
stances
where
course
a recent,
the
infected
annulus
septum
led
anatomic
septum,
that
the
ventricle
left
valve
to
the
viously
of acquired
left
occurring
secondary
lished
observations).
recognition
the
patient
and
long
that
along
of
of
Left
view
endocarditis
lus with
the
left
pulmonary
the
shunt,
diagnosis
of
suddenly,
sternal
aid
in
this
with
elevation.
holosystolic
border
in each
hearts
with
but in neither
some
was
congestion
or
edema
first
the
entire
case
the
no
aortic
intervenof the
septum,
is
ruptured
The
in both
emboembo-
The
markedly
ele-
the
possibility
that
into
the
of
devel-
diagnosis,
the sudden
patient
with
bacterial
suggested
with
A-V
it
abnormalities
tamponade.
had
confused
shunt
state
suggest
a coronary
artery
infarction,
pulmonary
leading
to tamponade.
was misinterpreted
was
ruptured
sepsis.
relationship
conduction
pressure
root
COHN
ventricular-right
membranous
pericardial
venous
left
the
the differential
shock
in a
of
AND
case, however,
this
and
the clinical
anatomic
the
might
myocardial
or
vated
to the
dominated
by
and uncontrolled
of
oped.
In assessing
appearance
lism,
due
the
long
cases;
pericardium,
systolic
in the
aortic
murmur
second
outflow
it
murmur
through
the McGovern
prosthesis,
and in the first
case it was thought
to be due to mitral
insufficiency
from
the
radiations
the left
ruptured
chordae
of murmurs
sternal
border
in ruptured
are
the
rial
endocarditis
ciency,
there
gestion
and
na!
findings.
with
if the
large
most
cases
severe
insuffi-
venous
edema;
these
atrial
if the
not
from
to surgical
and
con-
were
shunts
amenable
is sterilized
most
of bacte-
valvular
pulmonary
patients.
to right
are
region
ing the
retention.
In
pulmonary
endocarditis
the
these
cases
from
mitral
regurgitations,
acute
is pronounced
in our two
ventricular
Unusual
Perhaps
5
distinguishing
aortic
or
radiologic
present
Left
tendineae.
to either
the back
or along
into the base
are well known
chordae
prominent
feature
more
typical
acute
( unpub-
which
pressure
case
pre-
additional
atrial
differential
yen-
one
been
trauma
features
is
congeni-
an
ventricular-right
chest
It
of the
tract
of
only
has
aware
the
atria.
known
knowledge
endocarditis
are
In
of
left
interven-
atrium.
well
had enlarged
congestion,
striking.
the
inter-
form,
the
deteriorated
patients
vascular
degree
especially
interest
the
portion
outflow
right
are
pronounced
venous
systolic
murmurs-probably
present
case.
Both
pulmonary
and
clinical
and
One
-were
within
ina short
the
to be
septum
In
below
schematic
to blunt
are several
seemed
tricular
was
in the second
better
tolerated,
bundle
of the
perforation
between
the
We
4
shunt;
small,
cases
in
between
picture
atrial
was
the
in
shunts
tal defects,
:s but
to our
resulting
from
bacterial
shock
Loud,
a shunt
clinical
of ther-
vegetations
extended
ventricles
from
atrial
entity.
study,
the upper
membranous
septum
separates
the
tricular-right
There
this
relationship
tricular
the
form
the upper
portion
The
consequent
and right atrium.
2 demonstrates
evident
ventricular
case
in
to bacte-
in those
this
in
aortic
then
ventricle
Figure
normal
advance
utilized
described
onto
septum.
ventricular
the
re-
2
cases
aortic
or
been
successfully
employed
patients
have
received
only
the
from
repair
related
antibiotics,
of
In
to one
described.
successful
failure
Preferably
1
sterilized
fistula
been
valvular
intractable
rial
already
also
with
been
of
of Valsalva
has
intervention
placement
the
of sinus
cardiac
SANDERSON
bacte-
correction
tissue
surround-
defect
is not so friable
as to prevent
Under
such
circumstances,
closure
defect
namic
and
burden,
elimination
the
of
left-to-right
a marked
shunt
suture
of a
hemody-
could
be
life-
saving.
ACKNO\VLEDGNIENT:
Happe
and H. S. Barr
for
We are
referral
indebted
of the
to Doctors
first case.
D. J.
REFF.IIENCES
1 Stason
2
WB,
surgery
in
Braniff
BA,
ment
in
bacterial
Shumway
mitral
relationships
outflow
tract
of
and
interventniculan
tricuspid
valve.
septum
Reprint
Pacific
Harrison
Nloss
: Mycotic
aneurysm
Heart
involving
J 1 :703,
JJ, Vannitamby
insufficiency
due
Amen
requests
Nledical
CHEST,
AJ :
J Candiol
Amen
A, Kelly
tendineae.
Anatomic
AN,
et al:
Cardiac
38:514,
Circulation
DC:
endocarditis.
TA,
\i.
2.
bacterial
Amer
5 Seizer
Weinberg
Valve
New
1968
replace-
J Med
Eng
1967
C
septufll.
ventricular
NE,
communication.
4 Wilson
FIGURE
RN,
endocanditis.
Riemenschneiden
atrial
to left
Sanctis
active
276:1464,
3
De
to
isolated
VOL.
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21525/ on 05/06/2017
NO.
The
nipture
syndrome
of
the
of
chordae
1967
Keith
Cohn,
San
Francisco
60,
ventricular-right
19:710,
1967
the intraventricular
1926
M, et al:
J NIed 43:822,
: Dr.
Center,
Left
Presbyterian
94115
6,
DECEMBER
Hospital
1971