title: Echocardiographic presentations of endocarditis, and risk factors for rupture of a sinus of Valsalva in childhood.
abstract: BACKGROUND
  In recent years, the diagnosis of infective endocarditis has been enhanced by the use of echocardiography. We sought, therefore, to review its effect on the management of endocarditis in children.
  
  
  METHODS
  We reviewed all the patients presenting to our institution for evaluation for infective endocarditis from May 1994 to January 2002. The patients were stratified according to whether or not they had congenitally malformed hearts.
  
  
  RESULTS
  Of the 90 referred patients identified, 46 (51%) had positive ultrasonic findings. Of these, we excluded 26 patients because of the presence of indwelling lines. The remaining 20 patients with features of endocarditis had a median age of 6.5 years, and a range from 0.14 to 8.5 years. There were 4 patients with normal hearts, and 16 with congenital cardiac malformations. We identified rupture of a sinus of Valsalva in four patients, with rupture into the left ventricle in two, and into the right ventricle and right atrium in one each. The mitral valve was involved in six patients, the aortic valve in another six, including all four with rupture of the sinus of Valsalva, both mitral and aortic valves in three, the pulmonary trunk in three patients, and the tricuspid valve and a Blalock-Taussig shunt in one patient each. Organisms isolated included Streptococcus mitis in 4 patients, Streptococcus pneumoniae in 2 patients, Streptococcus sanguis in 1, Staphylococcus aureus in 3, Staphylococcus epidermidis in 1, and Enteroccocus in 2. Cultures proved negative in 7 patients. Surgical intervention was needed in 12 patients, and one died (5%). Only the left-sided chambers were involved in those with normal hearts. Both patients infected with Streptococcus pneumoniae had rupture of a sinus of Valsalva.
  
  
  CONCLUSIONS
  Involvement of the left-sided chambers is more likely in structurally normal hearts, and in cases with rupture of a sinus of Valsalva, in which case infection with Streptococcus pneumonia should be suspected.
authors.affiliation: Lille Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas 77030, USA. cmcmahon@bcm.tmc.edu
authors.forename: Colin J
authors.initials: CJ
authors.lastname: McMahon
authors.forename: Nancy
authors.initials: N
authors.lastname: Ayres
authors.forename: Ricardo H
authors.initials: RH
authors.lastname: Pignatelli
authors.forename: Wayne
authors.initials: W
authors.lastname: Franklin
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Vargo
authors.forename: J Timothy
authors.initials: JT
authors.lastname: Bricker
authors.forename: Howaida G
authors.initials: HG
authors.lastname: El-Said
mesh_terms: D001019:Aortic Rupture / Q000175:diagnosis*; D002648:Child; D002675:Child, Preschool; D004452:Echocardiography; D004697:Endocarditis, Bacterial / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000382:microbiology; D006330:Heart Defects, Congenital / Q000000981:diagnostic imaging; D006801:Humans; D007223:Infant; D012189:Retrospective Studies; D012307:Risk Factors; D012850:Sinus of Valsalva