Right-Sided Infective Endocarditis as a Consequence of Flow-Directed Pulmonary-Artery Catheterization

Abstract

We studied 142 consecutively autopsied patients prospectively to determine the frequency and clinical importance of right-sided endocardial lesions in patients who had undergone flow-directed pulmonary-artery catheterization within one month of death. Of the 55 catheterized patients, 29 (53 per cent) had one or more right-sided endocardial lesions: 12 (22 per cent) had subendocardial hemorrhage, 11 (20 per cent) sterile thrombus, 2 (4 per cent) hemorrhage and thrombus, and 4 (7 per cent) infective endocarditis. Of 41 lesions seen in the 29 patients, 23 (56 per cent) were located on the pulmonic valve, 6 (15 per cent) on the tricuspid valve, 6 (15 per cent) in the right atrium, 4 (10 per cent) in the right ventricle, and 2 (5 per cent) in the main pulmonary artery. All four patients with infective endocarditis had had positive antemortem blood cultures while the catheter was in place, but in only one had the diagnosis of endocarditis been suspected clinically. The unusual locations of the infected vegetations (on the pulmonic valve in three and in the right atrium in one) and the similar location of the uninfected lesions suggest that the infective endocarditis was a consequence of catheter-induced endocardial damage with concurrent or subsequent bacteremia. Among the 87 non-catheterized patients, there were two subendocardial hemorrhages and one resolving right atrial thrombus. We conclude that endocardial damage from flow-directed pulmonary-artery catheterization is common and that right-sided infective endocarditis should be suspected in bacteremic catheterized patients.

Isolated Pulmonary Valve Endocarditis

“…Likely explanations include the low pressure gradient within the right heart, lower prevalence of right-sided congenital malformations, lower oxygen content of venous blood, and differences in the covering and vascularization of the right heart endothelium [1]. Risk factors for the development of PVE include intravenous drug abuse (28%), sepsis (19%), alcoholism (13%), S. aureus infection (44%) [4] and central venous and Swan-Ganz catheters [5,6]. On the contrary, 28% of PVE has no predisposing factors [7].…”

Pulmonic valve endocarditis after orthotopic liver transplantation

“…4,6 Right-sided valvular endocarditis also occurs in patients in intensive care units who have undergone prolonged monitoring with an indwelling catheter across the tricuspid or pulmonic valve, or both. 7 Persistent bacteremia despite appropriate antibiotic therapy in the presence of a large mobile vegetation is an indication for surgical intervention. In the presence of preserved native valve structure and function, removal of the vegetation (vegetectomy) results in a cure.…”

Echocardiographic demonstration of pulmonary valve endocarditis associated with congenital ventricular septal defect.

“…'2 Indwelling catheters can cause endothelial damage; in Rowley et al's study of 55 patients dying after right heart catheterisation, three had vegetations on the pulmonary valve. 6 The endothelium can also be damaged by a high velocity blood jet. In Gersony and Hayes's series, five patients had subacute bacterial endocarditis associated with a ventricular septal defect, two with vegetations around the margin of the defect and three with vegetations on the aortic valve, one of whom had additional lesions on the tricuspid and pulmonary valves.…”