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Early Surgical Intervention for Aortic Insufficiency Due to Bacterial Endocarditis
Early Surgical Intervention for Aortic Insufficiency Due to Bacterial Endocardit is Stewart M. Scott, M.D., Robert G. Fish, M.D., and James C. Crutcher, M.D.
C
ongestive heart failure due to myocardial changes, preexistent valve deformities, or valve destruction in the infective period is the major cause of death in bacterial endocarditis [ Z ] . This report concerns only the management of progressive or intractable myocardial decompensation developing in the early phase of the disease due to aortic valve destruction by highly virulent organisms. Despite recent advances in antibiotic therapy, prognosis is hopeless without prompt surgical intervention and prosthetic valve replacement in this situation [3]. During the past year, we have encountered and successfully treated two such cases. Surgery was performed after 12 days of definitive antibiotic therapy in one and after 16 days in the other. CASE
1
A. D., a 33-year-old Negro male, was hospitalized on June 3, 1965, with pneumonia of the upper right lobe. One blood culture produced Diplococcus pneumoniae. The patient, a diabetic, received intravenous penicillin for 2 days, followed by 4 days of intramuscular penicillin and then 7 days of tetracycline. Three weeks later he was discharged afebrile and asymptomatic, although some upper right lung field infiltration remained on x-ray. His blood pressure during this admission was 140/80 mm. Hg, and there were no murmurs. In 1957 the patient had been hospitalized for polyarthralgia due to rheumatoid arthritis, at which time he did have a grade 1 apical systolic murmur. One week following discharge from the hospital, the patient developed dyspnea and orthopnea. When rehospitalized on July 8, 1965, his blood pressure was 152156, and his oral temperature was 99.6'. A grade 3 of 6 diastolic murmur was heard at the left sternal border. The patient was given 40 million units of penicillin and 2 gm. of streptomycin daily, and he was digitalized. Within 10 days the blood pressure was 16010, and the patient had developed severe and unresponsive congestive heart failure. There were nonspecific S-T changes and sinus tachycardia on the electrocardiogram. The chest x-ray revealed cardiac From the Cardiovascular Surgical Section and the Medical Service, Veterans Administration Hospital, Oteen, N.C., and the Medical Service, Veterans Administration Hospital, Atlanta, Ga. Presented at the Thirteenth Annual Meeting of the Southern Thoracic Surgical Association, Asheville, N.C., Nov. 3-5, 1966.
158
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Aortic Znsuficiency from B.E.
enlargement and pulmonary congestion. He was transferred to the Oteen Veterans Administration Hospital on July 20, 1965, for surgical consideration. The next day the aortic valve was totally excised and replaced with a StarrEdwards ball-valve prosthesis. Vegetations were present on all three leaflets but did not involve the aortic wall. The aortic root was washed with sodium methicillin, and the prosthesis was soaked in the antibiotic prior to insertion. T h e patient required some temporary pump support at the end of the procedure, and his cardiac output was augmented with intravenous isoproterenol. Postoperatively he received sodium methicillin, 1 gm. every six hours, chloramphenicol, 1 gm. three times daily, and aqueous penicillin, 4 million units intravenously daily. Although the patient became afebrile on the fourth postoperative day, penicillin, 2 million units daily, was continued for two weeks. His postoperative blood pressure ranged from 120/80 to 140/90, and he rapidly became asymptomatic. Fourteen months following surgery he continues to be well. CASE
2
W. W., a 44-year-old Negro male, was hospitalized on April 11, 1966. He apparently had been in excellent health until six weeks prior to admission, when he developed an acute illness characterized by fever, shaking chills, a slightly productive cough, daily sweats, generalized malaise, anorexia, and weakness. There was no antecedent history of rheumatic fever, syphilis, traumatic surgical procedures, or known valvular heart disease. The patient had been hospitalized twice before in his lifetime, first for meningitis in 1943 while in military service and again in 1950 for acute tonsillitis. His temperature on admission was 101", pulse 105, respirations 24, and blood pressure 130/45 mm. Hg. The patient was acutely ill and disoriented. Conjunctival petechia, Osler's nodes of the middle finger, left hand, and a Roth spot adjacent to the left disc margin were noted. Point of maximal impulse was in the fifth intercostal space, midclavicular line. The rhythm was rapid and regular at a rate of 105 per minute with a grade 3 of 4, high-pitched, decrescendo diastolic murmur, loudest along the left sternal border and radiating to the apex. In addition, a grade 2 of 4 aortic systolic ejection murmur and a grade 3 of 4 rumbling, apical diastolic murmur with axillary radiation were noted. Cervical vein distention, hepatosplenomegaly, and dependent edema were not noted. Eleven blood cultures were positive for alpha-hemolytic streptococci. Electrocardiograms were not remarkable aside from the presence of a sinus tachycardia and nonspecific S - T segment changes. Chest x-ray revealed cardiac dilatation and pulmonary congestion (Fig. 1A).
A
B
C
FIG. 1. ( A ) Chest x-ray of Case 2 taken 9 days before emergency aortic valve replacement. Minimal cardiac enlargement and pulmonary congestion are present. (B) Chest x-ray of Case 2 taken 2 days before valve replacement. Evidence of severe congestive heart failure is present. ( C ) Chest x-ray of Case 2 taken ten weeks after emergency aortic valve surgery. VOL.3,
NO. 2, FEB.,
1967
159
SCOTT, FISH, AND CRU'TCHER Immediately after serial blood cultures had been obtained, the patient was started on 60 million units of penicillin intravenously and 2 gm. of streptomycin intramuscularly daily. When the offending organism was noted to be Streptococcus viridans, penicillin dosage was lowered to 20 million units and streptomycin to 1 gm. daily. Until April 21, 1966, the patient showed evidence of continuing deterioration with temperature spikes to 101", persistent tachycardia, widening pulse pressure, and increasing dyspnea at rest. T h e patient was transferred to the Veterans Administration Hospital, Oteen, N.C., on April 21, 1966, for possible surgical intervention with prosthetic aortic valve replacement. Since the causative organism in this case was a sensitive alphahemolytic streptococcus, i t was hoped at the time of transfer that another 10 to 14 days of intensive antibiotic therapy might be possible in order to obtain a sterile valve. Antibiotic therapy was continued in the form of aqueous penicillin, 40 million units intravenously, and streptomycin, 1 gm. intramuscularly daily. For 5 days the patient remained relatively stable, but then he showed further deterioration with increasing pulmonary congestion and a sudden rise in heart rate to a persistent 144 per minute (Fig. 1B). It was not felt safe to delay surgery any further, and prosthetic aortic valve replacement was carried out the following morning, 16 days after the institution of antibiotic therapy. At the time of surgery the patient's femoral vessels were cannulated for extracorporeal circulation under local anesthesia. With induction of general anesthesia, the patient's arterial pressure fell precipitously, and pump support was immediately instituted. T h e operative procedure continued without further complications. Vegetations were present on all leaflets of the aortic valve, but the inflammation did not extend into the aortic wall. T h e leaflets were removed and the area copiously irrigated with penicillin and sodium methicillin. T h e valve was replaced with a Starr-Edwards prosthesis. Recovery was essentially uneventful. Postoperatively the patient received 40 million units of penicillin and 1 gm. of streptomycin daily for two weeks. T h e penicillin dosage was then reduced to 8 million units intramuscularly daily and continued for three and one-half weeks, a t which time streptomycin was also discontinued. Sodium oxacillin, 0.5 gm. every six hours, was administered during the same period and was then reduced to 0.5 gm. twice daily with the recommendation that it be continued for three months. Postoperative temperature ranged from 98.6" to loo", and after the 17th postoperative day the patient was afebrile. Blood pressure determinations prior to surgery ranged in the vicinity of 130/40 and postoperatively from 110/70 to 130/100. Chest x-ray a t time of discharge from the hospital is shown in Fig. 1C. Four months after surgery the patient is doing well. DISCUSSION
Since the advent of effective antibiotic therapy, congestive heart failure has been the major cause of death in bacterial endocarditis. Little can be done if this is due to irreversible myocardial damage, but failure resulting from dynamically significant valve defects is correctable. Despite the recent advances in prosthetic valve surgery, there is a continued reluctance to submit such severely ill individuals to the further hazards and risks of surgery. This is particularly true if the patient is felt to be in an actively infective phase or has not received a conventional course of antibiotic therapy. Procrastination in order to obtain a sterile valve or an otherwise ideally prepared patient is wise if it is possible to maintain a reasonably stable state of myocardial compensation. Such an attempt was made in 160
T H E ANNALS OF THORACIC SURGERY
CASE REPORT:
Aortic Insuficiency from B.E.
both cases presented. However, if progressive or intractable failure ensues despite intensive medical therapy, in the presence of severe aortic valvular insufficiency, there is no alternative to prompt surgical intervention. Unless the dynamic abnormality is corrected, one is faced with a hopeless situation [4].Further delay will only increase the surgical risk. Endocarditis may involve only the valve leaflets or it may extend into the aortic wall or along the endocardium of the heart chambers. Ordinarily the infectious process is initially confined to the valve substance. T h e time required to “sterilize” the vegetations of bacterial endocarditis is not known. In one of these two patients bacteria could be seen in the microscopic section, although the tissue cultures were negative in both. Organisms which are sensitive to antibiotics disappear from the circulation within twenty-four hours after initiation of treatment, and in ordinary circumstances a bacterial cure can often be expected within two weeks [l]. Organisms which are resistant to antibiotics are less easily suppressed. However, it is still possible with an effective umbrella of antibiotics to eradicate surgically the focus of infection. In view of the high incidence of negative blood cultures in bacterial endocarditis, we were fortunate in each case to identify a penicillin-sensitive organism. Intractable congestive failure limited intensive preoperative antibiotic therapy to 12 and 16 days. T h e operations were carried out as emergency procedures, and preparations were such that cardiopulmonary bypass could be instituted under local anesthesia should induction or intubation result in ventricular fibrillation. Each patient’s recovery was dramatic. SUMMARY
Salvage of two patients in intractable heart failure due to bacterial endocarditis with aortic valve destruction was obtained by surgical intervention and prosthetic valve replacement. One patient had received 12 days of intensive preoperative antibiotic therapy, and the other 16. T o defer surgery in the face of advancing heart failure despite supposedly inadequate antibiotic therapy jeopardizes chances for recovery. REFERENCES 1. Friedberg, C . K . Diseases of the Heart. Philadelphia: Saunders, 1966. P. 1374. 2. Robinson, M. J., and Ruedy, J. Sequelae of bacterial endocarditis. Amer. J. M e d . 32:922, 1962. 3. Tompsett, R., and Lubash, G. D. Aortic valve perforation in bacterial endocarditis. Circulation 23:662, 1961. 4. Wallace, A. G., Young, W. G., Jr., and Osterhout, S. Treatment of acute bacterial endocarditis by valve excision and replacement. Circulation 3 1 :450, 1965.
VOL.
3,
NO. 2, FEB.,
1967
161
C
ongestive heart failure due to myocardial changes, preexistent valve deformities, or valve destruction in the infective period is the major cause of death in bacterial endocarditis [ Z ] . This report concerns only the management of progressive or intractable myocardial decompensation developing in the early phase of the disease due to aortic valve destruction by highly virulent organisms. Despite recent advances in antibiotic therapy, prognosis is hopeless without prompt surgical intervention and prosthetic valve replacement in this situation [3]. During the past year, we have encountered and successfully treated two such cases. Surgery was performed after 12 days of definitive antibiotic therapy in one and after 16 days in the other. CASE
1
A. D., a 33-year-old Negro male, was hospitalized on June 3, 1965, with pneumonia of the upper right lobe. One blood culture produced Diplococcus pneumoniae. The patient, a diabetic, received intravenous penicillin for 2 days, followed by 4 days of intramuscular penicillin and then 7 days of tetracycline. Three weeks later he was discharged afebrile and asymptomatic, although some upper right lung field infiltration remained on x-ray. His blood pressure during this admission was 140/80 mm. Hg, and there were no murmurs. In 1957 the patient had been hospitalized for polyarthralgia due to rheumatoid arthritis, at which time he did have a grade 1 apical systolic murmur. One week following discharge from the hospital, the patient developed dyspnea and orthopnea. When rehospitalized on July 8, 1965, his blood pressure was 152156, and his oral temperature was 99.6'. A grade 3 of 6 diastolic murmur was heard at the left sternal border. The patient was given 40 million units of penicillin and 2 gm. of streptomycin daily, and he was digitalized. Within 10 days the blood pressure was 16010, and the patient had developed severe and unresponsive congestive heart failure. There were nonspecific S-T changes and sinus tachycardia on the electrocardiogram. The chest x-ray revealed cardiac From the Cardiovascular Surgical Section and the Medical Service, Veterans Administration Hospital, Oteen, N.C., and the Medical Service, Veterans Administration Hospital, Atlanta, Ga. Presented at the Thirteenth Annual Meeting of the Southern Thoracic Surgical Association, Asheville, N.C., Nov. 3-5, 1966.
158
THE ANNALS OF THORACIC SURGERY
CASE REPORT:
Aortic Znsuficiency from B.E.
enlargement and pulmonary congestion. He was transferred to the Oteen Veterans Administration Hospital on July 20, 1965, for surgical consideration. The next day the aortic valve was totally excised and replaced with a StarrEdwards ball-valve prosthesis. Vegetations were present on all three leaflets but did not involve the aortic wall. The aortic root was washed with sodium methicillin, and the prosthesis was soaked in the antibiotic prior to insertion. T h e patient required some temporary pump support at the end of the procedure, and his cardiac output was augmented with intravenous isoproterenol. Postoperatively he received sodium methicillin, 1 gm. every six hours, chloramphenicol, 1 gm. three times daily, and aqueous penicillin, 4 million units intravenously daily. Although the patient became afebrile on the fourth postoperative day, penicillin, 2 million units daily, was continued for two weeks. His postoperative blood pressure ranged from 120/80 to 140/90, and he rapidly became asymptomatic. Fourteen months following surgery he continues to be well. CASE
2
W. W., a 44-year-old Negro male, was hospitalized on April 11, 1966. He apparently had been in excellent health until six weeks prior to admission, when he developed an acute illness characterized by fever, shaking chills, a slightly productive cough, daily sweats, generalized malaise, anorexia, and weakness. There was no antecedent history of rheumatic fever, syphilis, traumatic surgical procedures, or known valvular heart disease. The patient had been hospitalized twice before in his lifetime, first for meningitis in 1943 while in military service and again in 1950 for acute tonsillitis. His temperature on admission was 101", pulse 105, respirations 24, and blood pressure 130/45 mm. Hg. The patient was acutely ill and disoriented. Conjunctival petechia, Osler's nodes of the middle finger, left hand, and a Roth spot adjacent to the left disc margin were noted. Point of maximal impulse was in the fifth intercostal space, midclavicular line. The rhythm was rapid and regular at a rate of 105 per minute with a grade 3 of 4, high-pitched, decrescendo diastolic murmur, loudest along the left sternal border and radiating to the apex. In addition, a grade 2 of 4 aortic systolic ejection murmur and a grade 3 of 4 rumbling, apical diastolic murmur with axillary radiation were noted. Cervical vein distention, hepatosplenomegaly, and dependent edema were not noted. Eleven blood cultures were positive for alpha-hemolytic streptococci. Electrocardiograms were not remarkable aside from the presence of a sinus tachycardia and nonspecific S - T segment changes. Chest x-ray revealed cardiac dilatation and pulmonary congestion (Fig. 1A).
A
B
C
FIG. 1. ( A ) Chest x-ray of Case 2 taken 9 days before emergency aortic valve replacement. Minimal cardiac enlargement and pulmonary congestion are present. (B) Chest x-ray of Case 2 taken 2 days before valve replacement. Evidence of severe congestive heart failure is present. ( C ) Chest x-ray of Case 2 taken ten weeks after emergency aortic valve surgery. VOL.3,
NO. 2, FEB.,
1967
159
SCOTT, FISH, AND CRU'TCHER Immediately after serial blood cultures had been obtained, the patient was started on 60 million units of penicillin intravenously and 2 gm. of streptomycin intramuscularly daily. When the offending organism was noted to be Streptococcus viridans, penicillin dosage was lowered to 20 million units and streptomycin to 1 gm. daily. Until April 21, 1966, the patient showed evidence of continuing deterioration with temperature spikes to 101", persistent tachycardia, widening pulse pressure, and increasing dyspnea at rest. T h e patient was transferred to the Veterans Administration Hospital, Oteen, N.C., on April 21, 1966, for possible surgical intervention with prosthetic aortic valve replacement. Since the causative organism in this case was a sensitive alphahemolytic streptococcus, i t was hoped at the time of transfer that another 10 to 14 days of intensive antibiotic therapy might be possible in order to obtain a sterile valve. Antibiotic therapy was continued in the form of aqueous penicillin, 40 million units intravenously, and streptomycin, 1 gm. intramuscularly daily. For 5 days the patient remained relatively stable, but then he showed further deterioration with increasing pulmonary congestion and a sudden rise in heart rate to a persistent 144 per minute (Fig. 1B). It was not felt safe to delay surgery any further, and prosthetic aortic valve replacement was carried out the following morning, 16 days after the institution of antibiotic therapy. At the time of surgery the patient's femoral vessels were cannulated for extracorporeal circulation under local anesthesia. With induction of general anesthesia, the patient's arterial pressure fell precipitously, and pump support was immediately instituted. T h e operative procedure continued without further complications. Vegetations were present on all leaflets of the aortic valve, but the inflammation did not extend into the aortic wall. T h e leaflets were removed and the area copiously irrigated with penicillin and sodium methicillin. T h e valve was replaced with a Starr-Edwards prosthesis. Recovery was essentially uneventful. Postoperatively the patient received 40 million units of penicillin and 1 gm. of streptomycin daily for two weeks. T h e penicillin dosage was then reduced to 8 million units intramuscularly daily and continued for three and one-half weeks, a t which time streptomycin was also discontinued. Sodium oxacillin, 0.5 gm. every six hours, was administered during the same period and was then reduced to 0.5 gm. twice daily with the recommendation that it be continued for three months. Postoperative temperature ranged from 98.6" to loo", and after the 17th postoperative day the patient was afebrile. Blood pressure determinations prior to surgery ranged in the vicinity of 130/40 and postoperatively from 110/70 to 130/100. Chest x-ray a t time of discharge from the hospital is shown in Fig. 1C. Four months after surgery the patient is doing well. DISCUSSION
Since the advent of effective antibiotic therapy, congestive heart failure has been the major cause of death in bacterial endocarditis. Little can be done if this is due to irreversible myocardial damage, but failure resulting from dynamically significant valve defects is correctable. Despite the recent advances in prosthetic valve surgery, there is a continued reluctance to submit such severely ill individuals to the further hazards and risks of surgery. This is particularly true if the patient is felt to be in an actively infective phase or has not received a conventional course of antibiotic therapy. Procrastination in order to obtain a sterile valve or an otherwise ideally prepared patient is wise if it is possible to maintain a reasonably stable state of myocardial compensation. Such an attempt was made in 160
T H E ANNALS OF THORACIC SURGERY
CASE REPORT:
Aortic Insuficiency from B.E.
both cases presented. However, if progressive or intractable failure ensues despite intensive medical therapy, in the presence of severe aortic valvular insufficiency, there is no alternative to prompt surgical intervention. Unless the dynamic abnormality is corrected, one is faced with a hopeless situation [4].Further delay will only increase the surgical risk. Endocarditis may involve only the valve leaflets or it may extend into the aortic wall or along the endocardium of the heart chambers. Ordinarily the infectious process is initially confined to the valve substance. T h e time required to “sterilize” the vegetations of bacterial endocarditis is not known. In one of these two patients bacteria could be seen in the microscopic section, although the tissue cultures were negative in both. Organisms which are sensitive to antibiotics disappear from the circulation within twenty-four hours after initiation of treatment, and in ordinary circumstances a bacterial cure can often be expected within two weeks [l]. Organisms which are resistant to antibiotics are less easily suppressed. However, it is still possible with an effective umbrella of antibiotics to eradicate surgically the focus of infection. In view of the high incidence of negative blood cultures in bacterial endocarditis, we were fortunate in each case to identify a penicillin-sensitive organism. Intractable congestive failure limited intensive preoperative antibiotic therapy to 12 and 16 days. T h e operations were carried out as emergency procedures, and preparations were such that cardiopulmonary bypass could be instituted under local anesthesia should induction or intubation result in ventricular fibrillation. Each patient’s recovery was dramatic. SUMMARY
Salvage of two patients in intractable heart failure due to bacterial endocarditis with aortic valve destruction was obtained by surgical intervention and prosthetic valve replacement. One patient had received 12 days of intensive preoperative antibiotic therapy, and the other 16. T o defer surgery in the face of advancing heart failure despite supposedly inadequate antibiotic therapy jeopardizes chances for recovery. REFERENCES 1. Friedberg, C . K . Diseases of the Heart. Philadelphia: Saunders, 1966. P. 1374. 2. Robinson, M. J., and Ruedy, J. Sequelae of bacterial endocarditis. Amer. J. M e d . 32:922, 1962. 3. Tompsett, R., and Lubash, G. D. Aortic valve perforation in bacterial endocarditis. Circulation 23:662, 1961. 4. Wallace, A. G., Young, W. G., Jr., and Osterhout, S. Treatment of acute bacterial endocarditis by valve excision and replacement. Circulation 3 1 :450, 1965.
VOL.
3,
NO. 2, FEB.,
1967
161