RESUMEN
Background: Infective endocarditis with septic emboli is a well-recognized sequala. However, emboli almost invariably are found 'downstream' to the vegetation. In the absence of congenital heart disease, the embolization from the left heart to the pulmonary circulation has never been described. Case summary: A 4-year-old boy presents with a background history of pharyngitis treated with antibiotics. Upon ambulatory review, he is noted to have a new murmur. Transthoracic echocardiogram demonstrated mitral valve vegetation with severe mitral regurgitation; in addition, there was a patent foramen ovale (PFO), and there were no congenital heart defects. The patient was treated for infective endocarditis on high clinical suspicion. He subsequently developed septic pulmonary emboli in the absence of right-sided vegetation. Subsequent mitral valve vegetectomy, resection of infected native anterior mitral valve leaflet, mitral valve repair, and valvuloplasty. The patient made an excellent recovery following the completion of antibiotic therapy. Discussion: Although not possible to confirm with certainty, this case demonstrates the most plausible explanation for this child's presentation being septic pulmonary emboli originating from left-sided heart vegetation migrating through a PFO.
RESUMEN
Kawasaki disease (KD) can be associated with high morbidity and mortality due to coronary artery aneurysms formation and myocardial dysfunction. Aim of this study was to evaluate the diagnostic performance of non-invasive myocardial work in predicting subtle myocardial abnormalities in Kawasaki disease (KD) children with coronary dilatation (CADL). A total of 100 patients (age 8.7 ± 5 years) were included: 45 children with KD and CADL (KD/CADL) (Z-score > 2.5), 45 age-matched controls (CTRL) and, finally, an additional group of 10 children with KD in absence of coronary dilatation (KD group). Left ventricular (LV) systolic function and global longitudinal strain (GLS) were assessed. Global myocardial work index (MWI) was calculated as the area of the LV pressure-strain loops. From MWI, global Constructive Work (MCW), Wasted Work (MWW) and Work Efficiency (MWE) were estimated. Despite normal LV systolic function by routine echocardiography, KD/CADL patients had lower MWI (1433.2 ± 375.8 mmHg% vs 1752.2 ± 265.7 mmHg%, p < 0.001), MCW (1885.5 ± 384.2 mmHg% vs 2175.9 ± 292.4 mmHg%, p = 0.001) and MWE (994.0 ± 4.8% vs 95.9 ± 2.0%, p = 0.030) compared to CTRL. Furthermore, MWI was significantly reduced in children belonging to the KD group in comparison with controls (KD: 1498.3 ± 361.7 mmHg%; KD vs CTRL p = 0.028) and was comparable between KD/CADL and KD groups (KD/CADL vs KD p = 0.896). Moreover, KD/CADL patients with normal GLS (n = 38) preserved significant differences in MWI and MCW in comparison with CTRL. MWI, MCW and MWE were significantly reduced in KD children despite normal LVEF and normal GLS. These abnormalities seems independent from CADL. Thus, in KD with normal LVEF and normal GLS, estimation of MWI may be a more sensitive indicator of myocardial dysfunction.