Human Pathology: Case Reports 10 (2017) 3942

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Human Pathology: Case Reports

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Case Report

Recurrent infective endocarditis causing heart valve failure: A case report

Victoria McIntyre, BASc Chemical Engineering (2018 candidate) a,1, Jagdish Butany, MBBS, MS, FRCPCDr. b,,2,
Dina Boles, MDDr. a, Tiffany Shao, MDDr. a
a
Laboratory Medicine and Pathobiology, Toronto General Hospital, Canada
b
Dept. of Laboratory Medicine and Pathobiology, University Health Network/Laboratory Medicine Program, Canada

a r t i c l e i n f o a b s t r a c t

Article history: Infective endocarditis (IE) is an infection that does not usually respond rapidly to treatment, often because its
Received 2 July 2015 early symptoms are non-specic. The diseased valves (native or bioprosthetic) may be calcied and the throm-
Received in revised form 9 September 2016 botic vegetations on them typically friable and embolize easily. Left untreated IE leads to damage to the infected
Accepted 30 September 2016
valve and to congestive heart failure (CHF). Its treatment usually requires heart valve replacement. Our 69-year-
Available online xxxx
old patient had IE, and underwent aortic valve replacement (AVR) with a bioprosthesis. This case stresses the
Keywords:
complications of IE and its tendency to recur in patients with bioprosthetic heart valves (BHV) who previously
Infective endocarditis had IE.
Bioprosthetic heart valves 2016 Published by Elsevier Inc. This is an open access ar-
Heart valve ticle under the CC BY-NC-ND license (http://
Bioprostheses creativecommons.org/licenses/by-nc-nd/4.0/).
Pannus
Vegetation
EPIC valve

1. Introduction
Infective endocarditis (IE) is a potentially fatal condition dened by
infection and inammation of heart valves, usually functionally abnor-
mal due to underlying disease [1]. Untreated, the patients progressively
worsen and develop congestive heart failure (CHF). IE is more common
in the elderly, 25%50% occurring in those over 60 years old [2] with a
higher incidence when the valve replacement was for IE [3]. IE has an in-
cidence of 67 cases per 100,000 in developed countries, likely higher
(610 cases per 100,000 life years) in developing countries [4]. In pa-
tients with IE, there is no signicant difference in mortality rate whether
a mechanical heart valve or a bioprosthetic heart valve is implanted,
however patients are usually recommended to receive a mechanical
heart valve if they are younger in age and a bioprosthetic heart valve
if they are greater than 60 years of age.
The infection is caused primarily by bacteria, and in some cases
fungi. The infection may be acute or subacute depending on the infect-
ing microorganism and often develops slowly, initially with vague and
non-specic symptoms such as low grade fever, aches, pains and
Corresponding author.
E-mail address: jagdish.butany@uhn.ca (J. Butany).
1
Research Fellow.
2
Consultant Cardiovascular Pathologist/Director Autopsy Services, Co-Editor-in-Chief,
Cardiovascular Pathology (01-11), Guest Editor, Seminars in Diagnostic Pathology, Secre-
tary-Treasurer, WASPaLM (09-), Professor, University of Toronto & Dir. Divn. of Pathology.
fatigue, making diagnosis difcult [5,6]. Acute onset is usually with
more virulent bacteria, signicant symptoms and rapid destruction of
the infected valve(s) tissues [5]. IE can also cause myocardial,
paravalvular, or annular abscesses, new intracardiac shunts, new cardi-
ac murmurs, embolic infarcts [7] and other life threatening complica-
tions [8], potentially with a mortality of 30% to 50% [9]. The bacteria's
adaptive intelligence allows it to consistently resist the most efca-
cious and recently engineered drugs. Prevention of IE needs an empha-
sis on the diagnosis of valve disease, dental hygiene and avoidance of
street drugs as well as a high incidence of suspicion of IE [6].
Native valve endocarditis (NVE) is predominantly caused by Strep-
tococci and Enterococci [10], although the trend is changing and Staph-
ylococcus seems to be increasingly common. Prosthetic valve
endocarditis (PVE) is caused more often by Staphylococci, bacteria of
the HACEK group (Haemophilus, Actinobacillus, Cardiobacterium,
Eikinella and Kingella) and fungi [10]. A diagnosis is made on positive
blood cultures as well as echocardiographic evidence of valvular/pros-
thesis infection, including but not limited to vegetations, paravalvular
regurgitation, thromboembolic events and abscesses [10].
PVE is most common in the rst two years after bioprosthetic heart
valve (BHV) implantation with an incidence of 16% [7]. This has been
decreasing, especially with the judicious use of perioperative antibiotics.
In consideration of the bacteria's strong resistance to antimicrobial and
antithrombotic treatments, in highly infectious cases, particularly in
those with PVE, early surgery is recommended to improve survival. A
major remaining concern is the prevention of high recurrence of IE.

http://dx.doi.org/10.1016/j.ehpc.2016.09.005
2214-3300/ 2016 Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
40 V. McIntyre et al. / Human Pathology: Case Reports 10 (2017) 3942

We report a patient who suffered from NVE and PVE on a porcine

bioprosthesis, and who had to undergo two heart valve replacements
with one of the newer porcine BHV.

2. Case presentation

A 69-year-old woman presented with recurrent IE. She had suffered

complications associated with the IE and had undergone multiple surgi-
cal procedures over 4 years. The patient had a history of type II diabetes
mellitus, chronic kidney disease, obesity, hypertension, asthma and dys-
lipidemia. She had received a permanent pacemaker VVI Medtronic in
2007 for sick sinus syndrome and coronary artery catheterization in
2007 and in 2012. She was diagnosed with IE and following medical
management underwent aortic valve replacement (AVR) with a porcine
bioprosthesis (EPIC by St Jude Medical Inc., Minneapolis, USA).
The patient was in good condition for about fteen months following
surgery when she developed symptoms of fever and dizziness, which
Fig. 2. Explanted bioprosthetic porcine valve (EPIC, SJM, Minneapolis, USA) at
led to a diagnosis of PVE with blood cultures positive for Enterococcus. 18 months. The non-ow surface has pannus (P) on the sewing cuff extending onto the
She was immediately started on antimicrobial therapy. Aortic PVE was leaets as well as large vegetations (arrow) on the cusps and in the sinuses.
conrmed by a transesophageal echocardiogram (TEE), which showed
prominent thickening of the leaets as well as signs of an infected pace-
maker lead, moderate tricuspid regurgitation, an aortic annular abscess (Fig. 2). All three commissural regions showed blue pledgetted sutures
and tricuspid vegetation. Following the diagnosis, the patient with some appearing to have been taken through the stent post fabric
underwent a second AVR with a pericardial bioprosthesis (21 mm (Fig. 3). All three cusps showed soft grey-brown vegetations on the
Mitroow pericardial bioprosthesis, Sorin Inc., Milan, Italy). There was sinus surfaces (Fig. 4) as well as focal calcication (Fig. 5). The cusps
conrmed hypokinesia of the right ventricle, dilatation of the right atri- were thickened and stiffer than normal. One commissural region was
um and a large abscess impeding the left ventricular outow tract. The narrowed by the presence of vegetations (thickness of 0.3 cm). Histo-
patient's aortomitral junction was repaired with a pericardial patch logically, microorganisms were seen in the thrombotic vegetations on
and the infected pacemaker lead removed. The postoperative course the infected cusps (Fig. 6), as were small foci of calcication.
was complicated, but she is back at home.
4. Discussion
3. Pathology
This case highlights the recurrence of IE in the BHV of older patients
The explanted specimen consisted of a porcine bioprosthesis (EPIC, who previously had NVE [11]. The recurrent infection led to the
SJM, Minneapolis, USA) with ow surface dimensions of 2.7 cm by patient's symptoms and to the marked destruction of annular cardiac
2.5 cm; the difference in dimension was due to a loss of sewing cuff. tissues. In addition, the vegetations and the infection with
The porcine valve showed evidence of pannus and thickening of the superimposed pannus lead to bioprosthesis dysfunction and to replace-
cusps due to signicant vegetation. ment of the porcine bioprosthesis. Untreated, this infected heart valve
On the ow surface, the cusps were thickened, had a greyish-white would have led to CHF and death.
to pale brown discoloration and a roughened appearance (Fig. 1). The Infection of a BHV is a life threatening condition. It may occur early
cusps did not open or close completely, on mild digital pressure. In at or late post valve replacement. Its early incidence has been decreasing,
least one commissural region, thrombotic material was present. Pannus likely due to improved surgical techniques and the increasing use of
was visible on the sewing ring along with 7 small, white pledgetted su- preoperative antibiotic prophylaxis. However, the incidence of late
tures (length 0.3 cm).
On the non-ow (or aortic) surface, pannus was found in the bias
areas and on all three stent posts, but signicantly greater on one

Fig. 3. Transverse sections through the commissural region of the bioprosthesis shows the
junction of two cusps (black arrows), suture sites (black broken arrows) and the
Fig. 1. Explanted bioprosthetic porcine valve (EPIC, SJM, Minneapolis, USA) at commissural end of the cusps (C). Pericardium (P) covers the porcine aortic tissue (A).
18 months. The ow surface shows thrombus (arrow) on the valve's leaets. (Original magnication 2.5; Movat pentachrome stain)
 V. McIntyre et al. / Human Pathology: Case Reports 10 (2017) 3942
Fig. 4. The porcine bioprosthetic cusp showing vegetations (arrows), pannus (broken
arrow), pericardium (P) and porcine aortic root (A). (Original magnication 1.25;
Movat pentachrome stain)
PVE appears to be increasing, and can occur with every PHV type im-
planted. The EPIC valve is a relatively new valve (similar to the
BIOCOR) and is made quite differently. It's tissue is comprised of
cusps from three [3] porcine valves that are stitched together. The tis-
sues are processed and xed in a manner similar to others, but the
Fig. 5. The valve displaying small foci of calcication (arrows). Calcication is largely in the
deeper parts of the thrombotic vegetations on the cusps. (Original magnication 10;
H&E)
41
Fig. 6. The porcine bioprosthesis demonstrating the presence of colonies of Gram positive
bacterial cocci (arrows). (Original magnication 5; GMS)
forward edge of the prosthesis is covered with pericardium to minimize
abrasion damage and the tissues are treated with the LINX technology
to reduce calcication of tissues. There are few reports available about
this bioprosthesis that detail the morphological ndings.
The vegetations on the leaets likely stiffened the cusps impeding
their operation [7]. The vegetations and excessive pannus growth
reduced the effective orice area (EOA) as well as reduced leaet mobil-
ity; and thus affected proper blood ow, inhibited normal hemodynam-
ics, and likely caused the patient's tricuspid regurgitation observed on
the TEE [12]. Bioprosthetic valve leaet thickening and stiffness are
common features of IE and causes of valvular and hemodynamic
dysfunction [13].
The valvular dysfunction was furthered, aggravated by focal calci-
cation. The calcication was seen predominantly in the deeper parts of
the vegetations and is evidence that the infection had been present for
some weeks. The actual duration of the IE is unknown; a common oc-
currence based on the infection's generally non-specic and slowly
evolving list of symptoms.
Pannus is a common occurrence at tissue injury sites as well as at the
sites of implantation of foreign material. Host tissue has a tendency to
cover the injured areas and or foreign materials in an attempt to prevent
thrombus deposition, minimize the irritation produced by the foreign
material and to promote healing [14]. The sutures found in the fabric
of the stent posts could have aided in the growth of pannus by bringing
the prosthesis into closer contact with the aortic root. The decreased
EOA could also result in greater prosthesis dysfunction, and cause post-
operative cardiac events and worsens long-term survival [15,16].
The patient's blood cultures were positive for Enterococcus, and
were the cause of the infection as well as the probable cause of her in-
fected pacemaker lead and the presence of excessive vegetations and
mitral - aortic root/annulus abscesses. These abscesses were found to
be impeding the left ventricular outow tract and necessitated immedi-
ate surgical intervention. Earlier diagnosis may have diminished the de-
gree of damage to the aortic root and adjacent tissues.
5. Conclusion
This report highlights the importance of an early diagnosis of IE and
the timing of treatment. The case reinforces the view that patients who
have previously suffered from IE are at higher risk of recurrence of IE
and should be followed up more frequently. Heightened awareness
amongst surgeons and clinicians could help reduce the risk of mortality
from IE.
42 V. McIntyre et al. / Human Pathology: Case Reports 10 (2017) 3942
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