Barriers to use of radial access for percutaneous coronary intervention.

OBJECTIVES: The aim of this study was to identify barriers to transradial access percutaneous coronary intervention (PCI). BACKGROUND: Transradial access yields fewer vascular complications, earlier ambulation, and more patient comfort. However, the adoption to practice is slow, and transfemoral access is still commonly used. METHODS: We identified all PCIs done by one operator in a radial-first trainee-driven practice. The individual charts were reviewed for all PCIs using femoral access. Reasons for not using radial access were identified. Descriptive statistics were used to report reasons for not using transradial access. Analyses were performed on a per-procedure basis. RESULTS: Of 1,948 PCIs, 1,790 (92%) were via radial access and 158 (8%) via femoral access. Femoral access was used to bail out unsuccessful radial access in 21 PCIs (13% of all femoral PCIs, 1% of all PCIs). Radial access was unsuccessful due to failure to cannulate radial artery, radial artery spasm, and radial loop in majority of radial access failure PCIs (n = 13). Femoral access was used as a primary strategy in 137 PCIs (87% of all femoral PCIs, 7% of all PCIs), mostly due to undetectable radial artery pulse (both left and right) (n = 40). CONCLUSIONS: Radial access can be used for PCI safely and effectively. Inadequate radial pulse is the main barrier. Adjunctive strategies such as ulnar access and use of ultrasound may further increase the success rate of arterial access from the upper extremities.

Chronic kidney disease is associated with increased mortality and procedural complications in transcatheter aortic valve replacement: a systematic review and meta-analysis.

OBJECTIVE: We performed a systematic review and meta-analysis to explore the association between chronic kidney disease (CKD) and mortality and procedural complications in transcatheter aortic valve replacement (TAVR). BACKGROUND: The impact of varying stages of CKD or end-stage renal disease (ESRD) on patients receiving TAVR is not clearly identified. METHODS: We searched the databases of MEDLINE and EMBASE from inception to May 2018. Included studies were published TAVR studies that compared the risk of mortality and procedural complications in CKD patients compared to control patients. Data from each study were combined using the random-effects model. RESULTS: Twelve studies (42,703 CKD patients and 51,347 controls) were included. Compared with controls, CKD patients had a significantly higher risk of 30-day overall mortality (risk ratio [RR] = 1.56, 95% confidence interval [CI]: 1.34-1.80, I2 = 60.9), long-term cardiovascular mortality (RR = 1.44, 95% CI: 1.22-1.70, I2 = 36.2%), and long-term overall mortality (RR = 1.66, 95% CI: 1.45-1.91, I2 = 80.3), as well as procedural complications including pacemaker requirement (RR = 1.20, 95% CI: 1.03-1.39, I2 = 56.1%) and bleeding (RR = 1.60, 95% CI: 1.26-2.02, I2 = 86.0%). Risk of mortality and procedural complications increased with severity of CKD for stages 3, 4, and 5, respectively, in terms of long-term overall mortality (RR = 1.28, 1.82, and 2.12), 30-day overall mortality (RR = 1.26, 1.89, and 1.93), 30-day cardiovascular mortality (RR = 1.18, 1.75, and 2.50), and 30-day overall bleeding (RR = 1.19, 1.63, and 2.12). CONCLUSIONS: Our meta-analysis demonstrates a significant increased risk of mortality and procedural complications in patients with CKD who underwent TAVR compared to controls.

Baseline fragmented QRS is associated with increased all-cause mortality in heart failure with reduced ejection fraction: A systematic review and meta-analysis.

BACKGROUND: Recent studies suggested that fragmented (fQRS) is associated with poor clinical outcomes in heart failure with reduced ejection fraction (HFrEF) patients. However, no systematic review or meta-analysis has been done. We conducted a systematic review and meta-analysis to assess the association between baseline fQRS and all-cause mortality in HFrEF. METHODS: We comprehensively reviewed the databases of MEDLINE and EMBASE from inception to February 2018. Published studies of HFrEF that reported fQRS and outcome of all-cause mortality and major arrhythmic event (sudden cardiac death, sudden cardiac arrest, ventricular fibrillation, or sustained ventricular tachycardia) were included. Data were integrated using the random-effects, generic inverse-variance method of DerSimonian and Laird. RESULTS: Ten studies from 2010 to 2017 were included. Baseline fQRS was associated with increased all-cause mortality (risk ratio [RR] 1.63, 95% confidence interval [CI] 1.22-2.19, p < 0.0001, I2  = 73%) as well as major arrhythmic events (RR = 1.74, 95% CI 1.09-2.80, I2  = 89%). Baseline fQRS increased all-cause mortality in both Asian and Caucasian cohorts (RR = 2.17 with 95% CI 1.33-3.55 and RR = 1.45 with 95% CI 1.05-1.99, respectively) as well as increased major arrhythmic events in Asian cohort (RR = 1.50, 95% CI 1.05-2.13). Baseline fQRS also increased all-cause mortality in patients who had not received implantable cardioverter-defibrillator, significantly more than in patients who had received implantable cardioverter-defibrillator (RR = 2.46 with 95% CI 1.56-3.89 and 1.36 with 95% CI 1.08-1.71, respectively). CONCLUSION: Baseline fQRS is associated with increased all-cause mortality up to 1.63-fold in HFrEF patients. Fragmented QRS could be a predictor of clinical outcome in patients with HFrEF.

ASSOCIATION OF RETINAL VEIN OCCLUSION WITH CARDIOVASCULAR EVENTS AND MORTALITY: A Systematic Review and Meta-analysis.

PURPOSE: Previous studies examining the association of retinal vein occlusion (RVO) and cardiovascular events have been inconsistent and have mostly focused on stroke and myocardial infarction. The goal of this study is to use meta-analysis to examine the available evidence examining the association of RVO with incident cardiovascular events and mortality. METHODS: Systematic review and meta-analysis of all longitudinal cohort studies published in PubMed, Embase, and the Cochrane Library from inception to April 7, 2018, that evaluated the association of baseline RVO and incident cardiovascular events and/or mortality, that provided multivariate-adjusted risk estimates with 95% confidence intervals (95% CIs), and that had average follow-up ≥1 year. The Newcastle-Ottawa scale was used to assess study quality. Multivariate-adjusted risk estimates with 95% CI along with study characteristics were extracted from each study, and pooled risk ratios (RRs) with 95% CI were generated using a random-effects model with inverse-variance weighting to account for heterogeneity. Main outcomes were incident stroke (fatal or nonfatal), myocardial infarction, heart failure, peripheral arterial disease, all-cause mortality, and cardiovascular mortality. RESULTS: Fifteen cohort studies with a total of 474,466 patients (60,069 with RVO and 414,397 without RVO) were included. Each study had Newcastle-Ottawa scale score ≥6, indicating moderate-to-high quality. Retinal vein occlusion was associated with increased risk of stroke (RR = 1.45; 95% CI, 1.31-1.60), myocardial infarction (RR = 1.26; 95% CI, 1.17-1.37), heart failure (RR = 1.53; 95% CI, 1.22-1.92), peripheral arterial disease (RR = 1.26; 95% CI, 1.09-1.46), and all-cause mortality (RR = 1.36; 95% CI, 1.02-1.81), but was not associated with increased risk of cardiovascular mortality (RR = 1.78; 95% CI, 0.70-4.48). CONCLUSION: This review suggests patients with RVO have an increased risk of cardiovascular events and all-cause mortality. More studies are needed to determine the highest risk periods for cardiovascular events and mortality after RVO and whether immediate cardiovascular evaluation and intervention will improve outcomes.

Fragmented QRS and mortality in patients undergoing percutaneous intervention for ST-elevation myocardial infarction: Systematic review and meta-analysis.

BACKGROUND: Fragmented QRS reflects disturbances in the myocardium predisposing the heart to ventricular tachyarrhythmias. Recent studies suggest that fragmented QRS (fQRS) is associated with mortality in ST-elevation myocardial infarction (STEMI) patients who underwent percutaneous coronary intervention (PCI). However, a systematic review and meta-analysis of the literature has not been done. We assessed the association between fQRS and overall mortality in STEMI patients who subsequently underwent PCI by a systematic review and meta-analysis. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to September 2017. Studies included in our analysis were published cohort (prospective or retrospective) and case-control studies that compared overall mortality among STEMI patient with and without fQRS who underwent PCI. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian, and Laird to calculate risk ratios and 95% confidence intervals. RESULTS: Six studies from 2014 to 2017 were included in this meta-analysis involving 2,516 subjects with STEMI who underwent PCI (888 fQRS and 1,628 non-fQRS). Fragmented QRS was associated with overall mortality in STEMI patients who underwent PCI (pooled risk ratio = 3.87; 95% CI 1.96-7.66, I2  = 43%). CONCLUSION: Fragmented QRS was associated with increased overall mortality up to threefold. Our study suggests that fQRS could be an important tool for risk assessment in STEMI patients who underwent PCI.

Baseline fragmented QRS increases the risk of major arrhythmic events in hypertrophic cardiomyopathy: Systematic review and meta-analysis.

BACKGROUND: Fragmented QRS reflects disturbances in the myocardium predisposing the heart to ventricular tachyarrhythmias. Recent studies suggest that fragmented QRS (fQRS) is associated with worse major arrhythmic events in hypertrophic cardiomyopathy (HCM). However, a systematic review and meta-analysis of the literature has not been done. We assessed the association between fQRS and major arrhythmic events in hypertrophic cardiomyopathy by a systematic review of the literature and a meta-analysis. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2017. Included studies were published prospective or retrospective cohort studies that compared major arrhythmic events (sustained ventricular tachycardia, sudden cardiac arrest, or sudden cardiac death) in HCM with fQRS versus non-fQRS. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. RESULTS: Five studies from January 2013 to May 2017 were included in this meta-analysis involving 673 subjects with HCM (205 fQRS and 468 non-fQRS). Fragmented QRS was associated with major arrhythmic events (pooled risk ratio = 7.29, 95% confidence interval: 4.00-13.29, p < .01, I2  = 0%). CONCLUSION: Baseline fQRS increased major arrhythmic events up to sevenfold. Our study suggests that fQRS could be an important tool for risk assessment in patients with HCM.

Baseline fragmented QRS increases the risk of major arrhythmic events in Brugada syndrome: Systematic review and meta-analysis.

BACKGROUND: Fragmented QRS reflects disturbances in the myocardium predisposing the heart to ventricular tachyarrhythmias. Recent studies suggest that fragmented QRS (fQRS) is associated with major arrhythmic events in Brugada syndrome. However, a systematic review and meta-analysis of the literature has not been done. We assessed the association between fQRS and major arrhythmic events in Brugada syndrome by a systematic review of the literature and a meta-analysis. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2017. Included studies were published prospective or retrospective cohort studies that compared major arrhythmic events (ventricular fibrillation, sustained ventricular tachycardia, sudden cardiac arrest, or sudden cardiac death) in Brugada syndrome with fQRS versus normal QRS. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. RESULTS: Nine studies from January 2012 to May 2017 were included in this meta-analysis involving 2,360 subjects with Brugada syndrome (550 fQRS and 1,810 non-fQRS). Fragmented QRS was associated with major arrhythmic events (pooled risk ratio =3.36, 95% confidence interval: 2.09-5.38, p < .001, I2  = 50.9%) as well as fatal arrhythmia (pooled risk ratio =3.09, 95% confidence interval: 1.40-6.86, p = .005, I2  = 69.7%). CONCLUSIONS: Baseline fQRS increased major arrhythmic events up to 3-fold. Our study suggests that fQRS could be an important tool for risk assessment in patients with Brugada syndrome.

ASSOCIATION OF OBSTRUCTIVE SLEEP APNEA WITH CENTRAL SEROUS CHORIORETINOPATHY AND CHOROIDAL THICKNESS: A Systematic Review and Meta-Analysis.

PURPOSE: Obstructive sleep apnea (OSA) has been associated with an array of ocular disorders. This systematic review aims to investigate the association of OSA with central serous chorioretinopathy (CSCR) and subfoveal choroidal thickness changes on enhanced depth imaging optical coherence tomography. METHODS: Systematic review and meta-analysis of all articles published up to November 2017 examining rate of OSA in patients with CSCR versus controls or examining subfoveal choroidal thickness measurements on enhanced depth imaging optical coherence tomography in patients with OSA versus controls. Pooled odds ratios and weighted mean difference with 95% confidence intervals (CIs) were calculated. RESULTS: For the CSCR/OSA analysis, 7,238 patients (1,479 with CSCR and 5,759 controls) from 6 studies were eligible. For the choroidal thickness/OSA analysis, 778 eyes of 778 patients (514 with OSA and 264 controls) from 9 studies were eligible. Patients with CSCR had a 1.56 increased odds of having OSA than controls (odds ratio, 1.56; 95% CI, 1.16-2.10). There was no statistically significant difference in choroidal thickness between mild OSA subjects and controls (weighted mean difference = -3.17; 95% CI, -19.10 to 12.76). Patients with moderate OSA (weighted mean difference = -24.14; 95% CI, -42.16 to -6.12) and severe OSA (weighted mean difference = -51.19; 95% CI, -99.30 to -3.08) had thinner choroidal thickness measurements than controls. CONCLUSION: In summary, our results suggest that patients with CSCR are more likely to have OSA, and that moderate/severe OSA is associated with smaller subfoveal choroidal measurements on enhanced depth imaging optical coherence tomography.

Testosterone, Sex Hormone-Binding Globulin and Nonalcoholic Fatty Liver Disease: a Systematic Review and Meta-Analysis.

INTRODUCTION AND AIM: Endogenous sex hormones are associated with the risk of diabetes and metabolic syndrome. Recent studies suggested the role of these hormones in nonalcoholic fatty liver disease (NAFLD). We conducted a systematic review and meta-analysis of observational studies investigating the association between sex hormones and NAFLD. MATERIAL AND METHODS: A comprehensive search of the databases of the MEDLINE and EMBASE was performed from inception through April 2016. The inclusion criterion was the observational studies that assessed the association of serum total testosterone (TT) and sex-hormone binding globulin (SHBG) and NAFLD. We calculated pooled effect estimates of TT and SHBG with 95% confidence intervals (CI) comparing between subjects with and without NAFLD by using random-effects model. RESULTS: Sixteen trials comprising 13,721 men and 5,840 women met the inclusion criteria. TT levels were lower in men with NAFLD (MD = -2.78 nmol/l, 95%CI -3.40 to -2.15, I2 = 99%) than in those without. Men with higher TT levels had lower odds of NAFLD whereas higher TT levels increased the odds of NAFLD in women. In both sexes, SHBG levels were lower in patients with NAFLD than controls and this inverse association was stronger in women than men and higher SHBG levels were associated with reduced odds of NAFLD. CONCLUSION: Our meta-analysis demonstrated a sex-dependent association between TT and NAFLD. Lower TT levels are associated with men with NAFLD and inversely associated with women with NAFLD, whereas higher SHBG levels are associated with lower NAFLD odds in both men and women.

Aspiration thrombectomy: safe removal of thrombi too big to aspirate.

Aspiration thrombectomy has been associated with an increased risk of stroke, and its routine use is not recommended. Ill-defined procedural techniques for aspiration thrombectomy may provide an explanation for inconsistent outcomes and adverse event rates in trials. Large thrombi can plug the aspiration port of the aspiration catheter and then be dislodged into the central circulation when they are retracted into the guide catheter, or when the aspiration catheter is removed from the Tuohy connector. We report a case of thrombus aspiration where a large distal thrombus was aspirated into the mouth of the aspiration catheter, held there with suction as it was removed and delivered outside the body without being dislodged. We offer several tips for safe removal of coronary thrombi too big to aspirate.

A Simple Method to Diagnose Arteria Lusoria During Right Radial Access Coronary Intervention.

Arteria lusoria (aberrant right subclavian artery) occurs in approximately 0.1-2.4 % of all individuals. The resulting tortuosity can pose a challenge for coronary angiography using radial artery access, but also can aid in the diagnosis if not already established. This case series reports three patients diagnosed with arteria lusoria by a single low-volume catheterization operator over a 6-month period, noting that its prevalence may be higher than usually reported, can be suspected when a catheter from the right radial artery crosses the midline and forms a loop as it traverses to the ascending aorta, and that it does not preclude successful catheterization and coronary intervention.

Stroke risk in radial versus femoral approach in coronary intervention: an updated systematic review and meta-analysis.

AIM: Peri-cardiac catheterization (CC) stroke is associated with increased morbidity and mortality. Little is known about any potential difference in stroke risk between transradial (TR) and transfemoral (TF) approaches. We explored this question through a systematic review and meta-analysis. METHODS: MEDLINE, EMBASE, and PubMed were searched from 1980 to June 2022. Randomized trials and observational studies comparing radial versus femoral access CC or intervention that reported stroke events were included. A random-effects model was used for analysis. RESULTS: The total population in our 41 pooled studies comprised 1 112 136 patients - average age 65 years, women averaging 27% in TR and 31% in TF approaches. Primary analysis of 18 randomized-controlled trials (RCTs) that included a total of 45 844 patients showed that there was no statistical significance in stroke outcomes between the TR approach and the TF approach [odds ratio (OR) 0.71, 95% confidence interval (CI) 0.48-1.06, P -value = 0.013, I2 = 47.7%]. Furthermore, meta-regression analysis of RCTs including procedural duration between those two access sites showed no significance in stroke outcomes (OR 1.08, 95% CI 0.86-1.34, P -value = 0.921, I2 = 0.0%). CONCLUSIONS: There was no significant difference in stroke outcomes between the TR approach and the TF approach.

Coronary Intravascular Lithotripsy.

Coronary artery calcification is strongly associated with adverse cardiac events and can impede the success of percutaneous coronary intervention (PCI) due to challenges with delivery of equipment and expansion of stents. Current treatment modalities for mitigation of coronary calcification have limitations and inherent risk of complications. Coronary intravascular lithotripsy (IVL) is a novel technique to modify coronary artery calcification via acoustic pressure waves. IVL utilizes an easy-to-use device, which does not require a steep learning curve. Prospective studies have shown this technique to be safe and effective and can be used to adequately modify calcified coronary stenoses in preparation for PCI and stent deployment and optimization. IVL has unique features that can be used alone or as an adjunctive therapy to other available calcium modification tools. As compared to the currently established modalities of calcium modification, IVL has the potential to facilitate successful PCI with fewer serious procedural complications. In this review article, we discuss the importance of coronary artery calcification, the role of IVL, its mechanism, the current clinical data behind its use and future directions. Overall, coronary IVL is a promising technology for the treatment of severely calcified coronary stenoses, with a need for, long-term clinical outcome data of IVL-facilitated PCI.

Burden and Predictors of Chest Pain-Related Health-Care Utilization Following Percutaneous Coronary Intervention.

Chest pain (CP) has been reported in 20% to 40% of patients 1 year after percutaneous coronary intervention (PCI), though rates of post-PCI health-care utilization (HCU) for CP in nonclinical trial populations are unknown. Furthermore, the contribution of noncardiac factors - such as pulmonary, gastrointestinal, and psychological - to post-PCI CP HCU is unclear. Accordingly, the objectives of this study were to describe long-term trajectories and identify predictors of post-PCI CP-related HCU in real-world patients undergoing PCI for any indication. This retrospective cohort study included patients receiving PCI for any indication from 2003 to 2017 through a single integrated health-care system. Post-PCI CP-related HCU tracked through electronic medical records included (1) office visits, (2) emergency department (ED) visits, and (3) hospital admissions with CP or angina as the primary diagnosis. The strongest predictors of CP-related HCU were identified from >100 candidate variables. Among 6386 patients followed an average of 6.7 years after PCI, 73% received PCI for acute coronary syndrome (ACS), 19% for stable angina, and 8% for other indications. Post-PCI CP-related HCU was common with 26%, 16%, and 5% of patients having ≥1 office visits, ED visits, and hospital admissions for CP within 2 years of PCI. The following factors were significant predictors of all 3 CP outcomes: ACS presentation, documented CP >7 days prior to the index PCI, anxiety, depression, and syncope. In conclusion, CP-related HCU following PCI was common, especially within the first 2 years. The strongest predictors of CP-related HCU included coronary disease attributes and psychological factors.

A Mechanism for Stroke Complicating Coronary Thrombus Aspiration.

Coronary thrombus aspiration was developed to remove thrombus, prevent distal embolization, and prepare the vessel for definitive intervention. However, its use is now limited by the risk of stroke. We describe a case where appropriate aspiration technique likely prevented central embolization of a coronary thrombus. (Level of Difficulty: Beginner.).

Coronary Angiography in Patients with Arteria Lusoria via Right Radial Access: A Case Series and Literature Review.

Transradial is becoming the access of choice for coronary angiography (CAG). Arteria lusoria (AL) poses a challenge for right transradial access because it can cause difficulty in accessing the ascending aorta. Of 18,686 patients who underwent CAG in Geisinger Medical Center from 2012 to 2018, 6 had a diagnosis of AL. Four underwent attempted right radial access, in 3 cases before AL was identified. All were successful, and one patient had successful right transradial percutaneous coronary intervention. CAG and PCI can be successfully performed using right radial access in patients with AL.

Epidemiology of infective endocarditis in transcatheter aortic valve replacement: systemic review and meta-analysis.

INTRODUCTION: Infective endocarditis following transcatheter aortic valve replacement (TAVR) is an emerging problem, with a high rate of morbidity and mortality. However, little is known about the burden of disease, and data on infective endocarditis incidence are scarce. This study aimed to evaluate the incidence of infective endocarditis in TAVR by performing a systematic review and meta-analysis of the literature. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to October 2019. Included studies were prospective or retrospective cohort studies that reported the event rate of infective endocarditis in patients who underwent TAVR. Data from each study were combined using the random-effects method to calculate pooled incidence with 95% confidence intervals (CIs). RESULTS: A total of 30 studies consisting of 73 780 patients undergoing TAVR were included in this meta-analysis. Overall, the pooled estimated incidence of infective endocarditis following TAVR was 7 in 1000 patients (95% CI: 0.5-1%). For early infective endocarditis, the pooled estimated incidence was 8 per 1000 patients (95% CI: 0.5-1.1%). For late infective endocarditis, the pooled estimated incidence was 2 in 1000 patients (95% CI: 0.1-0.4%). Significantly, the overall pooled infective endocarditis mortality rate was 39% (95% CI: 28.7-49.4%). CONCLUSION: The current study demonstrates the incidence of overall, early, and late infective endocarditis following TAVR, ranging from 2 to 8 per 1000 patients. Although it remains a rare event, infective endocarditis following TAVR is associated with high mortality.

Sex Difference and Outcome after Percutaneous Intervention in Patients with Chronic Total Occlusion: A Systematic Review and Meta-Analysis.

BACKGROUND: Recent studies suggest that sex difference is an outcome predictor in chronic total occlusion (CTO) patients who are undergoing percutaneous intervention (PCI). However, a systematic review and meta-analysis of the literature have not been done. We assessed the outcome of PCI in CTO between male and female. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to September 2017. Included studies were published cohort (prospective or retrospective) and case control studies of CTO patients who underwent PCI that compared successful procedure and major cardiac event (MACE), including cardiac death, target vessel revascularization, myocardial infarction, and stroke, between male and female. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate risk ratios and 95% confidence intervals. RESULTS: Nine studies were included in this meta-analysis involving 30,830 CTO subjects (8350 female and 22,480 male) who underwent PCI. Females were not significantly associated with reduced risk of MACE (pooled risk ratio = 0.86, 95% confidence interval: 0.66-1.12, p = 0.262, I2 = 47.0%) as well as successful rate of PCI (pooled risk ratio = 1.04, 95% confidence interval: 0.99-1.10, p = 0.161, I2 = 76.6%) in CTO patients who underwent PCI. CONCLUSION: Our study suggests that sex is not an independent risk factor of MACE or successful procedure in CTO patients who underwent PCI.

Tricuspid Valve Infective Endocarditis Due to Klebsiella pneumoniae in Intravenous Drug User.

Infective endocarditis is a high morbidity-mortality condition despite advancements in supportive care and medical therapy. One of the strongest risk factors is intravenous drug use, which has high prevalence in the Hawai'i population. Klebsiella pneumoniae is a rare but aggressive pathogen causing infective endocarditis. There is no strong evidence to guide management. We present a rare case of isolated tricuspid valve infective endocarditis due to Klebsiella pneumoniae in an intravenous drug user causing septic pulmonary emboli and multiple abscesses. The patient was managed with combined 6-week ceftriaxone and 2-week gentamicin together with early tricuspid valve repair.