Introduction

Brucellosis shows various clinical signs and can affect different organs.Although rare,endocarditis is important due to its fatality potential (1). Brucella endocarditis had been first reported in 1906, but surgical approach as a treatment modality has been introduced in 1964(2).Immediate surgery after medical treatment is very important because delaying surgery may lead to that are difficult to repair(3).

Case Presentation

Our case was a 46-year-old male. He was an employee in animal husbandry. His chief complaints were fatigue and dyspnea for 2 months. After his admission to our institution he was diagnosed as brucella endocarditis and severe aortic regurgitation. Antibiotic regimen with two agents was completed to 6 weeks of duration. Transthoracic echocardiography revealed severe aortic regurgitation with left ventricular hypertrophy (63/44 mm). Moreover, at supravalvular level of the aortic valve, a vegetative mass of 1.5x0.6 cm was detected. Another mobile and calcified vegetative mass of 0.5x0.8 cm was located on the left coronary cusp. Pulmonary arterial pressure was measured as 55 mm Hg and moderate tricuspid regurgitation was identified. The remaining valvular structures were normal.

With these findings, we brought our patient into the operating room. We carefully performed median sternotomy and routine cannulation with minimal manipulation.Arrest was achieved with moderate hypothermia of 28˚c,and incompressive retrograde isothermic potassiumed blood cardioplegia.Following aortotomy we explored; a normal left coronary cusp. On the other hand; there were vegetation, lysis of the leaflet and commissural destruction with excessive inflammation identified next to the commissure between right and non-coronary cusps (Figures 1 & 2).

Figure 1

Figure 1

Figure 2

Figure 2

A similar situation was also detectable between non-coronary and right coronary cusps. In addition, in the midportion of the right coronary cusp close to the annulus, a perforation of 1x1 cm was present (Figure 3).

Figure 3

Figure 3

A different vegetation of 0.6x0.6 cm was detected on the ventricular face of the non-coronary cusp (Figure 4).

Figure 4

Figure 4

Since its repair was unsuitable, the native valve was resected and a 21 mm St. Jude mechanical bileaflet valve was replaced using pledgeted horizontal mattress sutures. No additional problem was seen postoperatively and he was discharged on 8^th postoperative day with surgical cure and outpatient clinic follow was recommended. It was planned to continue the triple antibiotherapy regimen for 4 more weeks. He is still symptom-free and the valve functions are good in control TTE.

Discussion

Brucellosis is caused by Brucella organisms and acquired by direct contact of infected animals or indirectly by ingesting unpasteurized milk and products of milk(2,3). Generally aortic valve invasion is seen. Brucella endocarditis appears with a long-lasting subfebrile body temperature and a delayed (3 to 11 months afterwards) severe dysfunction occurring in aortic valve (4).

Such as Staph. Aureus,Serratia sp,Pseudomonas sp and Candida sp,Brucella sp also injure the tissues(2,5).Infective endocarditis injures the valve and causes insufficiency flow(1,6). Situations like leaflet perforation (ranging from small perforations to flail leaflets), rupture of paravalvular abscess, cardiac fistula and leaflet prolapsus due to rupture of commissure are responsible for acute valve insufficieny (6,7) .

Echocardiography is very important to determine the treatment protocol,and the morbidity and mortality rates in all infective endocarditis,including Brucellosis(3,5).It is a cheap,easy to use,noninvasive and reproducible method.

Brucella endocarditis does not show remission and has a high mortality if not treated(1).

Medical treatment alone is unsuccessful for Brucella endocarditis and surgery is necessary(2,8). This microorganism,which is adapted to the intracellular course,shows resistance to medication and shows recurrence that is actually not low(3,9).The most effective option is antibiotic and surgery combination. Combination of antibiotic therapy and mechanical valve replacement has a satisfactory result.Early and late reinfection incidence of mechanical valve replacement can be compared with the results and survival expectations of homografts and tissue valves (10).

The bacteria in Brucella endocarditis survive because they are in the intracellular compartment(3).For this reason, during the postoperative period, at least 4 weeks of duration of antibiotic use has a positive effect on survival (11). We used surgical debridement and mechanical valve replacement and added double antibiotherapy for 2 to 6 months.

In conclusion; echocardiography is very important for diagnosis(1). Since the valve injury is severe,surgical therapy must be combined with optimal antibiotherapy for a successful radical therapy and long-term life quality(12). Surgical approach increases the quality of life for a long period in this type endocarditis(9).