Emergency Aortic Valve Replacement in Brucella Endocarditis: Report of Two Cases Alberto Juffe, M.D., Julio Montes, M.D., Carlos G. Montero, M.D., Raul Burgos, M.D., Manuel S. Moya, M.D., Teodoro Martin, M.D., Valentin Cuervas, M.D., and Diego Figuera, M.D. T WO PATIENTS with acute infective endocarditis from Brucella are re- ported. Diagnosis was made solely on the basis of echocardiographic findings, and emergency valve replacement was success- fully accomplished in both patients. Since fatal valvular deterioration can oc- cur in patients when Brucella with infec- tive endocarditis causes valve regurgita- tion, immediate valve replacement is recommended. Case Reports Case 1 A 62-year-old man was diagnosed as having brucellosis 14 months prior to ad- mission, at which time he was started on a regimen of Aureomycin (chloretetracy- cline) and streptomycin sulfate. Micro- scopic examination of the hepatic biopsy at that time disclosed a sparse inflammatory infiltrate of lymphocytes, histiocytes, and marked hyperplasia of Kupffer's cells. Brucella was considered to be the causative agent of the process. The patient suddenly developed severe dyspnea, malaise, chills and sweating, and he was transferred to the intensive care unit. On admission, his cardiac output was low; blood pressure was 130/70 mm Hg, and pulse rate was 140 B/minute. Cardiac auscultation disclosed a Grade 3/6 diastol- ic murmur in the aortic area. A chest roentgenogram disclosed a pattern of in- terstitial pulmonary edema, and the elec- trocardiogram showed normal sinus rhythm. An echocardiogram suggested the presence of severe aortic regurgitation and vegetations on the aortic valve. Because acute infective endocarditis was suspected, multiple blood cultures were taken, which were positive for Brucella melitensis. In the light of these findings and the patient's clinical deterioration, an emergency aortic valve replacement was performed. After institution of cardiopulmonary bypass, the aorta was incised, disclosing a severely damaged aortic valve involved in a process of acute infective endocarditis (Fig. 1A and B). The valve was excised and re- placed with a No. 25 Bjork-Shiley valve prosthesis. The excised valve showed an acute in- flammatory infiltrate with mucopolysac- charide and granulomatous formations. After an uneventful recovery, the patient was discharged on a regimen of doxycy- cline (100 mg/day), Ryfampycin* (900 mg/ day), and streptomycin sulfate (1 gm/day) for 6 weeks. He is well and free of symp- toms 15 months after surgery. From the Clinica de Hierro, San Martin de Pores 4, Madrid, Spain. * Rifampin in the United States. Addressfor reprints: A. Juffe, M.D., Clinica Puerta de Hierro, Cardiovascular Surgery, San Martin de Pores 4, Madrid 35, Spain. Texas Heart Institute Joum3l 315