초록접수 현황
| 14F-265 | 포스터 발표 |
Infective Endocarditis with Vegetations Attached to Septal Endocardium and Aortic Valve Complicating Hypertrophic Cardiomyopathy
Sang-Ho Cho¹, Dae Hyun Kim¹, Young Tae Kwak¹, Joo-Chul Park¹, Hyo Chul Yoon², Soo-Cheol Kim², Bum-Sik Kim², Kyu-Seok Cho²
Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong¹
Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital²
Background : Infective endocarditis complicating hypertrophic cardiomyopathy (HCM) is not commonly reported but occurs almost universally in patients showing evidence of outflow tract obstruction. The estimated cumulative 10 year probability of developing endocarditis in obstructive HCM is < 5%. The most common sites of vegetation include the ventricular aspect of anterior mitral valve leaflet, subaortic hypertrophic septum, or aortic valve. We report a case of infective endocarditis with vegetations attached to septal endocardium and aortic valve complicating obstructive HCM.
Methods : A 73 year old woman was admitted following the occurrence of syncope caused by multiple embolic cerebral infarction with minimal hemorrhage. About 10 days earlier, she had presented to another hospital to investigate the origin of chilling , febrile sensation, general malaise, and myalgia. The conservative treatment including antibiotics administration was unsuccessful in reducing her symptoms. At presentation, the patient complained of generalized weakness, febrile sensation, and fatigue. Her blood pressure was 110/60 mm Hg and her temperature was 36.9℃. Initial blood tests showed leukocytosis (11.0 x 10³ /㎕) and raised inflammatory markers (C reactive protein, 8 mg/dl ; Erythrocyte sedimentation rate, 65 mm/h ). An ECG showed left ventricular hypertrophy and intraventricular conduction delay. Transthoracic echocardiography showed localized septal hypertrophy (2.1 cm), posterior wall thickness of 12mm, hyperkinetic left ventricle, dilated left atrium (LA volume index, 46.5ml/m2), and systolic anterior motion of the mitral valve with obstruction of the outflow tract (maximal gradient at 64mm Hg). There were mobile vegetations on the septal endocardium at the site of contact between the mitral valve leaflet and the hypertrophic septum and on the aortic valve (NCC and RCC). Three sets of blood cultures were negative.
Results : Intravenous ampicillin, gentamicin and ciprofloxacin was administered for four weeks. She underwent septal myectomy in addition to aortic valve replacement with a tissue prosthetic valve. At surgery, the patient was found to have fibrotic degeneration of the hypertrophic septum. Moreover, multiple vegetations of aortic valve and subaortic septum was confirmed. Postoperatively, the patient recovered well without any signs of reinfection and control echocardiography showed relieve of outflow tract obstruction (maximal gradient at 11mmHg) and correct function of aortic prosthesis. After six months of follow-up, she is free of symptom and echocardiographic parameters remain unchanged.
Conclusion : Infective endocarditis is a rare complication of HCM. It would seem that chronic endocardial trauma at the site of contact between the mitral valve leaflet and the hypertrophic septum, a common finding in obstructive HCM, may provide a fertile nidus for the development of bacterial vegetation. It is rare to report successful medical treatment under these circumstances. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Valve surgery combined with septal myectomy seems logical but requires great expertise because of a higher operative risk.
Methods : A 73 year old woman was admitted following the occurrence of syncope caused by multiple embolic cerebral infarction with minimal hemorrhage. About 10 days earlier, she had presented to another hospital to investigate the origin of chilling , febrile sensation, general malaise, and myalgia. The conservative treatment including antibiotics administration was unsuccessful in reducing her symptoms. At presentation, the patient complained of generalized weakness, febrile sensation, and fatigue. Her blood pressure was 110/60 mm Hg and her temperature was 36.9℃. Initial blood tests showed leukocytosis (11.0 x 10³ /㎕) and raised inflammatory markers (C reactive protein, 8 mg/dl ; Erythrocyte sedimentation rate, 65 mm/h ). An ECG showed left ventricular hypertrophy and intraventricular conduction delay. Transthoracic echocardiography showed localized septal hypertrophy (2.1 cm), posterior wall thickness of 12mm, hyperkinetic left ventricle, dilated left atrium (LA volume index, 46.5ml/m2), and systolic anterior motion of the mitral valve with obstruction of the outflow tract (maximal gradient at 64mm Hg). There were mobile vegetations on the septal endocardium at the site of contact between the mitral valve leaflet and the hypertrophic septum and on the aortic valve (NCC and RCC). Three sets of blood cultures were negative.
Results : Intravenous ampicillin, gentamicin and ciprofloxacin was administered for four weeks. She underwent septal myectomy in addition to aortic valve replacement with a tissue prosthetic valve. At surgery, the patient was found to have fibrotic degeneration of the hypertrophic septum. Moreover, multiple vegetations of aortic valve and subaortic septum was confirmed. Postoperatively, the patient recovered well without any signs of reinfection and control echocardiography showed relieve of outflow tract obstruction (maximal gradient at 11mmHg) and correct function of aortic prosthesis. After six months of follow-up, she is free of symptom and echocardiographic parameters remain unchanged.
Conclusion : Infective endocarditis is a rare complication of HCM. It would seem that chronic endocardial trauma at the site of contact between the mitral valve leaflet and the hypertrophic septum, a common finding in obstructive HCM, may provide a fertile nidus for the development of bacterial vegetation. It is rare to report successful medical treatment under these circumstances. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Valve surgery combined with septal myectomy seems logical but requires great expertise because of a higher operative risk.
책임저자: 곽영태
Department of Thoracic and Cardiovascular Surgery, Kyung Hee University Hospital at Gangdong
연락처 : 조상호, Tel: 02-440-6158 , E-mail : sinan75@khnmc.or.kr
