Korean J Thorac Cardiovasc Surg 2014;47:137-140 □ Case Report □http://dx.doi.org/10.5090/kjtcs.2014.47.2.137ISSN: 2233-601X (Print) ISSN: 2093-6516 (Online)

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1Department of Thoracic and Cardiovascular Surgery,

2Division of Cardiology, Department of Internal Medicine, Medical Research Institute,

Pusan National University Hospital, Pusan National University School of MedicineReceived: August 5, 2013, Revised: September 11, 2013, Accepted: September 17, 2013

Corresponding author: Seunghwan Song, Department of Thoracic and Cardiovascular Surgery, Medical Research Institute, Pusan National

University Hospital, Pusan National University School of Medicine, 179 Gudeok-ro, Seo-gu, Busan 602-739, Korea(Tel) 82-51-240-7267 (Fax) 82-51-243-9389 (E-mail) song77.sh@gmail.com

C The Korean Society for Thoracic and Cardiovascular Surgery. 2014. All right reserved.CC This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creative-

commons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Multiple Embolic Aortic Valve Endocarditis with Small Patent Ductus Arteriosus in Adult

Seon Hee Kim, M.D.1, Seunghwan Song, M.D.1, Min Su Kim, M.D.1, Sang-pil Kim, M.D.1, Jung Hyun Choi, M.D.2

A 50-year-old female was admitted to Pusan National University Hospital with complaints of fatigue and sweating. Echocardiography showed a small patent ductus arteriosus (PDA) and highly mobile vegetations on the aortic valve. Emergency operation was performed due to the high risk of embolization and severe aortic regurgitation. When the pulmonary artery opened, we found unexpected fresh vegetation. The tissue of the PDA was fragile and infected. We successfully removed the infected tissue, closed the PDA with a patch, and replaced the aortic valve with a mechanical prosthesis.

Key words: 1. Endocarditis2. Congenital heart disease (CHD)3. Aortic valve

CASE REPORT

A 50-year-old female presented to Pusan National Universi-

ty Hospital with a 1-month history of fatigue, loss of weight,

and shortness of breath. She had poor oral hygiene and a low

socioeconomic status. Her medical history was unremarkable.

On examination, she presented with fever and sweating, along

with marked conjunctival pallor. There was a continuous

murmur with thrill over the pulmonary area and a diastolic

murmur over the aortic area. Chest radiography showed bi-

lateral lower lobe infiltrates and mild cardiomegaly (Fig. 1A).

On a chest computed tomography (CT), pulmonary edema

and multiple cavitary lesions, which were surrounded by

ground-glass opacity suspecting septic emboli, were observed

(Fig. 1B). Splenic infarction was detected on the abdominal

CT (Fig. 1C). No brain lesion of septic emboli was described

in the brain magnetic resonance imaging. Laboratory inves-

tigations were remarkable for anemia and leukocytosis.

Transthoracic and transesophageal echocardiography revealed

severe aortic valve regurgitation, with highly mobile masses

on the right and the left coronary cusps, which were irregu-

larly thickened and prolapsed. Continuous shunt flow, from

the descending aorta to the pulmonary artery, was noted (Fig.

2). The defect size was 6 mm, and the amount of shunt flow

was too small to measure. Pulmonary hypertension was not

suspected because the pressure and the morphology of the

right ventricle remained normal. Other cardiac valves, includ-

ing the pulmonary valve, were normal, and no other vegeta-

tion was observed on the chambers and the great vessels.

Emergency operation was carried out due to highly mobile

Seon Hee Kim, et al

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Fig. 1. (A) Chest radiograph shows bilateral lower lobe infiltrates and mild cardiomegaly. (B) Chest com-puted tomography (CT) reveals cavi-tary lesion surrounded by ground glass opacity on the right middle lobe (arrow). (C) Abdominal CT shows multifocal low-density lesions on the spleen (arrow).

Fig. 2. (A) Echocardiography shows highly mobile vegetation on the aortic valve (arrow), which is severely destructed. (B) Color Doppler confirms a small shunt flow from the descending aorta to the pulmonary artery (arrow). LVOT, left ventricular outflow tract; Ao, aorta; PA, pulmonary artery.

vegetation and severe aortic regurgitation. The patent ductus

arteriosus (PDA) was isolated and identified primarily.

Cardiopulmonary bypass (CPB) was commenced with aortic

and bicaval cannulation. With external ligation of the duct,

the patient was then cooled to a temperature of 28oC, after

which the pulmonary artery was opened. Unexpected fresh

vegetation was found in the pulmonary artery, at the site op-

posite to the ductal opening (Fig. 3A). Blood flow was still

present despite the earlier ligation. With total circulatory ar-

rest, the pulmonary artery opening of the duct was identified.

As the tissue of the ductus was infected, and thus, fragile, the

ductus was removed completely. A fresh pericardial patch

was used to close the opening of the aortic wall. All vegeta-

tions on the pulmonary artery were debrided and removed,

and the defect of pulmonary artery was repaired directly. The

aortic valve was severely destructed with a large number of

Endocarditis with Ductus Arteriosus

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Fig. 3. (A) In the operative view, embolized fresh vegetations (black arrow) are noticed on the opposite site of the ductal opening (white arrow) inside of the pulmonary artery. (B) Highly mobile vegetations are observed on the aortic valve leaflets, which are severely destructed. PA, pulmonary artery; Ao, aorta.

mobile vegetations. All infected tissue, including the valve,

was resected and replaced with a mechanical prosthetic valve

(Fig. 3B). Bacterial culture revealed Streptococcus mutans.

After six weeks of penicillin injection, infection was con-

trolled completely, including that in the lung and the spleen.

In the 1-year follow-up, no recurrence was observed.

DISCUSSION

The risk of infective endocarditis (IE), with a small PDA

in adults, appears to be extremely low. Nowadays, IE has be-

come treatable with advanced antibiotics. Despite appropriate

medical treatment, IE occasionally needs surgical treatment

[1]. However, there is little experience of surgical treatment

[2].

According to the previous reports, open closure with CPB,

rather than ligation, was strongly recommended, as a surgical

intervention of PDA in adults, due to the risk of severe hem-

orrhage from the fragile ductal tissue. The risk of hemorrhage

is considerably higher when combined with endocarditis, in

particular [1]. In addition, considering pulmonary emboliza-

tion from the dislodgement of vegetation and the incomplete

elimination of infective foci, complete resection of PDA and

closure, under direct vision, was strongly suggested [3].

Infected emboli are common, and the frequently involved site

is the pulmonary arterial wall, opposite to the opening of

PDA [3-5]. To suspect the possibility of embolic vegetation

on the pulmonary artery is reasonable, even if vegetation is

preoperatively noticed only on the left side valve, as in our

case. In conclusion, inspection inside of the pulmonary artery

is essential for a complete removal of the infected material

and for ensuring the safety of closing the PDA with endo-

carditis in adult patients.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was

reported.

ACKNOWLEDGMENTS

This work was supported by the year 2014 clinical re-

search grant from Pusan National University Hospital.

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