Endocarditis in Hypertrophic Cardiomyopathy

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J Med Assoc Thai. 2006 Apr;89(4):522-6.
Infective endocarditis in hypertrophic cardiomyopathy--mural and aortic valve vegetations: a case report.
Pachirat O, Klungboonkrong V, Tantisirin C.
Cardiovascular Disease Division, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand.

Hypertrophic cardiomyopathy (HCM) is infrequently complicated by infective endocarditis (IE). The authors report the case of a 46-year-old woman developing IE in asymptomatic HCM. Blood cultures were positive for Streptococcus viridans. Echocardiography demonstrated: 1) a mobile (1.2 x 1 cm2) vegetation attached to the septal endocardium at the site of contact between the mitral valve leaflet and the hypertrophic septum; 2) two large (2.7 x 1.7 cm2 and 1.6 x 1.1 cm2) vegetations at NCC and RCC respectively of aortic valve, causing moderate valve regurgitation, and, 3) a mural (1 x 0.8 cm2) vegetation on the posterior wall of the left ventricle. On the third day of hospitalization, the patient underwent aortic valve replacement and removal of the vegetations. Antibiotics were continued for another four weeks. The patient recovered and follow-up was uneventful. Thus, chronic endocardial trauma of the septum, a common finding in HCM with outflow tract obstruction, may provide a fertile nidus for the development of vegetation, which in turn would play the major role in the pathogenesis of IE.

Eur J Echocardiogr. 2006 Dec;7(6):468-70. Epub 2005 Oct 24.
Infective endocarditis complicating hypertrophic obstructive cardiomyopathy.
Louahabi T, Drighil A, Habbal R, Azzouzi L.
Department of Cardiology, Ibn Rochd University Hospital, Casablanca, Morocco. taoufikl@caramail.com

Infective endocarditis is a rare complication of hypertrophic cardiomyopathy. It's estimated incidence is 1.4 per 1000 person/year in all patients and it increases to 3.8 per 1000 person/year in patients with left ventricular outflow obstruction. The most common site of vegetation is the ventricular aspect of anterior mitral valve leaflet. We report a case of a 43-year-old man who was admitted for mitral infective endocarditis resulting in severe mitral regurgitation complicating a hypertrophic obstructive cardiomyopathy. The patient underwent mitral valve replacement. Post-operative outcome was good with relieve of symptom and resolution of left ventricular outflow obstruction. Literature data are reviewed.

Rev Esp Cardiol. 2005 May;58(5):605-6.
Prophylaxis for hypertrophic cardiomyopathy and infective endocarditis: from recommendations to implementation
Montijano Cabrera AM, Rosa Jimenez F, Galan Priego A.
No Abstract

Eur J Echocardiogr. 2002 Jun;3(2):100-2.
Perforated aneurysms of left side valves during active infective endocarditis complicating hypertrophic obstructive cardiomyopathy.
de Castro S, Adorisio R, Pelliccia A, Papetti F, Fedele F, Pandian NG.
Department of Cardiovascular and Respiratory Sciences, La Sapienza University, Rome, Italy. stefano.decastro@uniroma1.it

The most frequent site of vegetative lesion in patients with hypertrophic cardiomyopathy is anterior mitral leaflet, due to chronic endocardial trauma arising from systolic anterior motion. We describe three cases of serious infective endocarditis complicated lesions (vegetation, aneurysm and perforation) on aortic and mitral valves, in patients with obstructive hypertrophic cardiomyopathy. In particular, we observed how severe valvular damage and dysfunction, combined with particular hemodynamic conditions, are followed by adverse clinical outcome. We performed transthoracic echocardiogram and transoesophageal echocardiography studies to define morphologic and hemodynamic features of infection, deciding the proper therapy and we planned the echocardiographic follow-up. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.

Circulation. 1999 Apr 27;99(16):2132-7.
Infective endocarditis in hypertrophic cardiomyopathy: prevalence, incidence, and indications for antibiotic prophylaxis.
Spirito P, Rapezzi C, Bellone P, Betocchi S, Autore C, Conte MR, Bezante GP, Bruzzi P.
Divisione di Cardiologia, Ente Ospedaliero Ospedali Galliera, Genoa, Italy. p.spirito@galliera.it

BACKGROUND: The literature on infective endocarditis in hypertrophic cardiomyopathy (HCM) is virtually confined to case reports. Consequently, the risk of endocarditis in HCM remains undefined. METHODS AND RESULTS: We assessed the occurrence of endocarditis in 810 HCM patients evaluated between 1970 and 1997. Endocarditis was diagnosed in 10 patients, 2 of whom were excluded from analysis of prevalence and incidence because they were referred for acute endocarditis. At first evaluation, echocardiographic features consistent with prior endocarditis were identified in 3 of 808 patients, a prevalence of 3.7 per 1000 patients (95% CI, 0.8 to 11). Of 681 patients who were followed, 5 developed endocarditis, an incidence of 1.4 per 1000 person-years (95% CI, 0.5 to 3.2); outflow obstruction was present in each of these 5 patients and was associated with the risk of endocarditis (P=0.006). In the 224 obstructive patients, incidence of endocarditis was 3.8 per 1000 person-years (95% CI, 1.6 to 8.9) and probability of endocarditis 4. 3% at 10 years. Left atrial size was also associated with the risk of endocarditis (P=0.007). In patients with both obstruction and atrial dilatation (>/=50 mm), incidence of endocarditis increased to 9.2 per 1000 person-years (95% CI, 2.5 to 23.5). Analysis of all 10 patients with endocarditis identified outflow obstruction in each and atrial dilatation in 7. CONCLUSIONS: Endocarditis in HCM is virtually confined to patients with outflow obstruction and is more common in those with both obstruction and atrial dilatation. These results indicate that antibiotic prophylaxis is required only in patients with obstructive HCM.

Am Fam Physician. 1998 Feb 1;57(3):457-68.
Preventing bacterial endocarditis: American Heart Association guidelines.
Taubert KA, Dajani AS.
University of Texas Southwestern Medical School, Dallas, USA.

The American Heart Association recently revised its guidelines for the prevention of bacterial endocarditis. These guidelines are meant to aid physicians, dentists and other health care providers, but they are not intended to define the standard of care or to serve as a substitute for clinical judgment. In the guidelines, cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on the potential outcome if endocarditis develops. Procedures that may cause bacteremia and for which prophylaxis is recommended are clearly specified. In addition, an algorithm has been developed to more clearly define when prophylaxis is recommended in patients with mitral valve prolapse. For oral and dental procedures, the standard prophylactic regimen is a single dose of oral amoxicillin (2 g in adults and 50 mg per kg in children), but a follow-up dose is no longer recommended. Clindamycin and other alternatives are recommended for use in patients who are allergic to penicillin. For gastrointestinal and genitourinary procedures, the prophylactic regimens have been simplified. The new recommendations are meant to more clearly define when prophylaxis is or is not recommended, to improve compliance, to reduce cost and the incidence of gastrointestinal side effects, and to approach more uniform worldwide recommendations.

N Engl J Med. 1997 Mar 13;336(11):775-85.
Comment in:
N Engl J Med. 1997 Jul 31;337(5):349-50.
The management of hypertrophic cardiomyopathy.
Spirito P, Seidman CE, McKenna WJ, Maron BJ.
Servizio di Cardiologia, Ospedale Sant'Andrea, La Spezia, Italy.
No Abstract

Ugeskr Laeger. 1992 Jul 6;154(28):1978-9.
Hypertrophic obstructive cardiomyopathy complicated with bacterial endocarditis
Nielsen HV, Prio TK.
Medicinsk afdeling B, Rigshospitalet, Kobenhavn.

A patient with hypertrophic obstructive cardiomyopathy (HOCM) and Staphylococcus aureus mitral valve endocarditis is reported. Bacterial endocarditis occurs with increased frequency and the prognosis is worse in these patients. All patients with HOCM should therefore be given antibiotic treatment every time they undergo invasive procedures to prevent potentially fatal bacteraemia.

J Am Coll Cardiol. 1992 Feb;19(2):365-71.
Severe mitral or aortic valve regurgitation, or both, requiring valve replacement for infective endocarditis complicating hypertrophic cardiomyopathy.
Roberts WC, Kishel JC, McIntosh CL, Cannon RO 3rd, Maron BJ.
Pathology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.

Certain clinical and morphologic findings are described in 11 patients with hypertrophic cardiomyopathy complicated by infective endocarditis that produced severe mitral or aortic valve regurgitation, or both, necessitating valve replacement. All 11 patients had changes in the operatively excised valve or valves characteristic of healed infective endocarditis. The infection involved only the mitral valve in seven patients, only the aortic valve in three patients and both valves in one patient. Study of the operatively excised mitral valves indicated that the healed vegetations were located most commonly on the left ventricular aspects of the anterior mitral leaflet, indicating that vegetation had formed at contact points of this leaflet with mural endocardium of the left ventricular outflow tract. In all 11 patients, the infective endocarditis either worsened preexisting valve regurgitation or initiated valve regurgitation and led to worsened signs and symptoms of cardiac dysfunction, necessitating valve replacement. Functional class improved in the nine patients who survived 7 to 101 months after valve replacement. Hypertrophic cardiomyopathy appears to be a factor predisposing to infective endocarditis. Patients with hypertrophic cardiomyopathy should receive prophylactic antibiotic therapy during procedures that predispose to infective endocarditis.

Eur Heart J. 1990 Nov;11(11):1041-8.
Hypertrophic obstructive cardiomyopathy and infective endocarditis: a report of seven cases and a review of the literature.
Alessandri N, Pannarale G, del Monte F, Moretti F, Marino B, Reale A.
II Cattedra Malattie Apparato Cardiovascolare, Universita La Sapienza, Roma, Italy.

Seven cases of infective endocarditis (IE) in patients with hypertrophic obstructive cardiomyopathy (HOCM) are presented in this report. The previous literature is critically reviewed, and the following points are discussed: (a) IE complicates HOCM in 5-9% of cases; (b) anatomical and haemodynamic alterations of HOCM cause microtraumas on heart valves and the endocardium; the resulting endocardial lesions represent sites for bacterial seeding as well as other congenital or acquired heart disease; (c) prognosis is worse in patients with IE associated with HOCM than in patients with IE alone or associated with congenital heart disease; (d) the most frequently isolated organisms are saprophytes; (e) most patients were exposed to bacteraemias before the onset of IE.

Thorac Cardiovasc Surg. 1989 Apr;37(2):99-102.
Recurrent infective endocarditis in idiopathic hypertrophic subaortic stenosis.
Stulz P, Zimmerli W, Mihatsch J, Gradel E.
Division of Cardiothoracic Surgery, University Hospital, Basel, Switzerland.

A patient with idiopathic hypertrophic subaortic stenosis suffered from five episodes of infective endocarditis of the mitral valve. At least two of these episodes were caused by Lactobacillus species, a microorganism known to be difficult to eradicate. Definitive cure was only achieved by surgical treatment.

Circulation. 1988 Sep;78(3):487-95.
Current operative treatment of obstructive hypertrophic cardiomyopathy.
McIntosh CL, Maron BJ.
Surgery Branches, National Heart, Lung, and Blood Institute, Bethesda, MD 20892.
No Abstract

N Engl J Med. 1987 Mar 26;316(13):780-9.
Hypertrophic cardiomyopathy. Interrelations of clinical manifestations, pathophysiology, and therapy (1).
Maron BJ, Bonow RO, Cannon RO 3rd, Leon MB, Epstein SE.
No Abstract

Chest. 1984 Sep;86(3):508.
Candida tropicalis endocarditis in idiopathic hypertrophic subaortic stenosis.
Malouf J, Nasrallah A, Daghir I, Harake M, Mufarrij A.
No Abstract

Chest. 1983 May;83(5):833.
Infective endocarditis in hypertrophic cardiomyopathy secondary to amiodarone treatment.
Ovsyshcher IA, Zimlichman R.
No Abstract

J Infect. 1983 Jan;6(1):81-4.
Actinobacillus actinomycetemcomitans endocarditis in hypertrophic obstructive cardiomyopathy.
Ah Fat LN, Patel BR, Pickens S.

We report a case of bacterial endocarditis due to Actinobacillus actinomycetemcomitans in a man with hypertrophic obstructive cardiomyopathy complicated by a mycotic aneurysm and thrombosis of the right common iliac artery. The patient was successfully treated with a combination of ampicillin and gentamicin, but was left with residual mitral incompetence.

Chest. 1982 Mar;81(3):346-9.
Infectious endocarditis in idiopathic hypertrophic subaortic stenosis: report of three cases and review of the literature.
Chagnac A, Rudniki C, Loebel H, Zahavi I.

Three cases of infective endocarditis (IE) occurringg in patients with idiopathic hypertrophic subaortic stenosis (IHSS) are described. A review of the literature reveals the IE occurs in about 50 percent of the patients suffering from IHSS. It appears to complicate the natural history of the severe cases, at least as it appears from hemodynamic studies, being precipitated by the same factors and caused by the same infective organisms as in valvular heart disease. It has the same clinical picture and outcome, although the appearance of new murmurs was more common than in other types of heart disease complicated by IE, and indicated the same poor prognosis. The infection seems to involve both the aortic and the mitral valve, with equal frequency, and less commonly the ventricular outflow tract. The need for IE prophylaxis in cases of IHSS is stressed.

Am J Cardiol. 1979 Sep;44(3):569-74.
Mural vegetations at the site of endocardial trauma in infective endocarditis complicating idiopathic hypertrophic subaortic stenosis.
LeJemtel TH, Factor SM, Koenigsberg M, O'Reilly M, Frater R, Sonnenblick EH.

In two patients infective endocarditis developed as the primary manifestation of idiopathic hypertrophic subaortic stenosis. Infected vegetations were present on the mitral and aortic valves. In addition, bacterial vegetations were observed on the septal endocardium at the site of contact between the mitral valve leaflet and the hypertrophic septum. Thus, chronic endocardial trauma, a common finding in idiopathic hypertrophic subaortic stenosis, may provide a fertile nidus for the development of bacterial vegetation.

Chest. 1979 Feb;75(2):182-3.
Acute valvular insufficiency complicating hypertrophic obstructive cardiomyopathy.
Greenland P, Murphy GW.

This report describes a patient with hypertrophic obstructive cardiomyopathy complicated by acute aortic and probably mitral valvular incompetence caused by endocarditis due to Staphylococcus aureus. Following the onset of valvular insufficiency, this patient developed hypotension and pulmonary edema and eventually underwent cardiac surgery in an attempt to control these complications. We review the unique pathophysiology of hypertrophic obstructive cardiomyopathy and its alterations in the presence of acute valvular incompetence and analyze the limitations of medical management of cardiac decompensation in patients with this combination of cardiac abnormalities. The possible need for early surgery in such patients is examined.

Br Med J. 1978 Apr 15;1(6118):961.
Listeria monocytogenes endocarditis in hypertrophic cardiomyopathy.
Pitcher D, Mary D.
No Abstract

Arch Intern Med. 1977 Sep;137(9):1171-4.
Infective endocarditis caused by Streptococcus mutans. A complication of idiopathic hypertrophic subaortic stenosis.
Robbins N, Szilagyi G, Tanowitz HB, Luftschein S, Baum SG.

Three patients with endocarditis caused by Streptococcus mutans were seen during a six-month period. All had clinical features of subacute bacterial endocarditis, including fever, heart murmurs, and positive blood cultures. One had underlying aortic insufficiency and two had idiopathic hypertrophic subaortic stenosis. All patients were treated with parenteral antibiotics and were cured. Streptococcus mutans is a pleomorphic, microaerophilic organism that is associated with dental caries and plaque. Differentiation of S mutans from enterococcal endocarditis is important because the former condition can be treated for a shorter period of time with penicillin alone, without the addition of aminoglycoside antibiotics.

J Cardiovasc Surg (Torino). 1976 Sep-Oct;17(5):380-7.
Mitral valve replacement for idiopathic hypertrophic subaortic stenosis. Results in 27 patients.
Cooley DA, Wukasch DC, Leachman RD.

Treatment of idiopathic hypertrophic subaortic stenosis (IHSS) remains a controversial problem and depending upon many factors, medical or surgical treatment may be elected. When medical therapy fails and surgery is recommended, choice of an appropriate surgical technique may be difficult. An analysis is given of 27 patients who have undergone only mitral valve replacement as definitive treatment. Twenty-six patients were dismissed from the hospital with good or excellent results and one died (3.7 percent mortality). Pressure gradients across the left ventricular outflow tract after operation were eliminated in every instance. The mean preoperative gradient was 74 mm Hg and postoperatively was 6.9 mm Hg. Advantages and disadvantages of mitral valve replacement as definitive treatment of IHSS are presented. This method of treatment should be reserved for patients with incapacitating symptoms, congestive heart failure, severe left ventricular hypertension, unusual electrocardiographic findings or in patients who have failed to respond favorably to previous septectomy.

Am Heart J. 1975 Mar;89(3):359-65.
Bacterial endocarditis in idiopathic hypertrophic subaortic stenosis.
Wang K, Gobel FL, Gleason DF.

Bacterial endocarditis complicating idiopathic hypertrophic subaortic stenosis (IHSS) is uncommon but endocarditis may be the first clinical manifestation of IHSS. In this report of such a case, the aortic and the mitral valves were the sites of the bacterial infection. Many chordae tendineae to the mitral valve were ruptured from the extension of the infectious process. The endothelial lesions, which served as the seat for the bacterial infection on the anterior mitral leaflet, likely resulted from its abutting action against the septal prominence. Damage to the aortic valve leaflet may have resulted from abnormal valve motion caused by IHSS and created an environment conducive to endocarditis. This patient developed aortic insufficiency during the course of bacterial endocarditis, suggesting that the occasional association of aortic insufficiency in patients with IHSS may be secondary to healed endocarditis of the aortic valve.

Arch Surg. 1971 Nov;103(5):606-9.
Idiopathic hypertrophic subaortic stenosis. Surgical treatment including mitral valve replacement.
Cooley DA, Leachman RD, Hallman GL, Gerami S, Hall RJ.
No abstract

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