Correspondence

Pulmonary-Valve Endocarditis

N Engl J Med 2007; 356:2224-2225May 24, 2007

Article

To the Editor:

Isolated pulmonary-valve endocarditis is quite rare, but it shares demographic, clinical, and microbiologic features with the more-common tricuspid endocarditis.1 We describe a 35-year-old intravenous drug abuser who presented with Staphylococcus aureus septicemia and fulminant circulatory failure, complicated by multiple lung abscesses and associated bronchopleural fistula. High-dose vasopressor and inotropic support and positive-pressure ventilation were required, in addition to intravenous antibiotics.

Echocardiography showed a large mobile mass in the right ventricular outflow tract, arising from the pulmonary valve and extending into the right pulmonary artery, causing severe pulmonary regurgitation. The right ventricle was dilated and hypokinetic. The tricuspid valve was structurally normal; however, moderate functional tricuspid regurgitation was present.

Surgery was performed on day 5 of the patient's hospital stay. The pulmonary trunk was opened during cardiopulmonary bypass, and a vegetation, 9 cm in length, was removed (Figure 1Figure 1Surgical Specimen of a Resected Pulmonary-Valve Leaflet.). The entire pulmonary root, up to the bifurcation of the pulmonary trunk, was excised and replaced with a pulmonary homograft. The patient had an excellent recovery. The bronchopleural fistula was managed conservatively and resolved. Six months later, the patient remained well, in New York Heart Association functional class I.

It is sometimes argued that right-sided endocarditis is better tolerated and more likely to respond to medical therapy than infection of the mitral and aortic valves. Consequently, an extended trial of antibiotic treatments in these patients may be appealing, especially when there is a risk of prosthetic-valve infection due to recidivism of intravenous drug abuse. The results of retrospective studies suggest that vegetations less than 1 to 2 cm long in right-sided endocarditis usually respond to medical treatment.2,3

Whereas for left-sided endocarditis there are established evidence-based guidelines,4 the indications for surgery and its timing in patients with right-sided endocarditis are much less clear. However, on the basis of current evidence, we suggest that infection with staphylococcus, the presence of large vegetations (>2 cm long), or cardiovascular instability should prompt consideration of early surgical intervention in patients with this condition.

Nicholas Kang, F.R.A.C.S.
Warren Smith, F.R.A.C.P.
Sally Greaves, F.R.A.C.P.
David Haydock, F.R.A.C.S.
Green Lane Cardiothoracic and Cardiovascular Service, Auckland 1148, New Zealand
nkang@adhb.govt.nz

4 References

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   Robbins MJ, Frater RW, Soeiro R, Frishman WH, Strom JA. Influence of vegetation size on clinical outcome of right-sided infective endocarditis. Am J Med 1986;80:165-171
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   Hecht SR, Berger M. Right-sided endocarditis in intravenous drug users: prognostic features in 102 episodes. Ann Intern Med 1992;117:560-566
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   Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006;114:e84-e231[Erratum, Circulation 2007;115:e409.]
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   Giovanni Melina, Ismail El-Hamamsy, Riccardo Sinatra, Magdi H. Yacoub. (2010) Late fulminant pulmonary valve endocarditis after the Ross operation. The Journal of Thoracic and Cardiovascular Surgery 139:5, e99-e100
   CrossRef