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      A rare case of aortic sinuses of valsalva fistula to multiple cardiac chambers secondary to periannular aortic abscess formation from underlying Brucella endocarditis Translated title: Ein seltener Fall von aortalen Nebenhöhlen mit Valsalva-Fisteln zur Herzkammer mit sekundärem Anulusabszess als Komplikation einer brucellösen Endokarditis

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          Abstract

          The concomitant presence of abnormal connection from three aortic valsalva sinuses to cardiac chambers is a rare complication of native aortic Brucella endocarditis. This case report presents a 37-year-old Iranian female patient who had native aortic valve Brucella endocarditis complicated by periannular abscess formation and subsequent perforation to multi-cardiac chambers associated with congestive heart failure and left bundle branch block. Multiple aorto-cavitary fistulas to right atrium, main pulmonary artery, and formation of a pocket over left atrial roof were detected by transthoracic echocardiogram (TTE). She had received a full course of antibiotics therapy in a local hospital and was referred to our center for further surgery. TTE not only detected multiple aorto-cavitary fistulas but also revealed large vegetation in aortic and mitral valve leaflets and also small vegetation in the entrance of fistula to right atrium. However, the tricuspid valve was not involved in infective endocarditis. She underwent open cardiac surgery with double valve replacement with biologic valves and reconstruction of left sinus of valsalva fistula to supra left atrial pocket by pericardial patch repair. The two other fistulas to main pulmonary artery and right atrium were closed via related chambers. The post-operative course was complicated by renal failure and prolonged dependency to ventilator that was managed accordingly with peritoneal dialysis and tracheostomy. The patient was discharged on the 25 th day after admission in relatively good condition. The TTE follow-up one year after discharge revealed mild paravalvular leakage in aortic valve position, but the function of mitral valve was normal and no residual fistulas were detected.

          Zusammenfassung

          Das gleichzeitige Vorhandensein einer anormalen Verbindung von drei aortalen Valsalva-Nebenhöhlen um die Herzkammern ist eine seltene Komplikation einer aortalen brucellösen Endokarditis. Dieser Fallbericht stellt eine 37-jährige iranische Patientin mit einer nativen brucellösen Endokarditis der Aortenklappe mit Anulusabszess und anschließender Perforation in die Herzkammer vor. Der Fall wurde durch eine kongestive Herzinsuffizienz mit Linksschenkelblock zusätzlich erschwert. Die Patientin wurde nach antibiotischer Vorbehandlung in einem Regionalkrankenhaus an unser Herzzentrum zur weiteren chirurgischen Behandlung überstellt. Mittels transthorakalem Echokardiogramm (TTE) wurden nicht nur mehrere aorto-kavitäre Fisteln, sondern auch weitere große Vegetationen in der Aorta und der Mitralklappe sowie kleine Vegetationen am Eingang der Fistel zum rechten Vorhof nachgewiesen.

          Die Patientin erhielt nach Sternotomie in offener Herzchirurgie einen Doppelklappenersatz mit biologischen Klappen, dazu wurde eine linke Sinus valsalva-Fistel durch Perikardpatch saniert. Postoperativ wurde der weitere Verlauf durch ein Nierenversagen und die Notwendigkeit zur mechanischen Beatmung kompliziert. Dennoch konnte die Patientin am 25. Tag nach der Aufnahme in relativ gutem Allgemeinzustand nach Hause entlassen werden.

          Die TTE-Nachsorgeuntersuchung 1 Jahr nach Entlassung zeigte eine milde paravalvuläre Leckage in Aortenklappen-Position, während die Funktion der Mitralklappe normalisiert war, und es wurden keine weiteren Restfisteln nachgewiesen.

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          Most cited references 21

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          An overview of human brucellosis.

           Susan Young (1995)
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            Complications associated with Brucella melitensis infection: a study of 530 cases.

            We carried out a prospective study of 530 patients older than 14 years of age with brucellosis. We describe the incidence and clinical features of the focal forms of the disease, analyzing some of the possible factors associated with their appearance. One hundred sixty-nine patients (31.9%) had a focal form or complication. Osteoarticular complications were the most frequent, totaling 113 cases (66%), followed by genitourinary with 18 cases (5.1% of males), hepatic (2.5%), neurologic (1.7%), and heart (1.5%). Nine patients (1.7%) had more than 1 complication. In a multivariate analysis, diagnostic delay greater than 30 days (OR 2.0), ESR > 40 mm/hr (OR 1.9), and levels of alpha-2 globulin > 7.5 g/L (OR 6.8) were statistically significant independent variables associated with the presence of focal forms. Twenty-five patients with complications (14.8%) required surgical treatment. The relapse rate was 3.6% for those patients without complications and 4.1% for patients with focal forms (p > 0.05). However, when therapeutic failure, relapses, and mortality were considered together, the risk of an unfavorable evolution was significantly greater in patients with focal forms (10.6% versus 3.6% in patients without complications; OR 1.9, 95% CI 1.4-7.1, p < 0.005). Given the worse prognosis, knowledge and early diagnosis of the focal forms of B. melitensis infection is especially important.
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              Brucella endocarditis: clinical, diagnostic, and therapeutic approach.

              Brucella endocarditis is an uncommon focal complication of brucellosis. Presented here are 11 cases of Brucella endocarditis, all managed uniformly. The median duration of symptoms prior to diagnosis was 3 months. Five patients (45%) had underlying valvular damage, and in six (55%) endocarditis involved a normal valve. There was a predominance of aortic involvement (82%) and a high incidence of left ventricular failure (91%). Diagnostic suspicion was essential in order to test blood cultures correctly, which in this series were positive in 63% of the patients. Surgical treatment was undertaken in eight patients (72%), all with aortic involvement and left ventricular failure impossible to control with medication. One patient died during the immediate postoperative period. All the other patients received antibiotic therapy for 3 months, with no signs of relapse of the infection or malfunction of the prosthesis during a minimum follow-up period of 24 months.
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                Author and article information

                Journal
                GMS Hyg Infect Control
                GMS Hyg Infect Control
                GMS Hyg Infect Control
                GMS Hygiene and Infection Control
                German Medical Science GMS Publishing House
                2196-5226
                10 November 2015
                2015
                : 10
                Affiliations
                [1 ]Preventive Cardiovascular Research Centre Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran
                [2 ]Department of Anesthesiology, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran
                Author notes
                *To whom correspondence should be addressed: Reza Faraji, Preventive Cardiovascular Research Centre Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran, Phone: +98 9183362603, Fax: +98 831 9360043, E-mail: r.faraji61@ 123456gmail.com
                Article
                dgkh000257 Doc14 urn:nbn:de:0183-dgkh0002579
                10.3205/dgkh000257
                4644062
                Copyright © 2015 Sabzi et al.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License.

                Categories
                Article

                heart surgery, endocarditis, brucella, fistula

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