Multi-valve Libman-Sacks's endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up.

We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up.

Lipomatous Atrial Septal Hypertrophy, an Unexpected Giant Interatrial Mass: A Case Report and Literature Review.

Lipomatous atrial septal hypertrophy (LASH) is a histological cardiac benign lesion finding with high prevalence in healthy population, usually detected during imaging procedures for other indications. Nevertheless, it could become clinically significant if it compromises venous return and diastolic left ventricular filling, up to becoming an anatomical substrate for atrial tachyarrhythmias. We present a case of LASH diagnosed in a 54-year-old female patient admitted to our emergency department after ground fall and collateral finding of positive blood cultures leading to transesophageal echocardiography. A giant mass involving the interatrial septum was observed, in the absence of primitive neoplasia evidence after performing a total-body computed tomography scan and abdominal echography. No signs or symptoms of pulmonary venous congestion were observed, and no relevant tachyarrhythmias were detected at continuous electrocardiogram monitoring during the hospitalization period.

There is Nothing More Invisible than the Obvious: A Case Summary and Literature Review.

Bioprosthetic valvular failure (BVF) is a pathological entity arising from a variety of conditions affecting prosthetic heart valves. It may present with an extremely varied pattern, and the identification of the exact etiology is vital to provide a prompt and adequate treatment. It is established that infective endocarditis mainly affects patients with intracardiac devices such as pacemakers or prosthetic valves, and it represents one of the principal mechanisms of BVF. Despite its high incidence, clinical presentations may be atypical, and a close monitoring is essential to prevent catastrophic consequences. We present the case of a partial valvular bioprosthesis detachment associated with a newly formed pseudoaneurysm due to a late infective endocarditis occurred after cardiac surgery, initially manifested with negative blood cultures and clinical findings. We also try to set up a literature review of the most common causes of valvular failure and pseudoaneurysm formation.

A giant and double-walled left atrial ball thrombus complicating a mitral stenosis: case report-a truck tire into the heart.

Background: High thromboembolic risk associated with rheumatic mitral stenosis has been well established, especially in concomitant atrial fibrillation; however, the presence of left atrium ball thrombus is an uncommon finding. Case Summary: A 75-year-old woman with a history of mild rheumatic mitral stenosis was admitted to Emergency Department with cardiogenic shock and high ventricular rate atrial fibrillation. Emergency electrical cardioversion was performed-before trans-oesophageal echocardiography (TOE)-due to haemodynamic deterioration which restored sinus rhythm.Transthoracic echocardiography (TTE) revealed severe reduction of left ventricular ejection fraction (LVEF: 15%), severe rheumatic mitral stenosis and a large, perfectly rounded mass, situated at the ostium of left upper pulmonary vein. Due to the persistence of haemodynamic instability and acute pulmonary oedema the patient was intubated and mechanically ventilated and treated with intravenous administration of inotropes and high doses of diuretics. During the stay in Intensive Care Unit, a TOE confirmed a spherical and double-walled mass suggesting a working diagnosis of left atrial ball thrombus (LABT). The case was discussed in Heart Team and considering the poor haemodynamic status in the contest of refractory cardiogenic shock with evidence of multi-organ failure, emergency surgical thrombectomy and mitral valve replacement was deemed prohibitive. Patient developed cardiac arrest and emergency TTE showed left atrial mass engaged into the mitral valve totally obstructing the left ventricle inflow tract. The autopsy and histologic examination confirmed the thrombotic nature of the mass. Discussion: A free-floating ball thrombus in the left atrium is an unusual occurrence in rheumatic mitral stenosis and it may cause fatal systemic embolization or acute left ventricular inflow obstruction, resulting in syncope, pulmonary congestion, and sudden cardiac death. When possible, emergency surgical thrombectomy and mitral valve replacement can be life-saving.

Different mechanisms of mitral regurgitation in hypertrophic cardiomyopathy: A clinical case and literature review.

Background: Abnormalities of the mitral valve (MV) apparatus are typical features of hypertrophic cardiomyopathy (HCM). These abnormalities include leaflet elongation, thick leaflets, displacement of papillary muscle, and systolic anterior motion (SAM) of the MV anterior leaflet. Mitral valve chordal rupture associated with HCM is a rare but serious issue capable of change the clinical apparence and the prognosis of the patient. Case summary: A 57-year-old lady with a history of diabetes, dyslipidemia, and a previous single episode of atrial fibrillation (treated with pharmacological cardioversion), presented to the Emergency Department for worsening dyspnea (New York Heart Association Classification class IV). A trans-thoracic echocardiogram (TTE) showed a significant, septal, and asymmetric left ventricular hypertrophy (basal anteroseptal wall diastolic thickness of 19 mm) with normal left ventricle systolic function. A SAM of AML was evident together with a left ventricular outflow tract gradient of 56 mmHg at rest, rising to 136 mmHg during the Valsalva maneuver. In addition, there was evidence of moderate to severe mitral regurgitation (MR) with an anteriorly directed jet, not very typical of MR related to SAM. A 2D-3D trans-esophageal echocardiogram (2D-3D TEE) revealed a combined MR mechanism based on PML degenerative prolapse with P2-flail from ruptured chordae with related eccentric anteriorly directed regurgitant jet, together with a second regurgitant posteriorly directed jet, related to SAM of AML. The patient underwent MV repair together with septal myectomy, with a good final outcome. Conclusion: Pre-operative echocardiography (both TTE and 2D-3D TEE) is an essential tool in order to detect different MV abnormalities in patients with HCM. These types of patients should never be treated by septal reduction alone. Surgical MV repair or replacement, together with septal myectomy, may be the preferred approach.

Urine alkalinisation to prevent contrast-induced acute kidney injury: the prospective, randomised, controlled, open-label TEATE trial.

BACKGROUND: Contrast-induced acute kidney injury (CI-AKI) is prognostically relevant in invasive cardiological and radiological procedures. The administration of sodium bicarbonate has controversial effects. It has been hypothesised that bicarbonate is ineffective when unable to achieve adequate urine alkalinisation. AIMS: We tested the hypothesis that alkaline urine status with oral or intravenous (i.v.) bicarbonate on top of hydration alone prevents CI-AKI. METHODS: In a prospective, randomised, parallel-group, open-label trial, we compared 1) saline hydration alone (n=81); 2) i.v. bicarbonate (n=82); and 3) oral bicarbonate (n=78), in patients with chronic kidney disease (CKD) scheduled for the intra-arterial administration of contrast medium. The primary endpoint was the incidence of CI-AKI according to alkaline urine status achieved immediately before angiography. Secondary endpoints were the mean change of urine pH up to the time of angiography and the incidence of CI-AKI in the three groups. RESULTS: The incidence of CI-AKI was not significantly different in the three treatment arms (20% in the hydration group, 21% in the oral bicarbonate group and 22% in the i.v. bicarbonate group; p=0.94). Patients achieving a pH >6 before angiography (n=145) had a significantly lower incidence of CI-AKI compared with the others (n=96; odds ratio [OR] 0.48, 95% confidence interval [CI]: 0.25-0.90; p=0.023, primary study hypothesis). The proportion of patients achieving a pH >6 was higher in the i.v. and oral bicarbonate groups compared with hydration alone. CONCLUSIONS: Urinary pH before administration of contrast medium is an inverse correlate of CI-AKI incidence, and bicarbonate is superior to hydration alone in achieving urinary alkalinisation. Since, however, bicarbonate did not reduce the incidence of CI-AKI, we conclude that urinary pH is a marker and not a mediator of CI-AKI (ClinicalTrials.gov: NCT02980003).

PrevenTion of contrast-inducEd nephropAThy with urinE alkalinization: the TEATE study design.

: Intravascular administration of iodinated contrast media is an essential tool for the imaging of blood vessels and cardiac chambers, as well as for percutaneous coronary and structural interventions. Along with the spreading of diagnostic and interventional procedures, the increasing incidence of contrast-induced nephropathy (CIN) has become an important and prognostically relevant problem. CIN is thought to be largely dependent on oxidative damage, and is a considerable cause of renal failure, being associated with prolonged hospitalization and significant morbidity/mortality. The most effective treatment strategy of this serious complication remains prevention, and several preventive measures have been extensively investigated in the last few years.Preprocedural hydration is the best-known and mostly accepted strategy. The administration of sodium bicarbonate has controversial effects, and is likely to be ineffective when the infused dose is unable to achieve adequate urine alkalinization. Since alkaline pH suppresses the production of free radicals, increasing urine pH would be an attractive goal for CIN prevention.In a prospective randomized controlled, open-label clinical trial we will test the hypothesis that urine alkalinization with either oral or intravenous bicarbonate on top of hydration alone is the main determinant of CIN prevention (primary endpoint) in a population of patients with moderate or severe chronic kidney disease scheduled for coronary angiography and/or angioplasty. If we then demonstrate nonsignificant differences in urine alkalinization and incidence of CIN between the two bicarbonate groups (secondary endpoint), a practical implication will be that oral administration is preferable for practical reasons over the administration of intravenous bicarbonate.