URGENT CARDIAC SURGERY IN GONOCOCCBMIA
HILLESS AND MOLLOY
URGENT AORTIC VALVE REPLACmENT IN DISSEMINATED GONOCOCCBMIA ASSOCIATED WITH SINUS OF VALSALVA ANEURYSM AND FISTULA FORMATION A. D. HILLESS~ A N D P. J. MOLLOY~ Cardiac Surgery Unit, Public Hospital, Dunedin, N e w Zealand A potient with aortic valve d k w p t i o n dlre do gonococcal endocurditis and associated with a sinus of Valsalva aneurysm and fistula into f k e righi vetitride is described. The rariiy of this CO?nbinQtiO?t of conditions and the place of m r g e r y in their manugement are discussed.
GONOCOCCAL ENDOCARDITIS has become a rare cause of valve lesions since the introduction of antibiotics. I t occurs during the bacterzmic stage of a gonococcal infection, and is encountered in 1% to 3% of patients with gonorrhea. The onset of gonococcmnia is characterized by fever, polyarthralgia and papular, petechial or hzmorrhagic skin lesions on the distal extremities. Endocarditis is suggested by changing heart murmurs, major embolic phenomena, or both (Harrison, 1974). Most of the cardiac lesions in gonococcal endocarditis are left-sided I Williams, 1938). In tbe period 1942 to 1970 there have been 18 cases of gonococcal endocarditis reported in detail, in only one of which operation was undertaken in the acute stage for treatment (Davis and Romansky, 1956; Voight st aZii.
heart lesion. On admission to hospital she had cardiac murmurs consistent with the presence of aortic regurgitation and was febrile. Her blood pressure was IIO/M nim Hg, and she had a sinus tachycardia of I40 beats per minute. Blood cultures were taken and antifailure therapy started, consisting of digoxin, frusemide and potassium supplements. She gave a history of an inff uenza-like illness which had been present for some six weeks prior to her admission. and also a one-week history of increasing dyspncea on effort, progressing to orthopnma and nocturnal dyspncea. There was no history of joint pain, skin rashes, sore throat or venereal disease, although she
1970). Aneurysms of the sinus of Valsalva are uncommon. I n a review in 1967 there were less than zoo congenitaf or acquired cases ( D e Bakey ct aEii, 1967), the congenital aneurysms being associated with aortic valve incnmpetence. The association of a small outpouching in the sinus area with fistula formation is almost always due to infection (Rjork and Rjork, 1 ~ 5 ) .
CLINICAL RECORD The patient, a 17-year-old-~irf,was admitted to Timarn Hospitat on June 6. 1975, in gross left-sided heart failure. She had no previous history of a Registrar in Cardiac Surgery. Cardiac Surgery. Reprints : Professor P. J. Molloy, address as above.
* Professor of 246
FIGURE I : Chest skiagram at time of patient's admission to hospital, showing gross pulmonary edema and cardiomegaly. AUST.N.Z. J. SURC., VOL,46-No.
3, AUGUST,1976
URGENT CARDIAC SURGERY IN GONOCOCCEMIA had had previous sexual contacts. T h e result of a VDRL test was negative. She failed to respond to therapy and was transferred to Dunedin Hospital on June 23, 1975. On admission she had a lmrnoglobin level of 10.8 Km/im ml, an ESR of 43 mm per hour and a white Mood cell count of 17,5W/mm*, with a differential count showing 58% neutrophils, 39% lymphocytes atid 3% monocytes. Her chest radiograph (Figure I ) confirmed the presence of gross pulmonary d e m a . In vicw of her critical condition and failure to rcspond to mcdical therapy she came forward to rardiac surgery on June 24, 1975, without cardiac catheter sttidies.
HILLESS AND MOLLOY
the relative diminution in size of the aortic root following obliteration of the sinus aneurysm. The heart took over the circulation well, and pacing wires were inserted. The following day blood ciiltures became available from the hospital of the patient's first admission, and these grew Neisseria gonorrhea, Culture of the excised valve was sterile. Postoperative antibiotic therapy consisted of penicillin 4 - 0 megaunits six-hourIy and cephalothin one gramme six-hourly, both given intravenously, the latter antibiotic being stopped 10 days after surgery. Anti failure therapy was also continued. She made an uneventful recovery and continued with intravenous penicillin therapy for six weeks. One week after cessation of therapy her ESR was 15 mm in an hour, and blood cultures at this stage were sterile. On discharge from hospital she had a murmur consistent with aortic regurgitation, which was noticed shortly after operation and thought to be due to a peripheral leak, probably occurring in the area where the abscess had been present in the conimissural space. She was also receiving maintenance doses of digoxin, f rusemide and potassium supplementation. H e r chest radiograph (Figure 2 ) showed a heart of normat size. with no evidence of failure.
DISCUSSION
1:ir;ua~
2:
Cliest skiagram three months after surgery.
Opcmtioti.-( Professor P. J. Molloy) The chest opened tliroiigh a median sternotomy and the aortic root was seen to be grossly cedematous. Right atrial aortic hypass was commenced with cooling to p" C, tfie aortic root was opened and coronary perfusion commenced. The aortic root was deformed I)y an aneurysm of the right sinus of Valsalva, and there was a fistula extending from the base of the sinus to the right ventricle. The right coronary citsp was almost destro ed, and there were granulations on tfie other lealets. The valve cusps were rxcisetl and the fistula closed with Teflon buttressed suturcs. The remainder of the sinus aneurysm was obliterated by suturing the free edge to the aortic wall, and then these sutures were passed through the prosthetic valve ring. In the aortic wall in the area of the commissure between the left and right cusps there was a n ahscess. A 25-mm Bjork-Shiley valve was sewn into position. A patch graft aortic angioplasty with pericardium-lined Dacron was inserted into the aortic root to facilitate closure because of was
AUST. N.Z. J. SURC., VOL.46-No.
3, AUGUST,1976
The first successful prosthetic valve replaccrnent in bacterial endocarditis was performed in 1g65 (Wallace ct alii, 1965). The necessity for early valve replacement when hzmodynamic failure supervenes in bacterial endocarditis has heen reported many times since. W e have heen able to find only one previously reported case of emergency valve surgery in rliseniminated gonococcreniia (Voight et alii. 1 ~ 7 0 )With . the worldwide increase in venereal disease (WHO, 1371). one may expect this condition to becotiie common. There has been no previously reported case of gonococcal endocarditis in New Zealand (Department of Health, 1975). despite an increase from 2.187 to 2.875 of persons attending hospital clinics €or the first time with gonococcal infection. Gonorrhcea is not a notifiable disease in New Zealand, and many patients attend their private practitioners for treatment. Patients with gonococcal endocarditis previously reported in the literature have been managed by antibiotic therapy, penicillin being the drug of choice (Jones, ~ 9 5 0 ; Davis and Romansky, 1956: Gilson et dii. 1960 : Holmes ef alii. 1g71),none of the patients in these reports suffering gross valve disease. Congestive heart failure is the prime indication for surgical management of infective endocarditis (Neville et alii, 19711. Other indications are recurrent ernboIi and persistent infec-
247
URGENT CARDIAC SURGERY IN GONOCOCCZMIA tion. In bacterial endocarditis with heart failure due to aortic valve disruption, the mortality is over 90% if the condition is not treated surgically (Manhas et alii, 1972). Early surgical intervention is necessary despite an operative mortality which may be as high as 25% (Windsor and Shanahan, 1967 ; Manhas et a%, 1972). The induction of anzesthesia in these critically ill patients may precipitate gross cardiac decompensation or uncontrollable dysrhythmias. This hazardous stage can be managed in a moribund patient by instituting partial femorofemoral bypass before induction. The incidence of paraprosthetic leaks is somewhat higher than in elective aortic valve surgery for non-infective conditions, in which it is from I % to 2% (Norman, 1972). I n some cases the cedematous, friable tissue in the aortic ring makes a poor base to which to anchor the stitches, and consequently paraprosthetic leaks are more common. In many cases the leak can be closed at reoperation by inserting buttressed mattress sutures at its site (Manhas et alii, 1972). Nevertheless, this complication does not negate the value of the procedure, as a lifethreatening regurgitation is relieved. Acute aortic regurgitation is a greater liability, for many of the leaks occurring after replacement surgery are not hzemodynamically significant (Kaiser et a%, 1967). Residual infection in the aortic root has not been the problem. A full course of intravenous antibiotics, selected by appropriate sensitivities, is given, blood cultures being repeated at the finish of the course. The management of sinus of Valsalva aneurysm with fistula formation is most easily achieved by the method described by Bjork and Bjork ( 1965), using an intraaortic buttressed suture to close the defect and obliterate the aneurysm. This indeed was the method used in our patient, and the fistula was typical of the type occurring in the “erosion aneurysms” described by Bjork and Bjork.
HILLESS AND MOLLOY
CONCLUSION Acute aortic regurgitation necessitating surgical intervention is rare in gonorrhcea. The management of such a case with associated abnormalities of the sinus of Valsalva is described. The necessity for early surgical intervention, despite the increased operative mortality associated with aortic valve replacement in bacterial endocarditis when hzemodynamic failure cannot be controlled by medical therapy, is emphasized.
REFERENCES BJORK,V. 0. and BJORK,L. (1965), J. thorac. cardiovasc. Surg., 50: 16. DAVIS,D. S . and ROMANSKY, M. (1956), Amer. J . Med., 21: 473. DE BAKEY,M. E., DIETHRICH,E. B., LIDDICOAT, J. E., KINARD,S. and GARRETT,H. E. (1967), J. thorac. cardiovasc. Surg., 54 : 312. DEPARTMENT OF HEALTH, N.Z. NATIONALHEALTH STATISTICS CENTRE(1975), personal communication. GILSON,B. J., TROUT, M. E. and ALLEMAN, H. (1g60), US. armed Forces med. 1.. 11: 1.775. HARRISON, T. R. (1974), “P;inciplesr >f Internal Medicine”, 7th Edition, McGaw-Hill. New York : 790. HOLMES, K. K., COMBS,G. W. and BEATY,H. N. (1971), Ann. intern. Med., 75: 979. JONES, M. ( I Q ~ o )Amer. , Heart J., 40: 106. KAISER,G. C., WILLMAN,V. L. and HANLOW, C. R. (1967)~J. thorac. cardiovasc. Surg., 54: 49. MANHAS,D. R., HITOSHI,M., HESSEL,E. A. and MERENDINO, M. S. (1g72), Amer. Heart. J., 84: 738. NEVILLE, N. E., MANGO, M., MOFFAT, J. and FOXWORTHY. D. (1071). J. thorac. cardiovasc. . .. Surg., 61: 916. NORMAN, J. C. (1972). “Cardiac Surgery”, Appleton, Century, Crofts, New York: 475. VOIGHT, G. C., BENDER,W., BUCKELS,L. J., DE MEESTER, T. and MACDONALD, W. (Ig70), Bull. Johns Hopk. Hosp., 126: 305. WALLACE. A. G.. YOUNG.W. B. and OSTERHART. S. (1965), Circhation, 31 : 450. WHO REPORT(1971), The Inter-Country Spread of Venereal Disease. WILLIAMS,R. H. (1938), Arch. intern. Med., 61: 26. WINDSOR, H. M. and SHANAHAN, M. (1967), Thorax, I
22:
-4UST.
.
25.
N.Z. J. SURG., VOL. 46 -NO. 3, AUGUST,1976
HILLESS AND MOLLOY
URGENT AORTIC VALVE REPLACmENT IN DISSEMINATED GONOCOCCBMIA ASSOCIATED WITH SINUS OF VALSALVA ANEURYSM AND FISTULA FORMATION A. D. HILLESS~ A N D P. J. MOLLOY~ Cardiac Surgery Unit, Public Hospital, Dunedin, N e w Zealand A potient with aortic valve d k w p t i o n dlre do gonococcal endocurditis and associated with a sinus of Valsalva aneurysm and fistula into f k e righi vetitride is described. The rariiy of this CO?nbinQtiO?t of conditions and the place of m r g e r y in their manugement are discussed.
GONOCOCCAL ENDOCARDITIS has become a rare cause of valve lesions since the introduction of antibiotics. I t occurs during the bacterzmic stage of a gonococcal infection, and is encountered in 1% to 3% of patients with gonorrhea. The onset of gonococcmnia is characterized by fever, polyarthralgia and papular, petechial or hzmorrhagic skin lesions on the distal extremities. Endocarditis is suggested by changing heart murmurs, major embolic phenomena, or both (Harrison, 1974). Most of the cardiac lesions in gonococcal endocarditis are left-sided I Williams, 1938). In tbe period 1942 to 1970 there have been 18 cases of gonococcal endocarditis reported in detail, in only one of which operation was undertaken in the acute stage for treatment (Davis and Romansky, 1956; Voight st aZii.
heart lesion. On admission to hospital she had cardiac murmurs consistent with the presence of aortic regurgitation and was febrile. Her blood pressure was IIO/M nim Hg, and she had a sinus tachycardia of I40 beats per minute. Blood cultures were taken and antifailure therapy started, consisting of digoxin, frusemide and potassium supplements. She gave a history of an inff uenza-like illness which had been present for some six weeks prior to her admission. and also a one-week history of increasing dyspncea on effort, progressing to orthopnma and nocturnal dyspncea. There was no history of joint pain, skin rashes, sore throat or venereal disease, although she
1970). Aneurysms of the sinus of Valsalva are uncommon. I n a review in 1967 there were less than zoo congenitaf or acquired cases ( D e Bakey ct aEii, 1967), the congenital aneurysms being associated with aortic valve incnmpetence. The association of a small outpouching in the sinus area with fistula formation is almost always due to infection (Rjork and Rjork, 1 ~ 5 ) .
CLINICAL RECORD The patient, a 17-year-old-~irf,was admitted to Timarn Hospitat on June 6. 1975, in gross left-sided heart failure. She had no previous history of a Registrar in Cardiac Surgery. Cardiac Surgery. Reprints : Professor P. J. Molloy, address as above.
* Professor of 246
FIGURE I : Chest skiagram at time of patient's admission to hospital, showing gross pulmonary edema and cardiomegaly. AUST.N.Z. J. SURC., VOL,46-No.
3, AUGUST,1976
URGENT CARDIAC SURGERY IN GONOCOCCEMIA had had previous sexual contacts. T h e result of a VDRL test was negative. She failed to respond to therapy and was transferred to Dunedin Hospital on June 23, 1975. On admission she had a lmrnoglobin level of 10.8 Km/im ml, an ESR of 43 mm per hour and a white Mood cell count of 17,5W/mm*, with a differential count showing 58% neutrophils, 39% lymphocytes atid 3% monocytes. Her chest radiograph (Figure I ) confirmed the presence of gross pulmonary d e m a . In vicw of her critical condition and failure to rcspond to mcdical therapy she came forward to rardiac surgery on June 24, 1975, without cardiac catheter sttidies.
HILLESS AND MOLLOY
the relative diminution in size of the aortic root following obliteration of the sinus aneurysm. The heart took over the circulation well, and pacing wires were inserted. The following day blood ciiltures became available from the hospital of the patient's first admission, and these grew Neisseria gonorrhea, Culture of the excised valve was sterile. Postoperative antibiotic therapy consisted of penicillin 4 - 0 megaunits six-hourIy and cephalothin one gramme six-hourly, both given intravenously, the latter antibiotic being stopped 10 days after surgery. Anti failure therapy was also continued. She made an uneventful recovery and continued with intravenous penicillin therapy for six weeks. One week after cessation of therapy her ESR was 15 mm in an hour, and blood cultures at this stage were sterile. On discharge from hospital she had a murmur consistent with aortic regurgitation, which was noticed shortly after operation and thought to be due to a peripheral leak, probably occurring in the area where the abscess had been present in the conimissural space. She was also receiving maintenance doses of digoxin, f rusemide and potassium supplementation. H e r chest radiograph (Figure 2 ) showed a heart of normat size. with no evidence of failure.
DISCUSSION
1:ir;ua~
2:
Cliest skiagram three months after surgery.
Opcmtioti.-( Professor P. J. Molloy) The chest opened tliroiigh a median sternotomy and the aortic root was seen to be grossly cedematous. Right atrial aortic hypass was commenced with cooling to p" C, tfie aortic root was opened and coronary perfusion commenced. The aortic root was deformed I)y an aneurysm of the right sinus of Valsalva, and there was a fistula extending from the base of the sinus to the right ventricle. The right coronary citsp was almost destro ed, and there were granulations on tfie other lealets. The valve cusps were rxcisetl and the fistula closed with Teflon buttressed suturcs. The remainder of the sinus aneurysm was obliterated by suturing the free edge to the aortic wall, and then these sutures were passed through the prosthetic valve ring. In the aortic wall in the area of the commissure between the left and right cusps there was a n ahscess. A 25-mm Bjork-Shiley valve was sewn into position. A patch graft aortic angioplasty with pericardium-lined Dacron was inserted into the aortic root to facilitate closure because of was
AUST. N.Z. J. SURC., VOL.46-No.
3, AUGUST,1976
The first successful prosthetic valve replaccrnent in bacterial endocarditis was performed in 1g65 (Wallace ct alii, 1965). The necessity for early valve replacement when hzmodynamic failure supervenes in bacterial endocarditis has heen reported many times since. W e have heen able to find only one previously reported case of emergency valve surgery in rliseniminated gonococcreniia (Voight et alii. 1 ~ 7 0 )With . the worldwide increase in venereal disease (WHO, 1371). one may expect this condition to becotiie common. There has been no previously reported case of gonococcal endocarditis in New Zealand (Department of Health, 1975). despite an increase from 2.187 to 2.875 of persons attending hospital clinics €or the first time with gonococcal infection. Gonorrhcea is not a notifiable disease in New Zealand, and many patients attend their private practitioners for treatment. Patients with gonococcal endocarditis previously reported in the literature have been managed by antibiotic therapy, penicillin being the drug of choice (Jones, ~ 9 5 0 ; Davis and Romansky, 1956: Gilson et dii. 1960 : Holmes ef alii. 1g71),none of the patients in these reports suffering gross valve disease. Congestive heart failure is the prime indication for surgical management of infective endocarditis (Neville et alii, 19711. Other indications are recurrent ernboIi and persistent infec-
247
URGENT CARDIAC SURGERY IN GONOCOCCZMIA tion. In bacterial endocarditis with heart failure due to aortic valve disruption, the mortality is over 90% if the condition is not treated surgically (Manhas et alii, 1972). Early surgical intervention is necessary despite an operative mortality which may be as high as 25% (Windsor and Shanahan, 1967 ; Manhas et a%, 1972). The induction of anzesthesia in these critically ill patients may precipitate gross cardiac decompensation or uncontrollable dysrhythmias. This hazardous stage can be managed in a moribund patient by instituting partial femorofemoral bypass before induction. The incidence of paraprosthetic leaks is somewhat higher than in elective aortic valve surgery for non-infective conditions, in which it is from I % to 2% (Norman, 1972). I n some cases the cedematous, friable tissue in the aortic ring makes a poor base to which to anchor the stitches, and consequently paraprosthetic leaks are more common. In many cases the leak can be closed at reoperation by inserting buttressed mattress sutures at its site (Manhas et alii, 1972). Nevertheless, this complication does not negate the value of the procedure, as a lifethreatening regurgitation is relieved. Acute aortic regurgitation is a greater liability, for many of the leaks occurring after replacement surgery are not hzemodynamically significant (Kaiser et a%, 1967). Residual infection in the aortic root has not been the problem. A full course of intravenous antibiotics, selected by appropriate sensitivities, is given, blood cultures being repeated at the finish of the course. The management of sinus of Valsalva aneurysm with fistula formation is most easily achieved by the method described by Bjork and Bjork ( 1965), using an intraaortic buttressed suture to close the defect and obliterate the aneurysm. This indeed was the method used in our patient, and the fistula was typical of the type occurring in the “erosion aneurysms” described by Bjork and Bjork.
HILLESS AND MOLLOY
CONCLUSION Acute aortic regurgitation necessitating surgical intervention is rare in gonorrhcea. The management of such a case with associated abnormalities of the sinus of Valsalva is described. The necessity for early surgical intervention, despite the increased operative mortality associated with aortic valve replacement in bacterial endocarditis when hzemodynamic failure cannot be controlled by medical therapy, is emphasized.
REFERENCES BJORK,V. 0. and BJORK,L. (1965), J. thorac. cardiovasc. Surg., 50: 16. DAVIS,D. S . and ROMANSKY, M. (1956), Amer. J . Med., 21: 473. DE BAKEY,M. E., DIETHRICH,E. B., LIDDICOAT, J. E., KINARD,S. and GARRETT,H. E. (1967), J. thorac. cardiovasc. Surg., 54 : 312. DEPARTMENT OF HEALTH, N.Z. NATIONALHEALTH STATISTICS CENTRE(1975), personal communication. GILSON,B. J., TROUT, M. E. and ALLEMAN, H. (1g60), US. armed Forces med. 1.. 11: 1.775. HARRISON, T. R. (1974), “P;inciplesr >f Internal Medicine”, 7th Edition, McGaw-Hill. New York : 790. HOLMES, K. K., COMBS,G. W. and BEATY,H. N. (1971), Ann. intern. Med., 75: 979. JONES, M. ( I Q ~ o )Amer. , Heart J., 40: 106. KAISER,G. C., WILLMAN,V. L. and HANLOW, C. R. (1967)~J. thorac. cardiovasc. Surg., 54: 49. MANHAS,D. R., HITOSHI,M., HESSEL,E. A. and MERENDINO, M. S. (1g72), Amer. Heart. J., 84: 738. NEVILLE, N. E., MANGO, M., MOFFAT, J. and FOXWORTHY. D. (1071). J. thorac. cardiovasc. . .. Surg., 61: 916. NORMAN, J. C. (1972). “Cardiac Surgery”, Appleton, Century, Crofts, New York: 475. VOIGHT, G. C., BENDER,W., BUCKELS,L. J., DE MEESTER, T. and MACDONALD, W. (Ig70), Bull. Johns Hopk. Hosp., 126: 305. WALLACE. A. G.. YOUNG.W. B. and OSTERHART. S. (1965), Circhation, 31 : 450. WHO REPORT(1971), The Inter-Country Spread of Venereal Disease. WILLIAMS,R. H. (1938), Arch. intern. Med., 61: 26. WINDSOR, H. M. and SHANAHAN, M. (1967), Thorax, I
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-4UST.
.
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N.Z. J. SURG., VOL. 46 -NO. 3, AUGUST,1976
