A "fishy" situation, rare pathogen and presentation in prosthetic valve infective endocarditis.

Lactococcus garviae (L. garviae) is a gram-positive coccus belonging to the Streptococcaceae family. While primarily a pathogen in fish farms causing hemorrhagic sepsis, it can act as a rare opportunistic pathogen in humans. A 2021 case report by Bravo et al. documented less than 30 cases of infective endocarditis caused by L. garviae worldwide at that time [1]. This case report describes the 27th documented case globally and 7th documented case in the USA of L. garviae causing infective endocarditis of a prosthetic valve [1]. L. garviae is found in unpasteurized dairy products, raw fish, and meat (pork, beef, and poultry), but the route of human transmission remains unclear [3]. It seems to have a predilection for individuals with prosthetic valves, immunocompromised states, prior gastrointestinal surgery, gastrointestinal disorders (colon polyps and diverticulosis), and the use of acid-reducing medications [1-3]. Infective endocarditis is the most common systemic disease caused by L. garviae [1-4]. This report details the case of a 75-year-old male, with multiple comorbidities and risk factors for L. garviae infection who was admitted for "symptomatic anemia". High clinical suspicion, coupled with an inadequate hemoglobin response to transfusion, a normal anemia workup, and blood cultures positive for L. garviae, promoted a transesophageal echocardiogram (TEE). However, the results were negative. Consequently, an 18F-fluorodeoxyglucose positron emission tomography/computed tomography scan (18FDG PET/CT) was performed. The scan revealed increased uptake in the aortic valve replacement consistent with prosthetic valve endocarditis in the setting of Lactococcus garviae bacteremia.

Trends and Outcomes of Left Atrial Appendage Occlusion in Renal and Liver Transplant Recipients: Insights From the United States National Inpatient and Readmission Database.

Left atrial appendage occlusion using the Watchman device has emerged as an alternative treatment strategy for preventing strokes in patients with atrial fibrillation. However, there is no data on its safety and clinical outcomes in prior renal or liver transplant recipients. We included a total of 61,995 patients from the National Inpatient Sample (NIS, in-hospital outcomes) and 55,048 patients from the National Readmission Database (NRD, 30-day outcomes) who underwent percutaneous left atrial appendage occlusion (LAAO). From this group, 0.65% (n=405) and 0.62% (n=339) were renal and liver transplant recipients in NIS and NRD respectively. Transplant recipients were younger compared with non-transplant recipients (mean age 69 vs 77 years, P=<0.01). There was little difference in terms of in-hospital mortality (0% vs 0.2%, P=0.43), major complications (6.2% vs 5.6%, P=0.61), cardiovascular complications (2.5% vs 2.8%, P=0.73), neurological complications (1.2% vs 0.7%, P=0.21) or bleeding complications (1.2% vs 0.7%, P=0.99) between transplant vs. non-transplant patients. Based on the NRD database, 30-day readmission rate was not meaningfully different for transplant recipients undergoing LAAO (9.44%) when compared to non-transplant patients (8.12%, [log-rank, P=0.56]). There was no difference between 30-day major or cardiovascular complications, however vascular complication rates were significantly higher for transplant recipients (OR 2.56, 95% CI [(1.66-3.47]). Our study findings suggest that LAAO may be safe for patients with a prior renal or liver transplant in terms of major complications, cardiovascular complications, and all-cause readmission rates. However vascular complications may be higher in transplant recipients. Further large-scale studies are needed to confirm these findings.

When cardiology meets endocrinology: sustained atrial flutter associated with thyrotoxic periodic paralysis.

Periodic paralysis is a rare muscle disease that manifests as episodes of painless muscle weakness, and the hypokalemic form is commonly associated with hyperthyroidism. Most tachyarrhythmias related with thyrotoxicosis include sinus tachycardia and atrial fibrillation, but an association between thyrotoxic hypokalemic periodic paralysis and typical atrial flutter has seldomly been documented. Here, we present the case of a young male who was diagnosed with thyrotoxic periodic paralysis causing cavotricuspid isthmus-dependent atrial flutter, successfully treated with diltiazem, propranolol, methimazole, potassium iodine (SSK) and rivaroxaban.

MitraClip repair of right-sided atrioventricular valve in a patient with congenitally corrected transposition of the great arteries: a case report.

BACKGROUND: Patients with congenitally corrected transposition of the great arteries (ccTGA) often develop tricuspid valve (systemic atrioventricular valve) dysfunction due to right ventricular overload and dilatation, but isolated mitral valve (MV) disease is rarely found. Isolated mitral (subpulmonic atrioventricular valve) interventions, specifically catheter-directed, have not been reported up to date. CASE SUMMARY: A man with ccTGA is evaluated for dyspnoea. Multimodality imaging assessment confirmed severe right-sided MV regurgitation due to prolapse. In light of high surgical risk, a minimally invasive transcatheter MitraClip procedure was pursued. DISCUSSION: To our knowledge, this is the first case of successful MV repair via percutaneous approach using MitraClip in a patient with ccTGA and biventricular failure. Our case illustrates the safety and feasibility of the edge-to-edge procedure in such a rare instance, but also the importance of multimodality imaging (both invasive and non-invasive) and the Heart Team approach when caring for these complex patients.

Cardioform Septal Occluder for the Closure of a Peri-Device Leak After Initial Watchman Implantation.

Left atrial appendage occlusion has become a safe and effective alternative for stroke-risk reduction among patients with non-valvular atrial fibrillation (AF). Although complete closure is ideal, residual peri-device leaks (PDL) are not uncommon and have been associated with an increased residual risk of stroke. PDL closure has been proposed as an alternate strategy to allow for the safe discontinuation of oral anticoagulation. We describe the safety and feasibility of successful PDL closure using a non-fenestrated Cardioform (Gore Medical, Flagstaff, Arizona) septal occluder after initial Watchman (Boston Scientific, Marlborough, Massachusetts) implantation.

Management of peri-device leak following left atrial appendage closure: A systematic review.

OBJECTIVE: This study aimed to examine the cumulative experience of peri-device leak (PDL) closure following left atrial appendage (LAA) closure. BACKGROUND: The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established. METHODS: A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed. RESULTS: We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2-26 mm). Leaks were classified according to size: small (<5 mm; 45%), moderate (≥5-9 mm; 25%), and large (≥10 mm; 30%). Endovascular coils and endovascular plugs were used to close both small and moderate sized leaks, and second LAA closure devices were exclusively used for large PDLs. Successful PDL closure occurred in 90%, and was similar between PDL sizes and types of occluder used. Procedural complication rates were uncommon (2.8%). No strokes were reported following PDL closure at 6 months. CONCLUSIONS: In patients with PDL for whom discontinuation of OAC may be considered unsafe, percutaneous closure using a tailored approach with either endovascular coils, plugs, or second occluder represents a safe, and feasible alternative associated with favorable clinical outcomes.

Cardiomiopatía hipertrófica: experiencia de 5 años / Hypertrophic cardiomyopathy: 5 year experience

Resumen Introducción: La cardiomiopatía hipertrófica se define como el engrosamiento de la pared ventricular izquierda que no es explicado por condiciones anormales de la carga y que impone un riesgo de: arritmias, falla cardiaca y muerte súbita. Objetivo: identificar prevalencia, las características clínicas y el tratamiento de los pacientes con cardiomiopatía hipertrófica atendidos en nuestra institución. Materiales y métodos: Se extrajeron y analizaron los registros de pacientes con cardiomiopatías hipertróficas, definiendo las características generales y explorando las diferencias entre subgrupos, todos los contrastes estadísticos asumieron una confianza del 95%. Resultados: Se evaluaron 22 casos de la cardiomiopatía hipertrófica, el sexo femenino aportó el 40,9% del total de los casos, la edad promedio fue 54 años. El 77,27% presentaron insuficiencia mitral, el 63,64% reportaron dolor torácico, el 68,18% se encontraban en tratamiento inhibidor de renina y el 95,45% tenían betabloqueador, el grosor promedio del septum fue del 22,77 mm, la prevalencia de fibrilación auricular fue del 22,7% y la de enfermedad coronaria del 18%. Conclusiones: La prevalencia de la cardiomiopatía hipertrófica en el período 2009-2013 fue del 2,35%, relacionado principalmente con la insuficiencia mitral y tenían antecedente de dolor torácico, la prevalencia de la fibrilación auricular en pacientes con cardiomiopatía hipertrófica en el presente estudio fue del 22,7% y la de enfermedad coronaria del 18%.

Abstract Introduction: Hypertrophic cardiomyopathy is defined as the thickening of the left ventricular wall that is not explained by abnormal loading conditions, imposing a risk for arrhythmias, heart failure and sudden death. We attempt to identify the prevalence, clinical features and treatment of patients with hypertrophic cardiomyopathy assisted within our institution. Material and methods: Records of patients with hypertrophic cardiomyopathy were pulled and analysed, defining general features and exploring differences among subgroups; all statistical contrasts assumed a confidence of 95%. Results: 22 cases of hypertrophic cardiomyopathy were assessed, 40.9% of whom were female, average age was 54. 77.27% showed mitral insufficiency, 63.4% reported chest pain, 68.18% were receiving renin inhibitor therapy and 95.45% were taking beta blockers. Average septum thickness was 22.77 mm, prevalence of atrial fibrillation was 22.7% and coronary disease 18%. Conclusion: Prevalence of hypertrophic cardiomyopathy during the 2009-2013 period was of 2.35%, mostly related to mitral insufficiency and previous history of chest pain; prevalence of atrial fibrillation in patients with hypertrophic cardiomyopathy in our study was of 22.7%,and 28% for coronary disease.

El ultrasonido: desde el murciélago hasta la cardiología no invasiva / Ultrasound: from bats to non-invasive cardiology

Resumen Introducción: El sonido se propaga en un medio aprovechando las propiedades elásticas del mismo. El presente estudio describe la evolución de la ultrasonografía cardiaca y su aplicación en la cardiología. Materiales y métodos: Revisión descriptiva en bases documentales, se exploraron conceptos en textos electrónicos de física y fisiología, ampliando los conceptos por método de Snowball. Resultados: Siglo xviii y xix: Spallanzani reconoció la existencia de la ecolocalización en el modelo animal (murciélagos), se descubre la piezoelectricidad. Siglo xx: aplicación de la ecolocalización en el sistema SONAR y la detección de tumores cerebrales, cuerpos extraños en tejidos orgánicos y lesiones malignas en el intestino y el tejido mamario. Década de los años 50 y 60, se identificaron masas en la aurícula izquierda, inicia la descripción de la enfermedad valvular mitral; se describen los primeros ecardiogramas en modo M (movimiento). En los años 60, un transductor de elemento único permitió los ecocardiogramas intracardiacos; luego un transductor de rotación lenta permitió obtener imágenes en 2 D. En los años 80, nace la ecocardiografía transesofágica para evaluar pacientes con pobre ventana acústica; en los años 90, se introdujeron los traductores omniplanares y biplanares con capacidad Doppler y flujo en color. En los últimos años, los desarrollos de la ecocardiografía han ampliado el alcance hasta la cirugía mínimamente invasiva. Conclusiones: Grandes avances se han logrado en consecuencia con la evolución del ultrasonido en medicina, su inicio en la ecolocalización descrita en los murciélagos hasta la ultrasonografía cardiaca en 3 D, han permitido el desarrollo de nuevas no invasivas en la medicina cardiovascular.

Abstract Introduction: Sound propagates in a medium taking advantage of its elastic properties. This study describes the evolution of cardiac ultrasonography and its application in cardiology. Material and methods: Descriptive review of data bases, concepts were explored in electronic physics and physiology texts, expanding the concepts by means of the Snowball method. Results: 18th and 19th century: Spallanzani recognised the existence of echolocation in the animal model (bats); piezoelectricity is discovered. 20th century: applying echolocation in the SONAR system and brain tumour detection, foreign bodies in organic tissue and intestinal and breast tissue malignancies. 50s and 60s: masses in the left atrium were identified, mitral valve disease description begins, first M-mode echocardiograms are described. In the 60s a single element transducer allowed for intracardiac echocardiograms, later on a slow rotating transducer displayed 2 D images. In the 80s transthoracic echocardiogram is born to assess patients with a poor acoustic window; in the 90s omniplane and biplane transducers with Doppler ability and colour flow were introduced. Over the last years, development of echocardiograms have broadened their scope towards minimally invasive surgery. Conclusion: Big steps have been taken in parallel with progress of ultrasounds in the medical field, their onset in echolocation described in bats until 3 D cardiac ultrasonography have contributed to the development of new non-invasive techniques in cardiovascular medicine.

Análisis de supervivencia según la oportunidadde atención en la enfermedad coronaria / Survival analysis according to the opportunity to receive medical care in coronary diseases

Resumen Introducción: La oportunidad en la atención de los servicios de urgencias es una determinante de la calidad en la salud asociado con la mortalidad, se pretende definir la relación entre la supervivencia de los pacientes con la enfermedad coronaria en la unidad de cuidados coronarios con la oportunidad de atención en urgencias. Materiales y métodos: Se realizó un estudio descriptivo retrospectivo, se extrajeron los registros de la unidad de cuidado coronario, urgencias y los certificados de defunción de los pacientes con diagnóstico de la enfermedad coronaria, se identificaron las características generales de los pacientes y se exploró la diferencia en la supervivencia según la oportunidad de atención en las curvas de Kapplan-Meier por subgrupos, para un nivel de confianza del 95%. Resultados: Se presentaron 266 casos, 68,4% de sexo masculino, la media de edad fue de 68 años; mediana de oportunidad de atención en urgencias de 57 minutos, de tiempo de estancia en unidad de cuidado coronario 2 días, y de supervivencia 2 días; el análisis de supervivencia para el estado de egreso, mostró mayor supervivencia en pacientes atendidos en menos de 70 minutos. Conclusiones: Los tiempos de atención en urgencias de los pacientes con la enfermedad coronaria superiores a 70 minutos se asocian con la mayor mortalidad, se requieren mejorías en los registros para evaluar los factores asociados con las demoras en la atención.

Abstract Introduction: The opportunity to receive emergency medical assistance is decisive in the health quality associated to mortality. This study aims to define the relationship between survival of patients with coronary disease in the coronary care unit who had the opportunity to receive emergency medical care. Material and methods: A descriptive retrospective study was conducted, registers for the coronary care unit, emergency room and death certificates of patients diagnosed with coronary disease were collected, general characteristics of patients were identified and differences in survival according to the opportunity of accessing to healthcare in Kapplan-Meier curves for subgroups for a confidence level of 95% was explored. Results: 266 cases were presented, 68.4% were male, average age was 68; median opportunity to receive emergency care was 57 minutes, median stay at the coronary care unit was 2 days and 2 days for survival; survival analysis for the state of the admission showed higher survival in patients who were assisted in less than 70 minutes. Conclusions: Patients with coronary disease waiting over 70 minutes in the emergency room are associated to higher mortality. Improvements in the registers are required in order to assess factors associated to the delay in the access to medical care.