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Heart, Lung and Circulation Case Reports 1612009;18:133–162

Mitral Valve Leaflet Abscess ComplicatingInfective Endocarditis

Pankaj Saxena, MCh, DNB ∗, Adam Boyt, MBBS and Mark A.J. Newman, FRACSDepartment of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, WA, Australia

Infective endocarditis is a life threatening condition with high morbidity and mortality. We present a case report of ayoung female who had a rare complication of infective endocarditis in the form of mitral valve leaflet abscess. Patientunderwent successful surgical treatment with valve replacement.

(Heart, Lung and Circulation 2009;18:133–162)© 2007 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and

New Zealand. Published by Elsevier Inc. All rights reserved.

Keywords. Infective endocarditis; Mitral valve abscess; Mitral valve replacement

Infective endocarditis is a life threatening condition withhigh morbidity and mortality even in the current era of

advanced medical and surgical treatment. We would liketo draw the attention of your readers to a rare complicationoa

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echocardiogram revealed large 1–1.5 cm sized vegetationson the anterior and posterior mitral valve leaflets withmild to moderate mitral regurgitation. Systolic functionof both ventricles was normal. Chest X-ray was sug-

f infective endocarditis in the form of mitral valve leafletbscess and the surgical management.

ase report

34-year-old woman with known cardiac murmur sincehildhood presented to the emergency department of ourospital with febrile illness of recent onset. This presen-

ation was on a background of four months of historyf malaise, myalgia, and arthralgia involving multiple

oints, and easy fatigue. Six months prior to the presen-ation, she was diagnosed with caries of wisdom tooth.

er dental infection was inadequately treated with oralntibiotics. She also had a past history of pelvic inflam-atory disease and ovarian cysts. There was history of

eavy alcohol intake. There was no history of intra-enous drug abuse or trauma. On examination, she wasebrile and had tachycardia. She was haemodynamicallytable at the time of admission. A pansystolic murmuruggestive of mitral regurgitation (MR) was audible onuscultation at apical area with radiation to back. Shead clinical features suggestive of early congestive heart

gestive of left lower lobe pneumonia. She deterioratedclinically over the next 24 hours with haemodynamic insta-bility and respiratory failure. The patient was admitted tointensive care unit (ICU) and was commenced on Nora-drenaline support for septic shock and was ventilatedmechanically. She was continued on supportive manage-ment and sensitive antibiotic treatment based on Penicillinand extended spectrum Penicillin antibiotics. Her over-all clinical picture was suggestive of adult respiratorydistress syndrome (ARDS), septicaemic shock and leftventricular failure. In the meantime the infected toothwas removed and the periodontal area was drained. Serialtransoesophageal echocardiograms (TEE) demonstrateda growth in size of vegetations and the formation of alarge abscess on the anterior leaflet (Fig. 1A and B). Also,now, her MR had progressed to 3–4/4 in severity. Duringthis period she sustained septic emboli to brain, kidneyand spleen.

Due to insignificant clinical improvement with ongoingmedical treatment, enlarging vegetations, worsening MRand evidence of emboli, it was decided to operate uponher. Median sternotomy and standard cardiopulmonary

ailure. bypass was used. Myocardial protection was achieved withmoderate hypothermia (28 ◦C) using antegrade and ret-

onl ri

Blood tests revealed an elevated leukocytosis, neu-trophilia and a C reactive protein (CRP) of 460.Screening for autoimmune disease was negative. Multipleblood cultures grew Streptococcus sanguis. Transthoracic

Received 22 February 2007; received in revised form 13 April2007; accepted 13 April 2007; available online 14 June 2007

∗ Corresponding author at: Department of CardiothoracicSurgery, Westmead Hospital, PO Box 533, Wentworthville, NSW2145, Australia. Tel.: +61 2 9845 5555.E-mail address: drpankajsaxena@hotmail.com (P. Saxena).

© 2007 Australasian Society of Cardiac and Thoracic SurgeAustralia and New Zealand. Published by Elsevier Inc. Al

rograde cold blood cardioplegia (aortic cross clamp time76 min, cardiopulmonary bypass time 99 min). The mitralvalve was exposed through lateral incision in the leftatrium. At the time of surgery the native mitral valve wastotally destroyed by 3 cm size large vegetations involvingboth the leaflets and a 2–3 cm size abscess was present onthe anterior leaflet (Fig. 2). The vegetations were invadingthe chordae. There was no perforation of the leaflet. Tur-bid pericardial effusion with pericarditis was also found.A thorough debridement of involved leaflets and sub-

s and the Cardiac Society ofghts reserved.

1443-9506/04/$30.00doi:10.1016/j.hlc.2007.03.019

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162 Case Reports Heart, Lung and Circulation2009;18:133–162

Figure 1. Pre-operative transoesophageal echo demonstrates ‘ring like’ abscess on anterior leaflet of mitral valve. (A) Short axis view. (B)Parasternal long axis view.

Figure 2. Intra-operative photograph with large abscess of anteriorleaflet of mitral valve. The arrow points to a part of wall of abscesscavity. Large vegetations destroying both leaflets are also visible.

valvular apparatus was performed. She underwent mitralvalve replacement with 29 mm St Jude valve (St Jude, StPaul, MN). Reimplantation of the papillary muscles intovalve sewing ring was performed with 5–0 Goretex suture(Gore-Tex, W.L. Gore and Associates, Newark, DE). Shehad satisfactory post-operative course without any neu-rological deficit. Operative specimens did not grow anyorganisms on bacterial cultures. Her ICU stay was 14days and she was discharged home on post-operative day20. Serial computed tomography (CT) scans showed animprovement in her splenic abscess. She was continuedon intravenous antibiotics for 4 weeks following surgery.Patient was doing quite well and was free from any recur-rence at the time of follow-up at 6 months.

Discussion

Mitral valve abscess is an exceedingly rare clinical condi-tion that develops in patients with infective endocarditis.We could only find two case reports on this entity on anextensive review of English literature.1,2 The actual inci-dence of this condition is not known. Aortic root abscessoccurring in patients with endocarditis or ring abscessaffecting the mitral valve annulus are relatively more com-mon. Methicillin resistant Staphylococcus aureus (MRSA)is the reported organisms involved in causing mitralabscess. The prognosis without surgical debridement andvalve replacement is uniformly poor.

The standard treatment for patients presenting withlarge vegetations is early surgery. Because of poor generalcondition and in an attempt to sterilise her infection withantibiotics, our patient was treated in ICU for 1 week priorto operative treatment. In those clinical situations whereconservative management is opted for, a close supervisionshould be maintained with frequent TEE to detect anygrowth of vegetations, worsening of valve regurgitationand more importantly to rule out abscess formation. TEEprovides best modality of follow up in this setting. More-over, MVR with preservation of as much of subvalvularapparatus as possible is a safe and effective option.

References

1. Kumbasar SD, Aslan SM, Erol C, Tekeli ME. A case of infec-tive endocarditis complicated with anterior mitral valve leafletabscess. Eur Heart J 1997;18:1194–5.

2. Massey WM, Samdarshi TE, Nanda NC, Sanyal RS, Pinheiro L,Jain H, Kirklin JK. Serial documentation of changes in a mitralvalve vegetation progressing to abscess rupture and fistulaformation by transoesophageal echocardiography. Am Heart J1992;124:241–8.