Complicated Native Aortic Valve Endocarditis: Complexities of Medical Optimisation Prior to Surgical Repair for Large Vegetations With Systemic Emboli.

A 43-year-old male with no history of valvular disease but ongoing intravenous drug use presented with acute confusion, pyrexia, and Osler's nodes. Transthoracic echocardiography uncovered a large 17 x 15 mm-sized vegetation on the aortic valve, causing moderate-to-severe aortic regurgitation. Subsequent multi-organ compromise and complexities regarding treatment adherence delayed surgical intervention; thus, six weeks of antibiotic therapy and medical optimisation, in close collaboration with cardiology, microbiology, and cardiothoracic teams, enabled definitive aortic valve repair to be performed. This case highlights the challenges encountered when managing this life-threatening condition and the obstacles of enacting the guidelines recommendations regarding the timing of surgical intervention. Our case portrays the effectiveness of medical management as bridge-to-surgery in patients not in a position to undergo immediate surgical repair.

TAVI and the future of aortic valve replacement.

Aortic valve stenosis (AS) is the most common valvular pathology and has traditionally been managed using surgical aortic valve replacement (SAVR). A large proportion of affected patient demographics, however, are unfit to undergo major surgery given underlying comorbidities. Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has gained popularity and transformed the care available to different-risk group patients with severe symptomatic AS. Specific qualifying criteria and refinement of TAVI techniques are fundamental in determining successful outcomes for intervention. Given the successful applicability in high-risk patients, TAVI has been further developed and trialed in intermediate and low-risk patients. Within intermediate-risk patient groups, TAVI was shown to be noninferior to SAVR evaluating 30-d mortality and secondary endpoints such as the risk of bleeding, development of acute kidney injury, and length of admission. The feasibility of expanding TAVI procedures into low-risk patients is still a controversial topic in the literature. A number of trials have recently been published which demonstrate TAVI as noninferior and even superior over SAVR for primary study endpoints.

Is contrast-enhanced ultrasound (CEUS) superior to computed tomography angiography (CTA) in detection of endoleaks in post-EVAR patients? A systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to assess the sensitivity and specificity of contrast-enhanced ultrasound (CEUS) compared to computed tomography angiography (CTA) for the detection of endoleaks within endovascular aortic aneurysm repair (EVAR) surveillance at time of follow up. METHODS: A comprehensive literature search was undertaken among the four major databases (PubMed, Embase, Scopus and Ovid) to identify all articles assessing diagnostic specificity and accuracy with comparative modality (CEUS vs CTA) for endoleaks in adult patients at time of follow-up following EVAR. Databases where evaluated and assessed to October 2018. RESULTS: A total of 1773 patients were analysed from across 18 included studies in the quantitative analysis of the parameters of interest. There was no significant difference in detection rate of endoleak type I with detection rate 4.3% for both groups OR 1.09, 95% CI [0.78, 1.53], p = 0.62; type II endoleak detection rate was 22% in the CEUS group vs 23% in the CTA group OR 1.16, 95% CI [0.75-1.79], p = 0.50; while type III detection rate was 1.8% in CEUS group vs 2% in CTA group OR 0.85, 95% CI [0.43, 1.68], p = 0.64. However, the sensitivity rate for endoleak detection was higher in CEUS (p = 0.001) while no difference in specificity rate was noted (p = 0.28). There was higher rate of missed endoleaks in CTA groups (n = 12 vs n = 20). CONCLUSION: Evidences from this study suggest that contrast-enhanced ultrasound scan post-EVAR can be utilised as safe and effective method in screening for endoleaks during post-EVAR surveillance without exposing the patient for additional risk of radiation and contrast. CEUS conveys no inferiority to CTA in detecting endoleaks.

Presentation of papillary fibroelastoma of the aortic valve with atypical symptoms.

Papillary fibroelastomas are rare benign tumours arising from the cardiac endothelium. The rationale behind the treatment of fibroelastomas is to eliminate the risk of embolic events and the associated morbidity and mortality. These tumours present predominantly in males during the seventh decade of life and most commonly affect the aortic valve. We report a case of aortic valve papillary fibroelastoma with an atypical clinical presentation, treated with valve-sparing surgical excision. Our case highlights the management of this rare but serious condition and emphasises the need to develop clear guidelines regarding the treatment of asymptomatic patients with a papillary fibroelastoma.