(Chest. 1999;116:1818-1820.)
© 1999
American College of Chest Physicians
Successful Treatment of Prosthetic Aortic Valve Mucormycosis*
Angel Sanchez-Recalde, MD;
Jose L. Merino, MD;
Francisco Dominguez, MD;
Isabel Mate, MD;
Jose L. Larrea, MD and
Jose A. Sobrino, MD
*
From the U. M. Q. Cardiología, Hospital General La Paz, Universidad Autónoma, Madrid, Spain.
Correspondence to: Angel Sanchez-Recalde, MD, U. M. Q. Cardiología (1a Pl. Centro), Hospital General "La Paz", P. de la Castellana 261, 28046 Madrid, Spain; e-mail: asrecalde{at}jet.es
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Abstract
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Mucor endocarditis after cardiovascular surgery is rare and
usually fatal. We report the first known case of prosthetic aortic
valve mucormycosis in a patient without predisposing risk factors who
was successfully treated using a combination of early antifungal drug
therapy and surgical removal of infected material.
Key Words: amphotericin • mucormycosis • prosthetic aortic valve
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Introduction
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Primary
cardiovascular involvement in mucormycosis is rare and typically leads
to death in the short term. This has been reported to be associated
with immunosuppression or prolonged antibiotic therapy. We report on a
patient without risk factors and with mucor prosthetic valve
endocarditis shortly after aortic valve replacement. The patient
received therapy with antifungal drugs for 7 days followed by surgery,
and no recurrence was evident at follow-up.
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Case Report
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A 60-year-old man underwent aortic valve replacement with a
mechanical prosthesis because of degenerative aortic valve disease.
Perfusion and ischemic times were 65 min and 35 min, respectively.
Cefazolin and tobramycin prophylaxis against infection was administered
during the first 2 postoperative days. The postoperative outcome was
unremarkable. Six weeks after discharge, the patient was readmitted due
to clinical deterioration, fever, and chills. An early prosthetic valve
endocarditis was suspected, and the patient was empirically treated
with vancomycin, gentamycin, and rifampicin without any clinical
improvement. Transesophageal echocardiography showed a
paraaortic abscess and a prosthetic vegetant mass (Fig 1
). There was significant transvalvular flow stenosis (mean gradient, 70
mm Hg) with no regurgitation that was partially relieved (mean
gradient, 45 mm Hg) following vegetation embolization (Fig 2
) 1 week after admission. Left inferior limb ischemia, due to
embolization, led to vascular surgery and microbiological examination
of the embolus, which demonstrated hyphae. The antibiotic therapy was
changed to United States Pharmacopeia amphotericin B, 300 mg/d IV, and
itraconazol, 400 mg/d orally. Two days later, he had no fever, clinical
improvement was evident, and prosthetic replacement was postponed for 1
week. At surgery, several vegetations (about 1 cm in length) and an
abscess were found in the aortic aspect of the aortic valve and in the
aortic-mitral intervalvular fibrosa, respectively. Mucor species were
demonstrated in the culture of the embolic material and by valvular
pathologic examination. After surgery, amphotericin and itraconazol
treatment were continued for 6 and 8 weeks, respectively. The patient
remains asymptomatic and without clinical, analytical, or
echocardiography evidence of infectious recurrence after 1 year
follow-up.
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Figure 1.. Transesophageal echocardiography:
(left, A) basal short-axis view in the
transverse plane showing a large aortic periprosthetic abscess (black
arrows); (right, B) longitudinal axis
showing a vegetation (white arrow) and abscess (black arrow).
LA = left atrium; RA = right atrium; RV = right ventricle;
LV = left ventricle; AO = aorta.
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Figure 2.. Aortic continuous-wave Doppler echocardiography
from the transesophageal transgastric view before (top,
A) and after (bottom, B)
vegetation embolization. Note the significant decrease in aortic flow
velocity: 5.5 m/s (top, A) vs 4.5 m/s
(bottom, B).
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Comment
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Mucormycosis after cardiovascular surgery almost always results in
death. It is usually associated with immunosuppression secondary to
severe concomitant diseases, or prolonged therapy with steroids or
broad spectrum antibiotics.1
2
3
4
5
6
Interestingly, our patient
showed no concomitant diseases and received prophylactic antibiotic
therapy for only 2 days.
Therapy of cardiovascular mucormycosis is controversial. Combined
treatment with surgery and amphotericin is the most accepted strategy.
However, the correct duration of antifungal drug therapy, both before
and after surgery, is not well established.2
4
To our
knowledge, there are six reported patients with mucormycosis after
cardiovascular surgery.1
2
3
4
5
6
Three of them were treated
with urgent cardiovascular surgery after the etiologic diagnosis was
established and followed by a 5-week course of amphotericin, and two of
them survived.2
4
The remainder died of fungal sepsis, and
the etiologic diagnosis was first suspected at
necropsy.1
3
5
6
In our patient, antifungal drug therapy
was associated with significant clinical improvement. For this reason,
it was decided to maintain this therapy for at least 1 week before
surgery in order to reduce the potential infectious load. The outcome
of our patient, together with previous experience, underlines the
importance of antifungal drug therapy and suggests that it should be
started before surgery whenever the clinical condition allows.
Received for publication April 15, 1999.
Accepted for publication July 23, 1999.
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References
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Virmani, R, Connor, DH, McAllister, HA (1982) Cardiac mucormycosis: a report of five patients and review of 14 previously reported cases. Am J Clin Pathol 78,42-47[Medline]
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Callard, GM, Wright, CB, Wray, RC, et al (1971) False aneurysm due to mucor following repair of a coarctation with a dacron prosthesis. J Thorac Cardiovasc Surg 61,181-185
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Jackman, JD, Simonsen, RL (1992) The clinical manifestations of cardiac mucormycosis. Chest 101,1773-1736
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Chaudhry, R, Venugopal, P, Chopra, P (1987) Prosthetic mitral valve mucormycosis caused by mucor species. Int J Cardiol 17,333-335[CrossRef][Medline]
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Khicha, GJ, Berroya, RB, Escano, FB, et al (1972) Mucormycosis in a mitral prosthesis. J Thorac Cardiovasc Surg 63,903-905[Medline]
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Balaguer, JM, Soto, E, Perry, D, et al (1994) Postoperative intramyocardial abscess caused by mucormycosis. Ann Thorac Surg 58,1760-1762[Abstract]
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A. Sanchez-Recalde, I. Mate, J. L. Merino, R. S. Simon, and J. A. Sobrino
Aspergillus aortitis after cardiac surgery
J. Am. Coll. Cardiol.,
January 1, 2003;
41(1):
152 - 156.
[Abstract]
[Full Text]
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Abstract
Introduction
