Management of infective endocarditis in pregnancy by a multidisciplinary team: a case series.

INTRODUCTION: The incidence of infective endocarditis (IE) in pregnancy is rare and has been increasing during the opioid epidemic. IE in pregnancy is associated with high rates of maternal and fetal morbidity and mortality. Multidisciplinary endocarditis teams for management of IE have been shown to reduce in-hospital and 1-year mortality. We present a single-center experience managing IE in pregnancy utilizing a multidisciplinary endocarditis team. METHODS: Patients diagnosed with IE while pregnant or within 30 days post-partum were identified. All patients discussed at the institution's weekly multidisciplinary endocarditis meeting were included. Demographic and clinical data and outcome-related variables were retrospectively reviewed and recorded. RESULTS: Between 1 October 2020 and 1 June 2021 6 pregnant or 30-day post-partum patients with IE were identified. All patients had co-morbid injection drug use; Staphylococcus aureus was the etiologic pathogen in all patients. All patients had embolic complications and 5 required ICU admission and mechanical ventilatory support. Four patients underwent valve replacement. There were no patient-directed discharges. All patients survived to hospital discharge and 90-days after diagnosis. Four pregnancies resulted in delivery at an average gestational age of 32.4 weeks with 3 requiring NICU admissions and prolonged lengths of stay. All patients were seen by addiction medicine and 5 were started on medication-assisted treatment for opioid use disorder. DISCUSSION: In a small retrospective cases series, coordination of care by a multidisciplinary endocarditis team led to a high-rate of surgical intervention with no patient-directed discharges and no in-hospital or 90-day mortality. CONCLUSION: Multidisciplinary endocarditis teams are a low-risk intervention that may improve outcomes in pregnant patients with IE.

Histologic evaluation of therapeutic responses in ischemic myocardium elicited by dual growth factor delivery from composite glycosaminoglycan hydrogels.

In this project, the ability of dual growth factor-preloaded, silk-reinforced, composite hyaluronic acid-based hydrogels to elicit advantageous histologic responses when secured to ischemic myocardium was evaluated in vivo. Reinforced hydrogels containing both Vascular Endothelial Growth Factor (VEGF) and Platelet-derived Growth Factor (PDGF) were prepared by crosslinking chemically modified hyaluronic acid and heparin with poly(ethylene glycol)-diacrylate around a reinforcing silk mesh. Composite patches were sutured to the ventricular surface of ischemic myocardium in Sprague-Dawley rats, and the resulting angiogenic response was followed for 28 days. The gross appearance of treated hearts showed significantly reduced ischemic area and fibrous deposition compared to untreated control hearts. Histologic evaluation showed growth factor delivery to restore myofiber orientation to pre-surgical levels and to significantly increase elicited microvessel density and maturity by day 28 in infarcted myocardial tissue (p < 0.05). In addition, growth factor delivery reduced cell apoptosis and decreased the density of elicited mast cells and both CD68+ and anti-inflammatory CD163+ macrophages. These findings suggest that HA-based, dual growth factor-loaded hydrogels can successfully induce a series of beneficial responses in ischemic myocardium, and offer the potential for therapeutic improvement of ischemic myocardial remodeling.

Cardio-obstetrics: Recognizing and managing cardiovascular complications of pregnancy.

Pregnancy can exacerbate known cardiovascular disorders and unmask previously unrecognized problems. Patients with congenital heart disorders, valvular disease, primary pulmonary hypertension, hypertensive disorders of pregnancy, and acquired peripartum cardiomyopathy need a collaborative interdisciplinary team that includes a cardiologist with specialty training in obstetrics.

Subaortic Stenosis With Elevated Aortic Gradients in a Pregnant Patient.

Subaortic stenosis is an obstructive lesion that may be exacerbated by pregnancy. We describe the management of a 39-year-old woman presenting at 37 weeks of pregnancy with a murmur who is found to have a subaortic membrane with severely elevated left ventricular outflow gradients. (Level of Difficulty: Beginner.).

Endovascular Treatment of Inferior Vena Cava Thrombosis in Metastatic Malignancy: A Case Report and Review of Literature.

Inferior vena cava (IVC) thrombosis is a specific form of thromboembolism that occurs at a rate of 1.5% in all patients hospitalized with a deep vein thrombosis. Malignant IVC thrombosis may occur due to compression from a tumor mass or metastasis or may also occur through tumor invasion of the venous vasculature. Obstruction of the IVC can lead to IVC syndrome, marked by ascites, lower extremity edema, and even congestive hepatic failure. We present a case of extensive IVC thrombosis in a 69-year-old female with metastatic adrenal cell carcinoma, presenting with severe bilateral lower extremity edema and ascites. Computed tomography showed IVC compression by the caudate lobe due to a metastatic liver mass and extensive clot burden of the IVC extending from the renal veins to the right atrium (RA). She underwent percutaneous IVC stenting with 4 stents placed in tandem from the IVC to the RA. Her hospital course was complicated by gastrointestinal bleed requiring clipping, acute liver failure, and hypophysitis due to trial therapy. Although her IVC symptoms were partially relieved with percutaneous intervention, her acute liver failure worsened and she was ultimately transitioned to hospice care.

Electrospun PGS:PCL microfibers align human valvular interstitial cells and provide tunable scaffold anisotropy.

Tissue engineered heart valves (TEHV) can be useful in the repair of congenital or acquired valvular diseases due to their potential for growth and remodeling. The development of biomimetic scaffolds is a major challenge in heart valve tissue engineering. One of the most important structural characteristics of mature heart valve leaflets is their intrinsic anisotropy, which is derived from the microstructure of aligned collagen fibers in the extracellular matrix (ECM). In the present study, a directional electrospinning technique is used to fabricate fibrous poly(glycerol sebacate):poly(caprolactone) (PGS:PCL) scaffolds containing aligned fibers, which resemble native heart valve leaflet ECM networks. In addition, the anisotropic mechanical characteristics of fabricated scaffolds are tuned by changing the ratio of PGS:PCL to mimic the native heart valve's mechanical properties. Primary human valvular interstitial cells (VICs) attach and align along the anisotropic axes of all PGS:PCL scaffolds with various mechanical properties. The cells are also biochemically active in producing heart-valve-associated collagen, vimentin, and smooth muscle actin as determined by gene expression. The fibrous PGS:PCL scaffolds seeded with human VICs mimick the structure and mechanical properties of native valve leaflet tissues and would potentially be suitable for the replacement of heart valves in diverse patient populations.