Recurrent Embolic Strokes in a Young Patient - a Case of Late Tavr Thrombosis and Endocarditis

Background Late complications of transcatheter aortic valve replacement (TAVR) are uncommon. We present a patient two-years post TAVR with recurrent strokes. Case A 56-year-old male with history of TAVR and pacemaker first presented with left-sided weakness found to have acute right MCA strokes and COVID. TTE showed a non-thickened valve with normal gradients and device interrogation revealed no arrhythmias. Six months later, he presented with acute left MCA strokes as well as new murmur, leukocytosis, and splenic infarcts on CT. TTE demonstrated a prosthetic aortic valve mean gradient of 43mmHg. TEE confirmed leaflet thrombosis with severe prosthetic aortic stenosis and mobile thrombus (Figure 1). Multiple sets of blood cultures were negative. Decision-making He was first treated with therapeutic anticoagulation but switched to broad spectrum antibiotics with increasing evidence for infection. He underwent Ross procedure with intra-operative evidence of multiple aortic root abscesses (Figure 1). PCR sequencing of the vegetation revealed staphylococcus species related to S. Haemolyticus. His course may be best explained by embolic stroke caused by progressive TAVR thrombosis in the setting of COVID-associated coagulopathy and subsequent superinfection leading to endocarditis and septic emboli. Conclusion Late TAVR thrombosis and endocarditis are rare complications. TAVR patients presenting with stroke merit prompt evaluation with dedicated echocardiographic imaging. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Possible reflex sympathetic dystrophy secondary to 'COVID toes'

A 51-year-old woman presented acutely to dermatology with an 8-week history of painful, purple discolouration of her toes, which started on her left foot but progressed to involve all of her toes. She was noted to have a positive COVID-19 polymerase chain reaction test after her symptoms began. There was some superficial ulceration of two of her toes. The episode lasted for 5 weeks;however, after 6 weeks her toes had flared again. No triggers were indentified;in particular, her symptoms were not related to the cold. There were no other rashes. She has a past medical history of endometriosis and gout. She takes desogestrel and allopurinol, which she had been on for 2 years. Vasculitis screen was negative. She was treated initially with clobetasol propionate and nifedipine. On follow-up 6 weeks later, the patient reported hypersensitivity of her toes, with severe pain reported from socks rubbing against her toes. The toes had normal appearances and cool peripheries. We suspect that the increased sensitivity and pain is a reflex sympathetic response secondary to 'COVID toes' and have treated with it gabapentin. It is thought that reflex sympathetic dystrophy occurs because inflammation causes damage to the nerves;however, the exact mechanism behind reflex sympathetic dystrophy is yet to be elucidated.