Intracardiac thrombus in a patient with mitral bioprosthesis and atrial fibrillation treated with direct oral anticoaugulant: A case report.

RATIONALE: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity, especially stroke and heart failure. There is also increasing awareness that atrial fibrillation is a major cause of embolic events which in 75% of cases are complicated by cerebrovascular accidents. PATIENT CONCERNS: A 50-year-old woman with mitral bioprosthesis under warfarin for nonvalvular atrial fibrillation was referred to our Coronary Intensive Care Unit due to acute myocardial infarction without evidence of significant coronary artery stenosis. DIAGNOSES: Cardiovascular examination showed an irregular pulse and a grade II diastolic murmur was audible at the apical area. The patient underwent coronary angiography showing absence of obstructive coronary artery disease. We decided to replace Warfarin with direct oral anticoagulants as anticoagulant therapy. INTERVENTIONS: Transoesophageal echocardiography revealed a thrombus in left atrial appendage that was treated by replacing warfarin with an oral direct thrombin inhibitor. OUTCOMES: At 2-month follow-up, the therapy showed to be effective for thrombus resolution. LESSONS: Our case demonstrated how AF has high risk of thromboembolic complications, not only in terms of stroke but also of myocardial infarction and death.The use of direct oral anticoagulants in AF patients with bioprosthetic heart valves is still debated due to an unclear definition of "nonvalvular" AF.

Lethal infective endocarditis due to Streptococcus agalactiae in a man with a history of alcohol abuse: A case report.

RATIONAL: Infective endocarditis (IE) is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium. PATIENT CONCERNS: A 53-years-old man with a history of alcohol abuse was admitted in hospital for fever, paroxysmal atrial fibrillation cardioverted by Amiodarone and pulmonary infection. DIAGNOSIS: A case of recurrent severe endocarditis, with neurological complications both ischemic and hemorrhagic and heart failure caused by Streptococcus agalactiae in healthy man we reported. INTERVENTIONS: Surgery was performed 2 weeks after admission. OUTCOMES: The onset of intracranial hemorrhage delayed second cardiac surgery and the patient died because of end-stage heart failure. CONCLUSIONS: Infective endocarditis caused by S. agalactiae is very rare, particularly in patients without underlying structural heart disease. This study showed that IE due to S. Agalactiae is a disease with high mortality when associated with neurological complication, heart failure but especially when it is recurrent and hits valve prosthesis.

Geometrical and functional cardiac changes after cardiac surgery: a phisiopatological explanation based on speckle tracking.

Cardiac surgery induces geometrical and functional changes, which are not clearly explained. Objective: to investigate the physiopathology of the heart after cardiac surgery using advanced techniques of echocardiography. Thirty patients undergoing cardiac surgery had echocardiographic study prior and after surgery. Left and right ventricular (RV) longitudinal displacement and strain were studied with speckle-tracking. Using longitudinal displacement, we defined a static longitudinal reference-point (sLRP) to which the other segments moved during systole. Transversal displacement and global function were determined by conventional-echo. Left and RV segments showed systolic longitudinal displacement towards the apex, which was the sLRP before surgery; and towards the medium segment of lateral RV-wall one week after surgery. The displacement of basal RV segment towards this sLRP was smaller, causing decreased TAPSE. Apical segments showed an inverse displacement towards the new sLRP, and septum displacement was decreased or inverted towards the lateral RV-wall, causing paradoxus septal motion. RV-wall longitudinal strain was reduced (- 23.1 ± 8.6 vs. - 14.6 ± 5.3;p < 0.001), RV transversal fractional shortening was increased (36.5 ± 10.5 vs. 41.7 ± 13; p = 0.011), and the RV fractional area change was unchanged (46.7 ± 9.5 vs. 47.8 ± 11.7; p = 0.625). The medium segment of RV lateral wall, in contact with sternotomy, remains static after surgery and acts as a new sLRP towards which the rest of segments move, explaining the reduction of TAPSE and paradoxus septal motion. The longitudinal strain of the lateral RV-wall gets impaired, but an increase of transversal motion maintains global RV function.

Stress cardiomyopathies beyond Takotsubo: does a common catecholaminergic pathophysiology fit all?

Diagnostic criteria for Takotsubo cardiomyopathy (TTC) still remains a matter of debate. The similarities between cardiac dysfunction which complicates cerebrovascular events and 'typical' TTC let us hypothesize that the current diagnostic criteria of TTC need to be widened. Moreover, clinical, histological and scintigraphic similarities have been robustly reported between TTC and other Takotsubo-like syndromes, and we agree that central to this unifying hypothesis is a catecholamine surge which triggers the abnormality in left ventricular contraction. Given these overlapping features, we propose that the terms 'acute ballooning cardiomyopathy' or 'catecholamine-induced stress cardiomyopathy' could be used to refer to these conditions in the future.