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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3695_Библиотеки_им_академика_М_И_Перельмана
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Figure 1 Heart in the patient described. (a) Exterior view showing the acute peri-
carditis. (b) Left parasagittal cut showing the left side of the heart. Avegetation is
barely seen on the atrial aspect of the posterior mitral leaet. As shown better in
(c), the mitral vegetation has ruptured into the left atrioventricular sulcus and then
out into the pericardial sac, causing a large hemopericardium. (d) Shown here is the
mitral vegetation “head on.” The underlying mitral valve is anatomically normal.
Only a minute calcic deposit was present in the mitral annular region.
for hemodialysis was more than double that of those receiving hemodialysis via
arteriovenous stulas.
IE more commonly affects a native aortic valve than a native mitral valve.
Analysis of 96 necropsy patients with active left-sided IE studied by Arnett and
1
Roberts
disclosed isolated aortic valve involvement in 34 patients (35%), isolated
mitral valve involvement in 22 patients (23%), and involvement of both valves in 18
(19%). Of 59 patients with IE involving the aortic valve, 24 (41%) had a ring abscess;
310
3
CASE 1763 ISOLATED MITRAL VALVE ENDOCARDITIS WITH RING ABSCESS AND PERICARDITIS
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Table 1: Causes of pericarditis in infective endocarditis
I. Extension of inammation from
A. Mycotic aneurysm of aortic root
B. Valve ring abscess
C. Embolus in extramural coronary artery
II. Rupture of mycotic aneurysm
of 36 patients with IE involving any valve other than the aortic, only 3 (6%) had a
ring abscess.
to ring abscess and pericarditis have been reported previously; three had the IE
superimposed on a calcied mitral annulus.
2
At least ve patients with IE involving the mitral valve and leading
3–6
Pericarditis is a relatively uncommon complication of IE. Arnett and Roberts2
found pericarditis in 18 (19%) of 95 patients with IE involving the aortic valve, 14 of
whom had a ring abscess. The same authors found pericarditis in only 6 (12%) of 48
patients with IE involving the mitral valve, only one of whom had a ring abscess.
What makes our patient’s pericarditis unusual is that it was in the setting of isolated
mitral valve IE. Causes of pericarditis in patients with IE are summarized in Table1.
REFERENCES
1. Arnett EN, Roberts WC. Active infective endocarditis: a clinicopathologic anal-
ysis of 137 necropsy patients. Curr Prob Cardiol 1976;1(7):1–76. doi:10.1016/01462806(76)90003-7.
2. Arnett EN, Roberts WC. Valve ring abscess in active infective endocarditis.
Frequency, location, and clues to clinical diagnosis from the study of 95 necropsy
patients. Circulation 1976;54(1):140 –145. doi:10.1161/01.CIR.54.1.140.
3. Mambo NC, Silver MD, Brunsdon DF. Bacterial endocarditis of the mitral valve
associated with annual calcication. Can Med Assoc J 1978;119(4):323–326.
4. Sandler MA, Kotler MN, Bloom RD, Jacobson L. Pericardial abscess extending
from mitral vegetation: an unusual complication of infective endocarditis. Am
Heart J 1989;118(4):857–859. doi:10.1016/0002-8703(89)90608-X.
5. Isotalo PA, Mai KT, Stinson WA, Veinot JP. Mitral annular calcication with
Staphylococcus aureus periannular abscess. Arch Pathol Lab Med 2000;124:924.
6. Wentzell S, Nair V. Rare case of infective endocarditis involving mitral annular
calcication leading to hemopericardium and sudden cardiac death: a case report.
Cardiovasc Pathol 2018;33:16–18. doi:10.1016/j.carpath.2017.11.005.
311
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Case 1780 Malignancy-Associated Non-Bacterial
Thrombotic Endocarditis Causing Aortic
Regurgitation and Leading to Aortic
Valve Replacement
Madiha Makhdumia, Dan M. Meyer
b,c
, and William C. Roberts
a,c,
*
Described herein is a 48-year-old woman with metastatic ovarian cancer who
developed aortic regurgitation considered clinically to be the result of infective
endocarditis but operative resection of the three aortic valve cusps disclosed
the valve lesions to be typical of non-bacterial thrombotic endocarditis (NBTE).
Aortic regurgitation as a consequence of NBTE is rare but at least 9 cases have
been reported previously. © 2021 Published by Elsevier Inc.
(Am J Cardiol 2021;154:120−122)
INTRODUCTION
Recently, we encountered a patient having aortic valve replacement for aortic
regurgitation considered clinically to be the result of active infective endocarditis,
but examination of an operatively excised aortic valve cusp disclosed the lesion to be
typical of non-bacterial thrombotic endocarditis (NBTE), not infective endocarditis.
The histological surprise stimulated us to search for previously reported cases
of aortic regurgitation secondary to NBTE leading to aortic valve replacement
(Table1).
1–7
CASE DESCRIPTION
2
A 48-year-old obese (body mass index of 32 kg/m
) woman with stage IV ovarian
cancer, ascites and swollen legs presented to the emergency department at Baylor
University Medical Center with dyspnea for two months. She was in no distress
and was afebrile. The blood pressure was 140/80mmHg. Aprecordial murmur (not
described further) was heard. No abnormalities were seen on the electrocardiogram.
A 2-dimensional transthoracic echocardiogram 3.5 months before aortic valve
replacement showed mild aortic regurgitation and cardiac catheterization showed
the simultaneous left ventricular and aortic pressures to be 112/2 and 102/63
mmHg, respectively. The left ventricular ejection fraction was about 65%. Computed
tomographic imaging disclosed small pleural effusions bilaterally. Transesophageal
echocardiography 3 days before aortic valve replacement disclosed moderate aortic
regurgitation, a left ventricular ejection fraction of about 35%, and a small mass on
the ventricular aspect of the left coronary cusp (Figure1). The blood cultures were
negative. The leukocyte count was 5,600/μL, blood hemoglobin was 12.0 g/dl, and
the platelet count was 260,000/μL. At operation, each aortic valve cusp was excised,
a
From the Baylor Heart and Vascular Institute, Dallas, Texas; bThe Departments of Cardiac
Surgery, Dallas, Texas; and
Texas. Manuscript received May6, 2021; revised manuscript received and accepted May21,
2021.
*
Corresponding author. Telephone 214-820-7911 Fax (214) 820-7533
E-mail address: William.Roberts1@bswhealth.org (W.C. Roberts).
312 DOI: 10.1201/9781003409281- 65
c
Internal Medicine, Baylor University Medical Center, Dallas,
Table 1: Certain observations in previously reported patients with non-bacterial thrombotic endocarditis (NBTE) and valve operation
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associated with pure regurgitation in one or both left sided valves
Before Valve Operation
First
Author
(Reference)
Case
1 Kardaras
2 Rabinstein
3 42 W AV “Moderate” + ? 0 + (B,F,K,S) + +
4 38 W MV “Moderate” ? 0 + + (B) + 0
5 Numnum
6 Hofstra
7 Tei
8 Kaneyuki
9 Soga
AV=aortic valve; B=brain; F=nger; IE=infective endocarditis; K=kidney; M=man; MV=mitral valve; NBTE=non-bacterial thrombotic endocarditis;
S=spleen; W=woman; VO=valve operation.
* All cancers were adenocarcinomas.
†
These patients were treated with anticoagulants for ischemic stroke, not NBTE.
4
5
7
Publication
1
2
3
6
Year of
1995 48 W AV “Signicant” + 0 0 0 0 +
2005 36 M MV “New” + 0 + + (B) + 0
2006 38 W AV “Severe” + Ovary, Uterus 0 + (B,F,K,S) 0 +
2009 34 W AV, MV “Severe” 0 Colon 0 + (B) 0 0
2010 45 W MV “Severe” + Pancreas 0 + (B) 0 +
2017 45 W AV, MV “Mild” + Uterus 0 + (B) + +
2018 69 M MV “Mild” + Stomach 0 + (B, K) + +
Age at
VO
(years) Sex
Valve
with
NBTE
Severity of
Regurgitation
IE
Diagnosed
in Life
Cancer
Location*
Antiphos-
pholipid
Syndrome
Systemic
Emboli
Anti-
coagulation
Therapy
Antibiotic
†
Therapy
CASE 1780 MALIGNANCY-ASSOCIATED NON-BACTERIAL THROMBOTIC ENDOCARDITIS
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Figure 1 Transesophageal echocardiogram in the patient described showing (A)
a mass characteristic of NBTE on the aortic valve; (B) a 3 dimensional image of the
mass on one of the aortic valve cusps.
Figure 2 View of one of the three aortic valve cusps showing the mass characteristic of NBTE in the patient described.
and histologically the masses consisted only of brin (Figure 2). The underlying
cusp was nor
mal.
DISCUSSION
Examination of the operatively excised aortic valve disclosed the presence of NBTE,
a lesion consisting entirely of brin with a few platelets. Although clinically our
patient and 7 of the 9 previously reported patients with NBTE were considered
clinically to have infective endocarditis, the latter was not present because the
valve lesions consisted only of brin without the presence of microorganisms
or polymorphonuclear leukocytes, requirements for the diagnosis of infective
endocarditi s (Fi g ure
3).
314
6
Also, the underlyi ng cusps were not damaged (no thickeni ng,
CASE 1780 MALIGNANCY-ASSOCIATED NON-BACTERIAL THROMBOTIC ENDOCARDITIS
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Figure 3 Photomicrograph of the lesion on the excised aortic valve cusp, showing
brin devoid of microorganisms and polymorphonuclear leukocytes. Hematoxylin
and eosin stain, x 400.
no perforations or indentations, or ring abscess). Cultures of the operatively excised
aortic valve cusp in our patient were negative for microorganisms and similarly
those of the previously reported patients were also negative.
1–7
The degree of the aortic regurgitation in our patient and in the previously
reported ones did not appear to be severe. The left ventricular cavity in our patient
was normal in size, the pulse pressure was not widened, and physical examination
did not mention the presence of a loud precordial murmur or “pistol-shot” femoral
pulses or other signs of severe aortic regurgitation.
Cases have been described with brin deposits on previously implanted
substitute cardiac valves: on stenotic native cardiac valves, on bioprosthesis and
mechanical valve prosthesis, and in patients with systemic lupus erythematosus,
and these cases were excluded from this report.
valve cusps were quite damaged were also excluded because healing of the active
infective endocarditis could not be excluded.
8–15
The patients in whom the aortic
16, 17
DISCLOSURES
The authors declare that they have no known competing nancial interests or
personal relationships that could have appeared to inuence the work reported in
this paper.
REFERENCES
1. Kardaras FG, Kardara DF, Rontogiani DP, Sioras EP, Christopoulou-Cokkinou
V, Lolas CT, Anthopoulos LP. Acute aortic regurgitation caused by non-bacterial
thrombotic endocarditis. Eur Heart J 1995;16:1152–1154.
2. Rabinstein AA, Giovanelli C, Ricci M, Romano JG, Koch S, Forteza AM. Surgical
treatment of nonbacterial thrombotic endocarditis presenting with stroke. J
Neurol 2005;252:352–355.
315
CASE REPORTS IN CARDIOLOGY
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3. Numnum TM, Leath CA, Straughn MJ. Synchronous primary endometrial
and ovarian carcinoma in a patient with marantic endocarditis. Obstet Gynecol
20 06;108:748 –750.
4. Hofstra JH, Timmer JR, Breeman A, Havenith MG. Non-bacterial thrombotic
endocarditis in metastatic caecal adenocarcinoma. Neth Heart J 2009;17:349–350.
5. Tei T, Nomura T, Naito D, Kojima A, Urakabe Y, Enomoto-Uemura S, Nishikawa
S, Keira N, Matsubara H, Tatsumi T. Effective surgical treatment for controlling
the acute heart failure induced by acutely progressed mitral regurgitation with
nonbacterial thrombotic endocarditis. J Cardiol Cases 2010;2:59–62.
6. Kaneyuki D, Matsuura K, Ueda H, Kohno H, Kanbe M, Matsumiya G. Surgical
management of nonbacterial thrombotic endocarditis in malignancy. Surg Case
Rep 2017;3:60.
7. Soga Y, Taira K, Sugimoto A, Kurosawa M, Kira H, Su T, Doi K, Nakano A,
Himura Y. Mitral valve nonbacterial thrombotic endocarditis: a rare multi-surgery-tolerant survivor of Trousseau’s syndrome. Surg Case Rep 2018;4:104.
8. Ram D, Armstrong G, Kha nijow V, Sibal AK. Nonbacterial thrombotic endocardi-
tis of a bioprosthetic valve: Questions to ponder before replacement of the valve.
J Card Surg 2020;35:1142–1144.
9. Brock MA, Bleiweis MS, Reid J, Moguillanksy D. Recurrent nonbacterial throm-
botic endocarditis: Anovel therapeutic approach. J Cardiol Cases 2018;17:175–177.
10. Lamba H, Deo S, Altarabsheh S, Elgudin Y, Markowitz A, Park S. Non-bacterial
thrombotic endocarditis of aortic valve due to hypereosinophilic syndrome.
J Heart Valve Dis 2016;25:760–763.
11. Kurdi M, Beanlands DS, Chan KL, Veinot JP. Nonbacterial thrombotic endocar-
ditis presenting as aortic stenosis with suspected infective endocarditis: clinicopathological correlation. Can J Cardiol 2004;20:549–552.
12. Moustafa S, Patton DJ, Balon Y, Kidd WT, Alvarez N. Mitral valve surgery for
marantic endocarditis and multiple cerebral embolisation. Heart Lung Circ
2013;22:545–547.
13. Elikowski W, Jarząbek R, Małek M, Witczak W, Łazowski S, Psuja P. Niebakteryjne
zakrzepowe zapalenie wsierdzia na dwupłatkowej zastawce aortalnej u 25letniego mężczyzny z antykoagulantem toczniowym [Non-bacterial thrombotic
endocarditis on the bicuspid aortic valve in a 25-year-old male with lupus anticoagulant]. Pol Merkur Lekarski 2016;40:182–185.
14. Basnet S, Stauffer T, Jayswal A, Tharu B. Recurrent nonbacterial thrombotic
endocarditis and stroke on anticoagulation. J Community Hosp Intern Med
Perspect 2020;10:466–469.
15. Yordan-Lopez NM, Hernandez-Suarez DF, Marshall-Perez L, Marrero-Ortiz W,
Sánchez-Pérez B, Lopez-Candales A. Nonbacterial thrombotic endocarditis of
the tricuspid valve in a male patient with antiphospholipid syndrome. Cureus
2018;10:2695.
16. Saito M, Asano N, Ota K, Niimi K, Tanaka K, Gon S, Takano H. Three mitral
valve operations in a patient with Trousseau syndrome and nonbacterial thrombotic endocarditis caused by ovarian cancer. Kyobu Geka 2016;69:1067–1071.
17. Reid G, Koechlin L, Reuthebuch O, R€uter F, Hopfer H, Eckstein F, Santer D.
Noninfective endocarditis: Acase report of hereditary coagulation disorders in
a 28-year-old male. Diagnostics (Basel) 2020;10:384.
316
Index
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Note: Page numbers in italics indicate a gure and page numbers in bold indicate a table on
the corresponding page.
A
abdominal aorta, 189
active infective endocarditis
antibiotic therapy, 305
complications, 308
diagnostic imaging, 305, 306
laparoscopic bowel resection, 305
patient history, 305
acute myocardial infarction, 109, 158, 159
acute rheumatic fever
Aschoff bodies, 68
in childhood, 67
incidence of death in, 67
patient history, 67
with pancarditis, 78
Aleri Stitch
echocardiographic data before and after
placement of, 268
echocardiographic images, 266, 267
operative insertion of, 266
patient history, 266
surgery, 267
alkaptonuric ochronosis
complication of, 190
necropsy, 190, 191
patient history, 190
with pigmentation, 191, 192
transverse section of, 192
ankylosing spondylitis, 88
diagnostic imaging, 89
examination, 89
operation, 93
patient history, 88
antistreptolysin-O, 73
aortic insufciency, 22
aortic regurgitation, 46, 46, 47, 88, 274
and orthotopic heart transplantation,
272, 274
fusiform ascending aortic aneurysm,
119
– 129
from systemic hypertension, 152
intermittent, 96
aortic stenosis, 158, 159, 223
sudden collapse in, 226
aortic valve, 64
bulge, 18
function, 17
– 69
– 68
– 79
– 268
– 89
– 23
– 156
– 98
– 228, 227
operatively excised, 212
replacement, 223
ring, 16
aortogram
ascending aortic aneurysm, 119, 120
fatal bioprosthetic regurgitation, 168
aortography, traumatic aortic
regurgitation, 14
arterial insufciency, see nonobstructive
mesenteric arterial insufciency
ascending aortic aneurysm, 125
diagnostic imaging, 119, 121
atrioventricular valves, 61, 63
autopsy
carcinoid heart disease, 31
mitral valve, 36
myocardial embolus, 28
quadrivalvular rheumatoid heart
disease, 51
rheumatoid arthritis, 60
Starr-Edwards prosthetic mitral valve, 81
– 214, 213
– 225, 224
B
bicuspid aortic valve, 99 – 103, 179 – 181, 180, 181
aortic dissection, 292
aortic valve replacement for, 255
criteria for, 101
diagnostic imaging, 99, 100, 288, 289
histologic analysis, 290
meta-analysis, 291
in nonagenarian, 223
occurrence, 254
patient history, 99, 252, 288
posterior mitral valve leaet, 253
surgery, 255
surgical intervention, 288
surgical risk, 292
bioprosthesis
in aortic valve position, 203, 203
calcication of, 171, 171
massive calcication of, 197
in mitral valve position, 194
205
– 207, 206
in tricuspid and mitral valve positions,
173, 174, 175, 175
bioprosthetic dysfunction, 144
145, 146
– 225, 224
– 255
– 289
– 204
– 172, 172
– 199, 198
– 196, 195,
– 146, 145,
317
INDEX
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bioprosthetic regurgitation, immediately
after mitral and tricuspid valve
replacements, 168
bioprosthetic valve, massively calcied,
197
bovine pericardial bioprosthetic valve
– 199, 198
implantation
after double-valve replacement, 231, 232,
232, 233, 233
anatomic studies, 140
calcication, 136
cotton bers, 142
histologic st udy, 137, 138
host factors and tissue factors, 140
morphologic observations, 142
patient history, 136
scanning electron microscopic
observations, 139
transmission electron microscopic
observations, 140, 141
ultrastructural studies, 140, 142
– 170, 169, 170
– 234
– 137
– 140, 169
C
caged-ball prosthetic mitral valve, 85 – 87
diagnostic imaging, 85
patient history, 85
Candida organisms, 3, 4
carcinoid heart disease
au topsy, 31
carcinoid plaques location, 260
cardiac valve replacement, 246
clinical features, 262
computed tomographic image, 262, 262
diagnostic imaging, 31, 243
electrocardiogram, 31
examination, 29
hemodynamic clues, 263
histologic section of, 263
patient history, 29
pulmonary hypertension, 246
pulmonic valve, 245, 246
QRS voltage on, 264
surgical options, 241
cardiac catheterization
bicuspid aortic valve, 252
bovine pericardial bioprostheses, 231, 232
caged-ball prosthetic mitral valve, 85, 87
carcinoid heart disease, 29
combined mitral and aortic stenosis,
double-valve replacement, 235
congenitally bicuspid stenotic aortic
valves, 200
extensive multifocal myocardial
infarcts, 182
fatal bioprosthetic regurgitation, 168
octogenarian, 221
– 86
– 244, 261
– 30, 244, 260
– 31, 240 – 241, 259 – 260
– 242
pulmonary arteriovenous stula, 35
severe coronary artery disease, 208
severe regurgitation, 205
severe stenosis, 181
stent-post deformity, 144, 145
traumatic aortic regurgitation, 14
cardiac valvular bioprosthesis, implantation
after removal, 161
anatomic ndings, 160
cholesterol accumulation, 164
crystalline material, 163, 163
morphologic observations, 164
patient history, 160
cardiac valvular lesions, in rheumatoid
arthritis, 59
central cyanosis, 35
chloroquine, disseminated Petriellidium
boydii, 131
chlorothiazide, nonobstructive mesenteric
arterial insufciency, 40
chordae tendineae, 92
combined mitral and aortic stenosis, double-
valve replacement, 235, 236, 237,
237
computed tomography, 229, 229
congenitally bicuspid stenotic aortic valves,
congestive heart failure, 158
coronary angiogram
corticosteroids and gluconeogenesis, 75
cor triatriatum
– 238
200
– 202, 201, 201
bicuspid aortic valve, 252
bicuspid stenotic aortic valves, 200
concept of, 148
development of, 151
M-mode echocardiograms, 148
preoperative view, 148
ring abscess, 149
surgical options, 149
– 163
– 66
– 230
D
diastolic murmur, 25
diffuse pericarditis, 76
digitoxin, nonobstructive mesenteric arterial
insufciency, 40
disseminated Petriellidium boydii
diagnostic imaging, 131, 132
infections, 133
with massive vegetations, 133
patient history, 130
treatment, 134
– 131
E
echocardiogram
Aleri Stitch, 266, 267
318
INDEX
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aortic stenosis, sudden collapse in, 226
ascending aortic aneurysm, 123
carcinoid heart disease, 261
disseminated Petriellidium boydii, 131
nonbacterial thrombotic endocarditis,
312, 314
octogenarian, 221
orthotopic heart transplantation, 270, 271
severe coronary artery disease, 208, 209
severe regurgitation, 205
severe stenosis, 181
Smeloff-Cutter ball-caged mitral valve, 249
Starr-Edwards model 6120 mechanical
prosthesis, 215
systemic hypertension, aortic
regurgitation from, 155
unicuspid aortic valve, 229
electrocardiogram
active infective endocarditis, 305, 306
ankylosing spondylitis, 89
aortic stenosis, sudden collapse in, 226
ascending aortic aneurysm, 119, 121
caged-ball prosthetic mitral valve, 85
carcinoid heart disease, 31, 261
congenitally bicuspid aortic valve, 99, 100
disseminated Petriellidium boydii, 131, 132
extensive multifocal myocardial
infarcts, 182
fatal bioprosthetic regurgitation, 168
Marfan cardiovascular disease, 126
orthotopic heart transplantation, 270, 271
prosthetic valve endocarditis, 105, 106
quadrivalvular rheumatoid heart
disease, 51
rheumatic heart disease, 100
systemic hypertension, aortic
regurgitation from, 154
traumatic aortic regurgitation, 11, 12, 13
endocardial brous lesions, 29
endocarditis,
see Libman-Sacks (L-S)
endocarditis
F
brinoid necrosis, 3, 5 – 6
brosis, 3, 5
focal embolic (endocarditic)
– 6
glomerulonephritis, 1, 6, 7, 8
au topsy, 2
cause of, 7
examination, 8
in fungal endocarditis, 1, 8
hematuria associated with, 8
incidence of, 8
patient report, 1
renal biopsy, 6
uremia, 9
– 3, 3 – 6, 6
– 2
– 7
fungal endocarditis, 1, 8, see also
focal embolic (endocarditic)
glomerulonephritis
fusiform ascending aortic aneurysm,
119
– 129
aortic root aneurysms of, 125
cardiovascular features, 124
dilatation of mitral anulus, 128
hemodynamic and angiographic
data, 120
operative treatment for, 127
patient history, 119
postoperative, 120, 122, 122
– 126
G
glomerulonephritis, see focal embolic
(endocarditic) glomerulonephritis
glomerular tufts, 6
glomerulus, 5, 6
granuloma, cardiac rheumatoid, 56
H
hyperglycemia, 74
hyperosmolar coma, 74
hypertension, aortic regurgitation from,
152
– 156
diagnostic imaging, 154
factors to develop, 156
frequency and severity of, 153
patient history, 152
systolic and diastolic systemic arterial
pressures, 153
hypoglycemia, 43
I
infective endocarditis
aortic valve, 256
causes of pericarditis, 310
development of, 258
patient history, 256
with ring abscess, 309
stenotic aortic valve, 258
surgery, 257, 257
intestinal infarction, 39
Ionescu-Shiley bioprostheses, 170
– 311, 311
– 257, 309
– 44
L
laparotomy, nonobstructive mesenteric
arterial insufciency, 44
left atrial endocardium, inammatory
nodule in, 69, 69
left atrial thrombus, unattached, 186
187
– 189
– 188,
319
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