Ventilatory Failure And Pulmonary Embolism In Covid-19 Requiring Enhanced Venous Drainage For Extracorporeal Membrane Oxygenation.

COVID-19 infection manifests as a spectrum of respiratory and vascular complications, including acute respiratory distress syndrome (ARDS) and pulmonary embolism. Herein, we describe a case of a healthy young male who presented with ARDS refractory to mechanical ventilation and concomitant bilateral pulmonary emboli managed with extracorporeal membrane oxygenation (ECMO) and embolectomy. The embolectomy and initial veno-venous ECMO configuration failed to correct the patient's hypoxemia despite maximal flows. This was thought to be due to a high-output state secondary to vasodilatory shock preventing adequate drainage from the existing single drainage ECMO cannulation, following which a second venous cannula was placed to form a unique veno-veno-venous ECMO circuit that resolved the persistent hypoxemia. The case underscores the importance of identifying embolic events and vasodilatory shock in COVID-19 patients, both of which need to be addressed simultaneously to avoid worsening right ventricular failure (via both mechanical and hypoxia-driven pathways) and the resulting veno-arterial ECMO along with its associated complications.

LEUKOCYTOCLASTIC VASCULITIS IN MITRAL VALVE ENDOCARDITIS

Background: Vasculitis is a known, although not commonly observed, manifestation of bacterial endocarditis. It is imperative that diagnosis is made promptly and appropriately treated, as vasculitis can often be painful and uncomfortable for patients. Case: 75-year-old male is admitted to the hospital for Coronavirus Disease 2019 (COVID-19). Several weeks after recovering from his respiratory infection, patient developed a diffuse, purpuric rash that began on his forearms and gradually spread throughout his bilateral upper extremities to his hands and fingers, as well as to his shoulders and lateral chest. Skin biopsy was performed and revealed findings suggestive of leukocytoclastic vasculitis. Blood work revealed Methicillin Resistant Staph Aureus (MRSA) bacteremia, sensitive to Vancomycin. Transthoracic echocardiogram revealed native mitral valve endocarditis. Transesophageal echocardiogram was not performed due to patient's underlying comorbidities and high risk. Decision-making: Patient was diagnosed with leukocytoclastic vasculitis secondary to bacterial endocarditis. Rheumatologic workup, including antineutrophil cytoplasmic antibodies, antinuclear antibodies, serum complement levels, anti-smith antibodies and double stranded deoxyribonucleic acid, was negative. Patient was ultimately discharged on a prolonged course of Vancomycin and his diffuse rash resolved one month later. Conclusion: There are only a few case reports describing the direct association between leukocytoclastic vasculitis and infective endocarditis. It is important to consider the association of vasculitis and endocarditis in order to effectively treat because immunosuppression, particularly with steroids, is the gold standard treatment for vasculitis. Our patient experienced near complete resolution of the rash after completion of antibiotics and no other therapy was deemed necessary.

Epidemiology of infective endocarditis: novel aspects in the twenty-first century.

INTRODUCTION: The epidemiology of infective endocarditis (IE) in this millennium has changed with emergence of new risk factors and reemergence of others. This, coupled with modifications in national guidelines in the setting of a pandemic, prompted an address of the topic. AREAS COVERED: Our goal is to provide a contemporary review of IE epidemiology considering changing incidence of rheumatic heart disease (RHD), cardiac device implantation, and injection drug use (IDU), with SARS-CoV-2 pandemic as the backdrop. METHODS: PubMed and Google Scholar were used to identify studies of interest. EXPERT OPINION: Our experience over the past two decades verifies the notion that there is not one 'textbook' profile of IE. Multiple factors have dramatically impacted IE epidemiology, and these factors differ, based, in part on geography. RHD has declined in many areas of the world, whereas implanted cardiovascular devices-related IE has grown exponentially. Perhaps the most influential, at least in areas of the United States, is injection drug use complicating the opioid epidemic. Healthy younger individuals contracting a potentially life-threatening infection has been tragic. In the past year, epidemiological changes due to the COVID-19 pandemic have also occurred. No doubt, changes will characterize IE in the future and serial review of the topic is warranted.

Escalating incidence of infective endocarditis in Europe in the 21st century.

AIM: To provide a contemporary analysis of incidence trends of infective endocarditis (IE) with its changing epidemiology over the past two decades in Europe. METHODS: A systematic review was conducted at the Mayo Clinic, Rochester. Ovid EBM Reviews, Ovid Embase, Ovid Medline, Scopus and Web of Science were searched for studies published between 1 January 2000 and 30 November 2020. All studies were independently reviewed by four referees and those that included a population-based incidence of IE in patients, irrespective of age, in Europe were included. Least squares regression was used to estimate pooled temporal trends in IE incidence. RESULTS: Of 9138 articles screened, 18 studies were included in the review. Elderly men predominated in all studies. IE incidence increased 4.1% per year (95% CI 1.8% to 6.4%) in the pooled regression analysis of eight studies that included comprehensive and consistent trends data. When trends data were weighted according to population size of individual countries, an increase in yearly incidence of 0.27 cases per 100 000 people was observed. Staphylococci and streptococci were the most common pathogens identified. The rate of surgical intervention ranged from 10.2% to 60.0%, and the rate of inpatient mortality ranged from 14.3% to 17.5%. In six studies that examined the rate of injection drug use, five of them reported a rate of less than 10%. CONCLUSION: Based on findings from our systematic review, IE incidence in Europe has doubled over the past two decades in Europe. Multiple factors are likely responsible for this striking increase. TRIAL REGISTERATION NUMBER: CRD42020191196.