A Case of Right Side Infective Endocarditis in Patient with Ventricular Septal Defect

A 25-years old white female was admitted to our emergency department presenting with dyspnea, fever, cough and nausea. Her medical background included a small ventricular septal defect (VSD) (congenital) with a left to right shunt, micropolicistic ovary syndrome, Sars Cov 2 infection on January 2022, history of cutaneous infection after sternal piercing in the last three years. Patient showed onset of fever, headache and nausea since 20 days and had a history of ampicillin and cephalosporin usage for 15 days for comunitary pneumonia. Upon arrival in the emergency room, physical examination revealed temperature 38degreeC, crackles on down right lung fields, regular but tachycardic rhythm, 3/6 holosystolic murmur in the third left intercostal space, also skin redness around the piercing zone. Laboratory test showed increasing of WB (white blood cells), C-reactive protein (CPR) and procalcitonin. Because of worsening of respiratory conditions, CTchest was performed, showing tree in bud sign, with pulmonary pattern suggestive of staphylococcal "emboligenous-like infectious state. According to patient's clinical history and CT results, she was referred to transthoracic echocardiogram (TTE) demonstrating the presence, on the right side of the small VSD, of a isoechoic large mass (20x 13 mm) with irregular margins attached to the right ventricular wall near the ostium of the VSD, compatible with vegetation;septal tricuspid valve leaflet involvement could not be ruled out. Methicillin-susceptible Staphylococcus aureus (MSSA) was detected six times from blood cultures;therapy with oxacillin 2 gr every 4 hours combined with daptomycin 750 mg daily was started. Cardiac MRI performed after few days, documented the infective involvement of the ventricular and atrial side of the septal leaflet with moderate tricuspid regurgitation (TR). Congenital heart disease (especially Tetralogy of Fallot, bicuspid aortic valve, aortic coarctation, ventricular septal defect) is a lifelong risk factor for infective endocarditis (IE). Size of VSD is generally not correlated with IE that is directly correlated with turbulent flow;tricuspid valve involvement is mostly seen in VSD, often complicated by pulmonary embolism. In this predisposing situation, skin infection of the piercing zone could have caused transient bacteremia which led to the formation of vegetations in the highest turbulence flow zone..

Complex Case of Endocarditis Post-COVID Infection

A 42-year-old man presented to hospital with fever, dyspnea and fatigue. In the previous days he reported illness and cough and he had not received the vaccination for COVID-19. Moreover, he had a bicuspid aortic valve with mild insufficiency. Blood tests showed raised inflammatory markers and leukocytosis;high-sensitivity cardiac troponin T and natriuretic peptides were also elevated. Serological tests showed a recent COVID-19 infection, but the nasopharyngeal test was negative. A transesophageal echocardiogram was performed showing moderate reduction in the systolic function of the left ventricle, an aneurysm of the aortic root (52mm) and endocarditis of the aortic valve with severe insufficiency and an abscess on the mitro-aortic junction. So, he was started on empirical antibiotic therapy. For the development of multiorgan failure it was decided to replace the aortic valve, the root and the ascending aorta according to Bentall technique. The bacteriological research on blood and surgical material was negative. During rehabilitation there was a new clinical worsening with raised inflammatory markers and fever. An aortic CT angiography and a transesophageal echocardiogram were performed with evidence of a para-aortic contrast medium collection and a fistula of the prosthetic tube. The patient was then transferred to another cardiac center for a new surgery. It is important to be vigilant for the possible cardiovascular complications of COVID-19, including infective endocarditis. Early diagnosis is the corner stone for early treatment and multimodality imaging has a central role.

Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.

Objectives: Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement. Methods: From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients. Results: Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019. Conclusions: Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Myocardial Fitness of Bicuspid Aortic Valve Athletes during COVID 19 Pandemic.

COVID 19 pandemic has induced a large sedentarism in several kinds of sports. Some peculiar categories of athletes could particularly suffer from a prolonged inactivity as those affected by minimal cardiopathies as bicuspid aortic valve (BAV) athletes. This study aims to verify the myocardial performance in a restricted group of BAV athletes compared to a control group of agonistic athletes evaluated by traditional echocardiography and deformation parameters. 2D standard and deformations parameters were measured at rest conditions in BAV athletes and controls. Particularly EF, LVDD/LVS diameters, GLS rotation and twisting were considered as myocardial performance data; E/A, E1 and A1 as diastolic ones. All the 2D standard parameters measured were within the normal range in both groups, especially the EF value. Significant differences were found in the diastolic function with reduced values of E and E1 waves in BAV vs. controls. The strain analysis showed a significant reduction in GLS measured in 2C, 3C, 4C in BAV if compared to controls, while no significant differences were found in torsional and rotational parameters. These results are suggestive for a potential long term negative impact of inactivity on cardiac performance more evident in BAV athletes, if compared to athletes with normal aortic valve. GLS of LV and RV can be considered as a predictive parameter of this mild dysfunction and assumed as follow-up parameter to restore a progressive training.

30th Annual Scientific Meeting of Indonesian Heart Association (ASMIHA)

The proceedings contain 200 papers. The topics discussed include: an ultra-rare case of Hutchinson-Gilford progeria syndrome with severe aortic regurgitation due to bicuspid aortic valve in a 9-year-old girl;pulse dose corticosteroid improves clinical outcome in pulmonary hypertension patient: a potential of immense affordability and availability medication in suburban area;infected femoral artery pseudoaneurysm with klebsiella pneumoniae bacteremia in injected drug abuser: a case report;cardiac complications in immunocompromised patient : a case report;cardiac arrest in COVID-19 patient presenting with takotsubo cardiomyopathy;cardiac amyloidosis: a great pretender of left ventricular hypertrophy with systemic manifestation;and managing acute decompensated heart failure with exacerbation of chronic obstructive pulmonary disease in rural area: a case report.