Unusual Cardiac Complications of Staphylococcus

aureus Endocarditis
Chandra Kunavarapu, MD, Yefin Olkovsky, MD, James C. Lafferty, MD, Ali R. Homayuni, MD,
Sowjanya S. Mohan, MD, Joseph McGinn, MD Augusta, Georgia; and Staten Island, New York

Bacterial endocarditis is a complex disease that is associated with significant morbidity and mortality.
Staphylococcus aureus is an organism commonly responsible for acute bacterial infective endocarditis.
Patients many times develop an acute fulminant infection resulting in multiple complications, even in the face
of adequate therapy. We report an unusual case of S aureus acute bacterial infective endocarditis in an
immunocompromised patient resulting in multiple cardiac complications, including bacterial pericarditis with
effusion, mycotic aneurysm of one of the coronary arteries, a valvular vegetation leading to an aneurysmal
dilatation at the mitral-aortic junction (intervalvular fibrosa), and a fistulous communication between the left
ventricle and left atrium. We present detailed echocardiographic images of these anomalies, which were
subsequently confirmed intraoperatively. The patient underwent open heart surgery with pericardial patch
repair of the mitral-aortic intervalvular fibrosa aneurysm and fistula.

S taphylococci, as a group, cause at least 20% to 30% of infective
endocarditis and in some areas may be the leading cause of infective
endocarditis.1 We report rare cardiac complications of Staphylococcus
aureus endocarditis in an immunocompromised patient resulting in
bacterial pericarditis with effusion, an aneurysmal dilatation at the
From the Department of Cardiology, (C.K.) and Department of Infectious Disease
(S.S.M), Medical College of Georgia, Augusta, Georgia; Department of Cardiology
(Y.O., J.C.L., A.R.H.) and Department of Cardiothoracic Surgery (J.M.), Staten
Island University Hospital, Staten Island, New York.
Reprint requests: Chandra Kunavarapu, Department of Cardiology, Medical
College of Georgia, 1120 15 St, BBR 6515B, Augusta, GA 30912 (E-mail:
ckunavarapu@mcg.edu).
0894-7317/$34.00
Copyright 2008 by the American Society of Echocardiography.
doi:10.1016/j.echo.2007.06.016
mitral-aortic junction (intervalvular fibrosa) (MAIVF) and a fistulous
communication between the left ventricle (LV) and left atrium (LA).
We present detailed echocardiographic images of these anomalies.
The case not only illustrates the destructive nature of S aureus
endocarditis, but also the potential for unusual complications, which
require a high degree of clinical suspicion and early intervention to
prevent further morbidity and mortality.
CASE REPORT
A 59-year-old man presented to the emergency department with
symptoms of fever, chills, fatigue, and loss of appetite for 5 days. His
medical history was significant for cadaveric renal transplantation 10
years before presentation, with mild renal insufficiency, type 2 dia-
betes mellitus, peripheral arterial disease, and a chronic right lateral
foot ulcer. The patient’s medications included cyclosporine (100 mg
twice a day), prednisone (5 mg once a day), insulin, and folic acid.

Figure 1 Midesophageal long-axis view on transesophageal Figure 2 Midesophageal 5-chamber view on transesophageal
echocardiography demonstrating echogenic mass suggestive echocardiography demonstrating aneurysmal dilation of mitral
of endocarditis (pointer). aortic intervalvular fibrosa (pointer).
187.e3
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187.e4 Kunavarapu et al Journal of the American Society of Echocardiography
February 2008

Figure 3 Coronary angiogram, right anterior oblique caudal

view demonstrating aneurysm at site of proximal portion of left
circumflex artery.
Chest radiograph revealed a widened mediastinum and a left pleural
effusion. A bedside transthoracic echocardiogram revealed a large peri-
cardial effusion with no evidence of cardiac tamponade. A pericardial
window procedure was performed and 600 mL of serosanguineous
fluid was drained–laboratory analysis determined it was an exudate. A
biopsy specimen of the pericardium revealed acute and chronic pericar-
ditis. Blood cultures drawn at the time of admission and pericardial fluid
cultures revealed S aureus sensitive to methicillin. A transesophageal
echocardiogram (TEE) was obtained and revealed low-normal LV func-
tion and a mobile density on the mitral anterior valve annulus site that
Figure 4 Midesophageal long-axis view on transesophageal
echocardiography demonstrating Doppler color flow evidence
of fistula from left ventricular outflow tract to left atrium; there is
also evidence of mild to moderate mitral regurgitation.
was consistent with an infective vegetation. There was no clear evidence
of an abscess (Figure 1). A 6-week course of antibiotics was started and
a repeated TEE was performed after 4 weeks because the patient had
acute worsening of symptoms (shortness of breath, fatigue). Figures 2
and 3, and Movies 1 and 2, reveal the findings. The vegetation is no
longer visualized, but a large pulsatile, thin-walled echolucent space in
the region of the MAIVF is seen protruding into the LA. There was a
systolic expansion within the area of the MAIVF with color flow

Figure 5 Intraoperative view looking into aortic valve from above: anterior mitral valve leaflet is dehisced from aortic annulus and pink fleshy
looking aneurysm is visualized. On palpation of aneurysm communication was felt into left atrium. MAIVF, Mitral aortic intervalvular fibrosa.

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Journal of the American Society of Echocardiography
Volume 21 Number 2
evidence of an eccentric high-velocity systolic jet between the LV and
the LA. There was also mild mitral regurgitation, evidence of right heart
volume overload, and mildly depressed global LV function. There was
no evidence of abscess or pericardial effusion. A cardiac catheterization
was performed that demonstrated an aneurysm at the proximal site in
the left circumflex artery (Figure 4 and Movie 3) and moderate left
anterior descending coronary artery disease.
Based on these findings, the patient was referred for open heart
surgery. Intraoperatively, an aneurysm adjacent to the noncoronary cusp
of the aortic valve and the anterior mitral valve was visualized. The
anterior mitral valve leaflet had dehisced from the annulus site, resulting
in an aneurysm (Figure 5). In addition, on palpation of the aneurysm, a
communication was felt between the LV outflow tract and the LA,
confirming the TEE findings. A pericardial patch was used to close the
fistula and repair the aneurysm.
DISCUSSION
S aureus is a leading pathogen involved in both community acquired
and nosocomial infections. Staphylococcal bacteremia remains a
disease with high mortality and morbidity despite appropriate antibi-
otic therapy. The presence of prosthetic devices and host immuno-
suppression increase risk for morbidity and mortality.1-3 The case
presented illustrates a very unusual complication of staphylococcal
acute bacterial infective endocarditis. The MAIVF is a thin area of
fibrous tissue between the base of the anterior mitral leaflet and the
posterior aortic root. It is an avascular region that can become
secondarily infected as a result of acute bacterial infective endocardi-
tis involving the aortic valve. Aneurysms of this region are rare, prone
to rupture and embolization, and can lead to further destruction of
the aortic or mitral valve apparatus.4-6 TEE has been demonstrated to
be highly accurate in the diagnosis of these complications. In one
series of 55 patients with aortic valve endocarditis, 11 patients
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Kunavarapu et al 187.e5
developed either an MAIVF aneurysm or a rupture into the LA.4 In
all, 8 of the 11 patients who developed these complications had a
prosthetic valve endocarditis and 45% of these patients had poor
outcomes (death, persistent infection, or perforation).
With a high proportion of acute bacterial endocarditis caused by S
aureus and in view of its highly destructive nature, clinicians should be
acutely suspicious of adverse changes in a patient’s clinical course–
even after institution of appropriate antibiotic therapy. TEE will be of
high diagnostic value in identifying these complications.
REFERENCES
1. Miro JM, Anguera I, Cabell CH, Chen AY, Stafford JA, Corey GR, et al;
International Collaboration on Endocarditis Merged Database Study
Group. Staphylococcus aureus native valve infective endocarditis: report of
566 episodes from the international collaboration on endocarditis merged
database. Clin Infect Dis 2005;41:507-14.
2. Fowler VG Jr, Miro JM, Hoen B, Cabell CH, Abrutyn E, Rubinstein E, et al;
ICE Investigators. Staphylococcus aureus endocarditis: a consequence of
medical progress [erratum in JAMA 2005;294:900]. JAMA 2005;293:
3012-21.
3. Mansur AJ, Grinburg M, da Luz PL, Bellotti G. The complications of
infective endocarditis: a reappraisal in the 1980s. Arch Intern Med 1992;
152:2428.
4. Karalis DG, Bansal RC, Hauck AJ, Ross JJ Jr, Applegate PM, Jutzy KR, et al.
Transesophageal echocardiographic recognition of subaortic complications
in aortic valve endocarditis: clinical and surgical implications. Circulation
1992;86:353-62.
5. Koch R, Kapoor A, Spencer KT. Stroke in patient with an intervalvular
fibrosa pseudoaneurysm and aortic pseudoaneurysm. J Am Soc Echocar-
diogr 2003;16:894-6.
6. Afridi I, Apostolidou MA, Saad RM, Zoghbi WA. Pseudoaneurysms of the
mitral-aortic intervalvular fibrosa: dynamic characterization using transesoph-
ageal echocardiographic and Doppler techniques. J Am Coll Cardiol 1995;
25:137-45.