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From the Department of Anesthesiology, Divisions of *Cardiovascular Anesthesiology, Pediatrics, Cardiothoracic Surgery, and Pediatric Cardiology, University of Arizona College of Medicine, Tucson, Arizona.
Address correspondence and reprint requests to Daniel T. Redford, MD, Associate Professor, Clinical Anesthesiology, Division of Cardiovascular Anesthesiology, Department of Anesthesiology, University of Arizona, PO Box 245114, Tucson, AZ 85724. Address e-mail to Rdaniel29{at}msn.com.
An 11-yr-old girl with acute lymphoblastic leukemia was taken to the operating room for the removal of a left ventricular (LV) mass. Prior transthoracic echocardiography diagnosed a long, peduculated mass attached to the base of a papillary muscle. A differential diagnosis of vegetation (bacterial or fungal) versus a thrombus was entertained. She was therefore treated with broad-spectrum antibiotics, antifungal therapy, and heparin. Despite these interventions, sequential transthoracic echocardiography studies over a 6-day period demonstrated continued growth of the LV mass and the development of LV outflow tract (LVOT) obstruction (peak Doppler velocity 2.2 m/s). Therefore, the decision was made to intervene surgically.
After induction of general anesthesia and placement of arterial and central venous catheters (CVC), a transesophageal echocardiogram (TEE) was performed. The presence of a peduculated vegetation anchored to the chordae tendinae and the posterior-medial papillary muscle of the mitral valve apparatus was confirmed (Figs. 1 and 2). The vegetation was noted to be highly mobile with dynamic extension through the aortic valve annulus during systole and recoiled into the left ventricular (LV) apex in diastole (Video 1; please see video clip available at www.anesthesia-analgesia.org). The vegetation occupied most of the LV outflow tract (LVOT) during systole (vegetation = 12 mm diameter, LVOT diameter = 17 mm), and resulted in LVOT obstruction with peak Doppler velocities of 2.4 m/s, predicting a gradient of 23 mm Hg. The mitral valve motion and function were normal. The remaining cardiac valves appeared normal and no further vegetations or masses were noted. Both ventricles were under-filled with hyperdynamic contractility. Sinus tachycardia (140 bpm) and hypotension (systemic blood pressure 75 mm Hg) were noted with the patient receiving a dopamine infusion at 7.5 µg · kg–1 · min–1. The dopamine was stopped and ventricular preload was augmented with a fluid bolus. Phenylephrine was titrated to maintain mean arterial blood pressure above 55 mm Hg while the patient’s anesthetic depth was increased. These maneuvers decreased the LVOT velocity to <2 m/s before initiation of cardiopulmonary bypass. TEE was used to guide these therapeutic interventions and to ensure that the vegetation had not completely embolized before cardiopulmonary bypass. After successful surgical resection of the LV mass, TEE revealed the LVOT peak gradient was reduced to 6 mm Hg and that the mitral valve and LV function were normal. Pathology and cultures confirmed the mass to be a Candida albicans fungal vegetation. The patient’s postoperative course was complicated by antifungal medication-induced renal failure, decreased mental status, and eventually death from a massive intracranial hemorrhage secondary to a fungal abscess.
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As in adults, the clinical findings of IE in children relate to four underlying phenomena: bacteremia (or fungemia), valvulitis, immunologic response, and emboli.1 Extracardiac manifestations of IE (e.g., petechiae, Roth’s spots, Osler nodes, or splenomegaly) are considerably less common in children than adults. Emboli to the abdominal viscera, the brain, or heart may produce symptoms associated with ischemia, hemorrhage, or both. In rare cases, central nervous system mycotic aneurysms can occur; their rupture can be catastrophic. FE in children is usually caused by Candida and less frequently Aspergillus species. In the past 25 yr, with frequent use of CVCs and high glucose concentration associated with hyperalimentation, Candida infections of the mural or valvular endocardium in infants have been widely recognized.2
The Duke Criteria, published in 1994, aid in the diagnosis of IE.3 The major clinical criteria include persistently positive blood cultures and evidence of endocardial involvement. Echocardiographic findings consistent with IE include: (1) oscillating intracardiac mass, on valves or supporting structures, or in the path of regurgitant jets, or on implanted synthetic material, in the absence of an alternative anatomic explanation, (2) an abscess, (3) new partial dehiscence of prosthetic valve. Modifications to the Duke Criteria were published in 2000 and recommend TEE evaluation in patients with prosthetic valves or complicated IE.4 The higher spatial resolution of TEE versus transthoracic echocardiography yields a higher sensitivity in detecting endocarditis (94%–100% TEE vs 44%–62% transthoracic echocardiography).5
Di Salvo et al. suggested that early surgical intervention may be recommended in patients with large (>15 mm) or highly mobile vegetations detected by TEE. These lesions were approximately three times more likely to embolize than smaller, less mobile vegetations.6
FE generally has a poor prognosis with a mortality rate of 75%–90%.7 To optimize survival in these high risk patients, an early diagnosis, prompt institution of appropriate antifungal therapy and early surgical intervention are paramount.7
Footnotes
This article has supplementary material on the Web site: www.anesthesia-analgesia.org.
Accepted for publication February 25, 2008.
REFERENCES
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