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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