Circulation: Cardiovascular Imaging. 2009;2:71-74
doi: 10.1161/CIRCIMAGING.108.797506
Endocarditis After Pectus Excavatum Repair
A Case Report
C. Jerry Jou, DO, PhD
;
Phillip T. Burch, MD
;
Christopher R. Mart, MD
;
Linda M. Lambert, PNP
;
Peter C. Kouretas, MD, PhD
and
L. LuAnn Minich, MD
From the Primary Children’s Medical Center, Salt Lake City, Utah.
Correspondence to C. Jerry Jou, DO, PhD, Primary Children’s Medical Center, Department of Pediatric Cardiology, 100 Mario Capecchi Drive, Salt Lake City, Utah 84113-1103. E-mail jerry_jou{at}hotmail.com
 |
Introduction
|
|---|
Pectus excavatum is a common congenital musculoskeletal disease
occurring in approximately 1 in 800 births.
1 Indications for
surgical repair include pain, exercise intolerance, abnormal
pulmonary function, right ventricular (RV) dysfunction, tricuspid
valve compression, and cosmetic enhancement.
2 We present an
unusual case of endocarditis after pectus repair.
A 14-year-old girl presented to the emergency room with a 2-week history of intermittent fever, chills, and pain in the lower parasternum 2 months after pectus excavatum repair. The modified Ravitch technique was used, inserting an 18-cm vitallium strut for stabilization. Physical examination revealed a 3/6 holosystolic midfrequency murmur heard throughout the precordium and an early, short diastolic murmur. Initial laboratory studies demonstrated a mild left shift and elevated inflammatory markers. Chest radiograph demonstrated a normal cardiac silhouette with inferior and posterior displacement of the pectus bar at the level of the RV anterior wall (Figures 1 and 2
). The findings from the ECG were normal. A nuclear medicine white blood cell scan demonstrated nonspecific abnormal increased radiotracer uptake in the mediastinum.
The initial transthoracic echocardiogram demonstrated shadowing
in the RV with mild compression of the RV outflow tract (
Figure 3;
Movie I). Repeat transthoracic and transesophageal echocardiograms
48 hours later demonstrated the presence of a large mobile mass
in the RV outflow with direct compression of the RV anterior
wall by the pectus bar (
Figure 4; Movie II). She was taken to
the operating room and underwent emergent removal of the pectus
bar. An endocardial inflammatory mass involving the septum as
well as the anterior papillary muscle to the tricuspid valve
was debrided, and cultures were obtained (
Figures 5 and 6).
A transmural fistulous track was identified at the RV anterior
free wall, but the pericardium was intact. The intraoperative
surgical debridement and subsequent postoperative course were
uncomplicated. Cultures from the debridement were positive at
110 hours for
Propionibacterium acnes.
View larger version (92K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Transesophageal echocardiographic modified apical 4-chamber imaging plane showing compression of the RV by the pectus bar and the vegetation (arrow). LV indicates left ventricle.
|
|
|
Discussion
|
|---|
The modified Ravitch technique is frequently used for repair
of pectus excavatum. This open technique involves subperichondrial
resection of the costal cartilages, elevation of the sternum,
and stabilization of the repair using a retrosternal strut.
2,3 Complications of pectus excavatum repair by the modified Ravitch
technique include bar displacement, pericarditis, pleural effusion,
pneumonia, pneumothorax, wound seroma, and hematoma.
2
We report endocarditis as a complication of pectus repair after a modified Ravitch procedure, secondary to displacement of the pectus bar in the postoperative period. P acnes is an anaerobic, nonspore forming, Gram-positive bacillus that is part of the normal flora of human skin and rarely causes endocarditis. However, this organism has a predilection for prosthetic valves and other foreign material.4 It is conceivable that the pectus bar was contaminated during the repair, resulting in an infectious process that began in the mediastinum and subsequently involved the pericardium, adjacent epicardium, and finally the endocardium. When the pectus bar became displaced and compressed, the myocardium turbulence across the RV outflow tract may have abraded the endothelium, which provided a nidus for infection. Endocarditis and ongoing compression from the bar likely contributed to the creation of the fistulous tract from the endocardial to the epicardial surface in the presence of an intact pericardium.
This is an unusual case of endocarditis secondary to pectus bar displacement during the postoperative period and emphasizes the need for a high level of suspicion for endocarditis in patients who present with fever and chest pain after pectus repair.
|
Acknowledgments
|
|---|
The authors thank Karen Gollaher for assistance in literature
search and Lance Erickson for the histology slide.
Disclosures
None.
|
Footnotes
|
|---|
The online-only Data Supplement is available at http://circep.ahajournals.org/cgi/content/full/2/1/71/DC1.
|
References
|
|---|
1. Kelly RE, Lawsonb ML, Paidasc CN, Hruban RH. Pectus excavatum in a 112-year autopsy series: anatomic findings and the effect on survival.
J Pediatr Surg. 2005; 40: 1275–1278.
[CrossRef][Medline]2. Fonkalsrud EW, Mendoza J, Finn PJ, Cooper CB. Recent experience with open repair of pectus excavatum with minimal cartilage resection. Arch Surg. 2006; 141: 823–829.[Abstract/Free Full Text]
3. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949; 129: 429–444.[Medline]
4. Zedtwitz-Liebenstein K, Gabriel H, Graninger W. Pacemaker endocarditis due to Propionibacterium acnes. Infection. 2003; 31: 184–185.[Medline]
Top
Introduction
Discussion
