Correspondence

Intraaortic Vegetations as a Manifestation of Infective Endocarditis

N Engl J Med 2007; 356:874-875February 22, 2007

Article

To the Editor:

Despite advances in diagnosis and treatment, acute infective endocarditis remains a therapeutic challenge, with considerable morbidity and mortality. The therapeutic strategies for this condition are currently well defined by the guidelines of the American Heart Association.1 Operative treatment may be required to restore heart-valve function and eliminate vegetations as a source of embolism and infectious load. To achieve this goal, the exact extent of the bacterial vegetations has to be known. We describe a case of endocarditis with an unusual location of vegetations.

A 60-year-old man was initially treated for acute cholecystitis. Fever persisted for 2 months, despite treatment with various antibiotics, until he was readmitted for the acute coronary syndrome. Coronary angiography revealed occlusion of the right coronary artery. Transesophageal echocardiography showed moderate mitral insufficiency with vegetations and moderate aortic insufficiency. In addition, two floating structures were visualized in the proximal descending aorta (Figure 1Figure 1Transesophageal Echocardiogram Showing Floating Structure in the Proximal Descending Aorta (Arrow).). Blood cultures were positive for Enterococcus faecalis, and the patient was treated with piperacillin and ciprofloxacin.

Antimicrobial treatment was changed to imipenem when recurrent fever developed. On transesophageal echocardiography, the vegetations on the mitral valve were unchanged. Thoracic computed tomography confirmed an intraluminal mass in the descending aorta. Owing to persistent sepsis, a decision was made to proceed with operative treatment.

During surgery, vegetations were found on the mitral and aortic valves, and soft intraluminal masses were found in the proximal descending aorta. It was not possible to determine macroscopically whether the aortic masses were soft atheromatous material or infectious vegetations. Both valves were repaired, and the intraaortic material was removed under conditions of hypothermic circulatory arrest. Culture results confirmed that the valvular and aortic specimens were infected with two different types of coagulase-negative staphylococci. The infection responded to 6 weeks of therapy with vancomycin.

Persistent sepsis, like that in our patient, may require surgical intervention to provide material for diagnostic purposes and to decrease the infectious load. In such instances, surgical treatment with complete eradication of the infectious focus and sufficient postoperative antimicrobial therapy has been shown to have excellent results.2,3

We know of no other reports of infectious vegetations in the proximal descending aorta. Mobile thrombus in the aortic arch or descending aorta is relatively rare but may be a manifestation of an ulcerated atherosclerotic plaque.4

It is unclear whether the floating vegetations in our patient were purely of infectious origin or, rather, were superinfected atherosclerotic material. Nevertheless, their removal was important for successful therapy through identification of the bacteria and reduction of infectious load. We conclude that in patients who have endocarditis with persistent sepsis, extracardiac foci of infection — for example, the aorta — should always be considered.

Oliver Adam, M.D.
Thorsten Kramm, M.D.
University Hospital Homburg, 66421 Homburg, Germany

Herman Hubert Klein, M.D., Ph.D.
Municipal Hospital, 55743 Idar-Oberstein, Germany

Hans-Joachim Schäfers, M.D., Ph.D.
University Hospital Homburg, 66421 Homburg, Germany

4 References

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Bonow RO, Carabello B, de Leon AC, et al. ACC/AHA guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association. J Am Coll Cardiol 1998;32:1486-1588
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Khubulava GG, Maslov SVC, Ktsovea TV, Kovalev IR. Survival of patients with infectious endocarditis in various treatment methods. Klin Med (Mosk) 2004;82:58-62
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Murashita T, Sugiki H, Kamikubo Y, Yasuda K. Surgical results for active endocarditis with prosthetic valve replacement: impact of culture-negative endocarditis on early and late outcomes. Eur J Cardiothorac Surg 2004;26:1104-1111
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4
Laperche T, Laurian C, Roudaut R, Steg PG. Mobile thromboses of the aortic arch without aortic debris: a transesophageal echocardiographic finding associated with unexplained arterial embolism. Circulation 1997;96:288-294
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