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Complete cure with medical treatment of prosthetic mitral valve endocarditis, which is initially diagnosed as mitral valve thrombus/Baslangicta mitral kapak trombusu tanisi konulup medikal tedavi ile tam iyilesme saglanan yapay mitral kapak endokarditi.

Dear Editor,

A 59-year-old male patient was admitted to hospital with a complaint of fatigue and anorexia. He underwent mitral valve replacement operation nine months before the presentation. After the operation, patient attended control examinations irregularly. On admission; his blood pressure, heart rate and body temperature were within the normal range. Physical examination was also normal except prosthetic valve sound on auscultation. Electrocardiogram showed normal sinus rhythm and first laboratory findings were as following: INR; 1.64, prothrombin time: 21.8 second, sedimentation rate: 83 mm/h, hemoglobin: 13.9 gr/dl, hematocrit: 41.8%, platelets: 278000/[mm.sup.3], white blood cells: 11200/[mm.sup.3] with 82% of granulocytes. Transthoracic echocardiography revealed thrombus at the edge of prosthetic valve. Transesophageal echocardiography (TEE) displayed multiple and mobile with a maximum of 1.4x0.4 cm sized thrombus at sutured site of prosthetic valve (Fig. 1). During first 3 days, patient was managed with warfarin and unfractionated heparin. Despite 3-day heparin infusion, control TEE did not show any regression in thrombus size. After that, 50 mg of alteplase was infused with a 4 mg/h dosage. TEE revealed mild regression in the thrombus size after thrombolytic therapy (Fig. 2). However, 24 hours after alteplase infusion, prominent fever, malaise and deterioration of consciousness were observed. Infective endocarditis was thought as possible diagnosis and eight tubes of blood culture was taken. Then, methicillin resistant Staphylococcus aureus was isolated in the four specimens as causative microorganism although first two specimens that had been taken during initial evaluation were clear. After six-weeks of antibiotics treatment, control TEE was free of the thrombus and/or vegetation (Fig. 3) and patient was discharged from hospital with a complete cure of prosthetic valve endocarditis (PVE).

PVE is associated with a high mortality rate despite diagnostic and therapeutic improvements. It's incidence is increasing and reaches 20-30% of all infective endocarditis episodes. PVE is a common indication for surgery (1,2). Complete cure with medical therapy was reported up to 20% of selected cases (2,3). TEE is a standard method for diagnosis of PVE. However, differentiation of thrombus and vegetation in the prosthetic valves could be difficult in the atypical presentation as our case (4). In such cases, final diagnosis usually is made according to clinical picture (5). Suspicion of endocarditis in such cases could prevent overlooked diagnosis of endocarditis. In the progression of our case, we thought that, initial thrombolytic therapy elicit the clinical signs of endocarditis. Thrombolytics could clear the surface of vegetation from covering thrombus and direct exposing of vegetation surface can lead to development of fever and other signs of endocarditis. Thrombolytic therapy may also enhance the effect of antibiotics via cleaning of thrombus coat, and by the way, antibiotics could penetrate inside of vegetation more easily.




In conclusion, thrombolytic treatment is not medical fault in the atypical cases of PVE in which differential diagnosis from thrombus could not be done. Rarely, thrombus coat can accompany vegetation in PVE cases and combined therapy with thrombolytics and antibiotics could yield complete cure without any need of surgery.



(1.) Nataloni M, Pergolini M, Rescigno G, Mocchegiani R. Prosthetic valve endocarditis. J Cardiovas Med (Hagerstown). 2010; 11: 869-83.

(2.) Revilla A, Lopez J, Sevilla T, Villacorta E, Sarria C, Manzano Mdel C, et al. In-hospital prognosis of prosthetic valve endocarditis after urgent surgery. Rev Esp Cardiol 2009; 62:1388-94.

(3.) Truninger K, Attenhofer Jost CH, Seifert B, Vogt PR, Follath F, Schaffner A, et al. Long-term follow up of prosthetic valve endocarditis: what characteristics identify patients who were treated successfully with antibiotics alone? Heart 1999; 82: 714-20.

(4.) Alonso-Valle H, Farinas-Alvarez C, Garcia-Palomo JD, Bernal JM, Martin-Duran R, Gutierrez Diez JF, et al. Clinical course and predictors of death in prosthetic valve endocarditis over a 20-year period. J Thorac Cardiovasc Surg 2010; 139: 887-93.

(5.) Lengyel M, Horstkotte D, VSIIer H, Mistiaen WP; Working Group Infection, Thrombosis, Embolism and Bleeding of the Society for Heart Valve Disease. Recommendations for the management of prosthetic valve thrombosis. J Heart Valve Dis 2005; 14: 567-75.

Ahmet Karabulut, Ozgur Surgit [1], Ozgur Akgul [1], Aydin Yildirim [1]

Clinic of Cardiology, Istanbul Medicine Hospital, Istanbul

[1] Clinic of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Center,

Training and Research Hospital, Istanbul--Turkey

Address for Correspondence/Yazisma Adresi: Dr. Ahmet Karabulut Hoca Ahmet Yesevi Cad. No:149, 34203 Bagcilar, Istanbul-Turtev Phone: +90 212 489 08 00 Fax: +90 212 474 36 94 E-mail: Available Online Date/Cevrimici Yayin Tarihi: 11.08.2011
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Author:Karabulut, Ahmet; Surgit, Ozgur; Akgul, Ozgur; Yildirim, Aydin
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Sep 1, 2011
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