Staphylococcus lugdunensis infective endocarditis with perforation of the sinus of Valsalva: a case report.

Background: Staphylococcus lugdunensis endocarditis is a rare but fulminant disease. Case summary: A 74-year-old female with a history of asymptomatic severe aortic valve stenosis and permanent atrial fibrillation presented with acute onset of fever (39.0°C). Electrocardiogram showed diffuse ST-segment elevation. She was hospitalized for further analysis. All blood cultures were positive for Staphylococcus lugdunensis and antibiotic treatment was started. Transthoracic echocardiography (TTE) showed known aortic valve stenosis without clear signs of endocarditis. The following day, a transoesophageal echocardiogram (TEE) showed a new moderate aortic valve regurgitation, new pericardial effusion (PE), and a thickened sinus of Valsalva (SOV) consistent with endocarditis with paravalvular involvement. Positron emission tomography-computed tomography was consistent with aortic valve endocarditis with paravalvular expansion. The patient was transferred to a tertiary referral centre for surgical treatment. On admission, patient was in shock and a second TTE revealed a new systolic and diastolic flow through the SOV to the right ventricle indicating SOV perforation. Additionally, there was flow in the PE suggestive of perforation of one of the cardiac chambers or large vessels. Emergent surgery showed extended infection with SOV perforation and a large perforation of the right ventricle. Ultimately, patient died during the operation because of extensive infection and refractory shock. Conclusion: Staphylococcus lugdunensis endocarditis is a severe disease with poor response to conventional anti-microbial treatment, destructive complications requiring surgery, and has a high mortality risk.

Transcatheter aortic valve implantation amid the COVID-19 pandemic: a nationwide analysis of the first COVID-19 wave in the Netherlands.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has put tremendous pressure on healthcare systems. Most transcatheter aortic valve implantation (TAVI) centres have adopted different triage systems and procedural strategies to serve highest-risk patients first and to minimise the burden on hospital logistics and personnel. We therefore assessed the impact of the COVID-19 pandemic on patient selection, type of anaesthesia and outcomes after TAVI. METHODS: We used data from the Netherlands Heart Registration to examine all patients who underwent TAVI between March 2020 and July 2020 (COVID cohort), and between March 2019 and July 2019 (pre-COVID cohort). We compared patient characteristics, procedural characteristics and clinical outcomes. RESULTS: We examined 2131 patients who underwent TAVI (1020 patients in COVID cohort, 1111 patients in pre-COVID cohort). EuroSCORE II was comparable between cohorts (COVID 4.5 ± 4.0 vs pre-COVID 4.6 ± 4.2, p = 0.356). The number of TAVI procedures under general anaesthesia was lower in the COVID cohort (35.2% vs 46.5%, p < 0.001). Incidences of stroke (COVID 2.7% vs pre-COVID 1.7%, p = 0.134), major vascular complications (2.3% vs 3.4%, p = 0.170) and permanent pacemaker implantation (10.0% vs 9.4%, p = 0.634) did not differ between cohorts. Thirty-day and 150-day mortality were comparable (2.8% vs 2.2%, p = 0.359 and 5.2% vs 5.2%, p = 0.993, respectively). CONCLUSIONS: During the COVID-19 pandemic, patient characteristics and outcomes after TAVI were not different than before the pandemic. This highlights the fact that TAVI procedures can be safely performed during the COVID-19 pandemic, without an increased risk of complications or mortality.

Antithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals.

PURPOSE: To assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI). METHODS: For every Dutch hospital performing TAVI (n = 14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI. RESULTS: The response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over two-thirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively. CONCLUSIONS: Leaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approach.

Can minimized cardiopulmonary bypass systems be safer?

Although a growing body of evidence indicates superiority of minimized cardiopulmonary bypass (mCPB) systems over conventional CPB systems, limited venous return can result in severe fluctuations of venous line pressure which can result in gaseous emboli. In this study, we investigated the influence of sub-atmospheric pressures and volume buffer capacity added to the venous line on the generation of gaseous emboli in the mCPB circuit. Two different mCPB systems (MEC - Maquet, n=7 and ECC.O - Sorin, n=8) and a conventional closed cardiopulmonary bypass (cCPB) system (n=12) were clinically evaluated. In the search for a way to increase volume buffer capacity of mCPB systems, we additionally evaluated the 'Better Bladder' (BB) in a mock circulation by simulating, repeatedly, decreased venous return while measuring pressure and gaseous embolic activity. Arterial gaseous emboli activity during clinical perfusion with a cCPB system was the lowest in comparison to the mCPB systems (312±465 versus 311±421 with MEC and 1,966±1,782 with ECC.O, counts per 10 minute time interval, respectively; p=0.03). The average volume per bubble in the arterial line was the highest in cases with cCPB (12.5±8.3 nL versus 8.0±4.2 nL with MEC and 4.6±4.8 nL with ECC.O; p=0.04 for both). Significant cross-correlation was obtained at various time offsets from 0 to +35 s between sub-atmospheric pressure in the venous line and gaseous emboli activity in both the venous and arterial lines. The in vitro data showed that incorporation of the BB dampens fluctuations of venous line pressure by approximately 30% and decreases gaseous emboli by up to 85%. In conclusion, fluctuations of sub-atmospheric venous line pressure during kinetic-assisted drainage are related to gaseous emboli. Volume buffer capacity added to the venous line can effectively dampen pressure fluctuations resulting from abrupt changes in venous return and, therefore, can help to increase the safety of minimized cardiopulmonary bypass by reducing gaseous microemboli formation resulting from degassing.

[Systemic lupus erythematosus over hemophagocytic lymphohistiocytosis]. / Systemische lupus erythematosus-geassocieerde hemofagocytaire lymfohistiocytose.

A woman was admitted to the hospital with lymphadenopathy, fever and a generalised exanthema. Laboratory examination revealed leucopenia, anaemia, high sedimentation, elevated CRP and a markedly elevated serum ferritin. Further exploration showed a positive anti-nuclear factor-titre with anti-double-stranded DNA antibodies, positive p-ANCA and a falsely positive syphilis-test. Bone marrow examination revealed an elevated number of phagocytizing macrophages. Diagnosis of secondary haemophagocytic lymphohistiocytosis in a patient with systemic lupus erythematosus was made, a serious and sometimes fatal condition with often repeated exacerbations of the systemic lupus erythematosus that stays active for long periods in spite of the use of immunosuppressive therapy. Haemophagocytic lymphohistiocytosis and systemic lupus erythematosus are sometimes difficult to differentiate because the clinical presentation and laboratory findings are frequently very similar. The diagnosis depends on the clinical picture, blood and bone marrow examination. Bone marrow reveals an elevated haemophagocytosis. In patients with secondary haemophagocytic lymphohistiocytosis, the treatment of the underlying disorder is sometimes sufficient. In some cases there is need for a specific treatment with corticosteroids, intravenous immunoglobulin, immunosuppressive therapy or etoposide.

Primary monophasic mediastinal, cardiac and pericardial synovial sarcoma: a young man in distress.

A 19-year-old male was admitted because of exertional dyspnoea. The imaging studies revealed epicardial, pericardial and mediastinal masses. The tumours could not be resected through a minor thoracotomy, only biopsies could be taken. Analyses led to the final diagnosis of a monophasic synovial sarcoma. The patient preferred a conservative and palliative approach. Three months later he died at home. Autopsy demonstrated dramatic extension of the tumour masses. We conclude this report with a discussion on primary cardiac tumours. (Neth Heart J 2007;15:226-8.).

Choroidal metastasis presenting as a painful red eye: clinicopathologic report.

Metastasis is the most common ocular malignancy. An atypical clinical presentation whoever, can delay the diagnosis, particularly when there is no history of malignant disease. Our patient initially presented with a painful red eye and a subretinal mass, but without signs of intraocular inflammation or glaucoma. The results of the diagnostic work-up were inconclusive. Postmortem histopathologic examination revealed a metastasis to the posterior choroid.

[General argyria caused by administration of tobacco-withdrawal tablets containing silver acetate]. / Veralgemeende argyrose door het gebruik van tabak-ontwenningstabletten met zilveracetaat.

In a 49-year-old man generalised argyria was diagnosed, a systemic dissemination and tissue deposition of silver in the body. The clinical picture was brought about by use of a silver acetate-containing lozenge as a deterrent to smoking. Argyria is characterised by a slate blue-gray discolouration of the skin, particularly in areas exposed to light. Generally, it causes patients a great deal of anguish and embarrassment. Present understanding is that it does not entail non-cutaneous, systemic effects. There is no effective treatment--the discolouration is permanent. Currently, prevention is the only possible measure. Efforts should be made to eliminate the uncontrolled use of silver-containing preparations.