The application experience of focused ultrasound heart examination in patients with COVID-19 in Prone-position.

Aim of the study. To study the experience of using focused transthoracic echocardiography in patients with COVID-19 in prone position (fEchoPr) in intensive care units (ICU). Materials and methods. The retrospective observational study included 53 patients (period from 15 April to 31 December 2020). Inclusion criteria: confirmed diagnosis of COVID-19, availability of fEchoPr data, outcome certainty (discharge/death). We analyzed electronic medical records. The fEchoPr was performed in patients in the prone position with a bolster under the left side of the chest and left arm raised ('swimmer's position'). We assessed the systolic function of the right ventricle (RV) (tricuspid annular plane systolic excursion (TAPSE)), RV size, RV/LV ratio, systolic function of the left ventricle (LV) (left ventricular outflow tract velocity time integral. (LVOT VTI)), and pulmonary hypertension (PH) (tricuspid regurgitation peak gradient (PGTR). Depending on the results, the patients were divided into 2 groups: informative (+fEchoPr) and non-informative (-fEchoPr) examinations. Results. There was no statistically significant difference in the groups (+fEcho n = 35 vs -fEcho n = 18) by age (65.6 +/- 15.3 vs 60.2 +/- 15.8, p > 0.05), by gender (male: 23 (65.7%) vs 14 (77.8%), p > 0.05), by body mass index (31.3 +/- 5.3 kg/m2 vs 29.5 +/- 5.4 kg/m2, p > 0.05), by mechanical ventilation support (24 (68.6%) vs 17 (94.4%), p = 0.074), by NEWS scale indicators (6.9 +/- 3.7 vs 8.5 +/- 3.5 points), by mortality (82.8% vs 94.4%, p > 0.05). Correlation analysis revealed a moderate inverse relationship between being on mechanical ventilation and the informative value of the study (Spearman's r = -0.30 at p = 0.033). In the +fEchoPr group, the correct measurement of TAPSE and RV/LV was carried out in 100%: a decrease in RV systolic function was recorded in 5 patients (14%), expansion of the RV in 13 patients (37%). Signs of PH were detected in 11 patients (31%), PGTR could not be measured in 10 patients (28%). LV systolic dysfunction was detected in 7 patients (20%). No pathology was detected in 16 patients (46%). One patient was diagnosed with infective endocarditis of native mitral valve, which was later confirmed by autopsy. Conclusion. In 66% of cases, fEchoPr examinations were informative, especially in terms of assessing the state of the right heart. fEchoPr examination is an affordable, valid and reproducible method to assess and monitor the state of the heart in ICU patients.Copyright © 2021 VIDAR Publishing House. All Rights Reserved.

Mitral valve thromboendocarditis in a patient with a novel coronavirus disease COVID-19

Since the beginning of the novel coronavirus disease pandemic, which has claimed millions of lives around the world, vaccines and effective therapeutic strategies have been developed, but along with this, approaches to the diagnosis and treatment of well-known diseases have changed, these metamorphoses also affected cardiovascular diseases. So, a flurry of publications is devoted to the development of myocarditis and myocardial damage within the framework of novel coronavirus infectious disease, however, there are practically no data on the concomitant course of COVID-19 and infective endocarditis or thromboendocarditis. In our case, we demonstrate the combined course of novel coronavirus infectious disease, viral pneumonia and infectious thromboendocarditis in a patient with pre-existing corrected valvular heart disease. Of particular interest are the pathogenetic links, the nature of the clinical course and prognosis in the combination of these nosologies.Copyright © 2022 Creative Cardiology. All rights reserved.

Dialysis catheter-related sepsis resulted in infective endocarditis, septic pulmonary embolism and acute inferolateral STEMI: a case report.

Background: Embolic myocardial infarction is an uncommon but increasingly recognized complication of infective endocarditis (IE). Although the incidence is low and ranges from 1% to 10%, the mortality rate is high (64%). The characteristics of septic embolism on presentation are nonspecific and usually are unrecognized by clinicians. This case report aims to build a high index of suspicion among clinicians for IE presenting with the complication of embolic myocardial infarction especially in patients with indwelling venous catheters. Case Summary: A 62-year-old woman with end-stage renal disease on haemodialysis presented with shortness of breath and desaturation. Her history was significant for end-stage renal disease managed with regular haemodialysis by a right-sided double-lumen tunnelled catheter. An initial diagnosis was made of pulmonary embolism, and management with intravenous heparin was initiated. She subsequently developed inferolateral ST-elevation myocardial infarction, and treatment with percutaneous coronary intervention to the posterior descending artery failed. Then, the patient developed complete heart block, aortic valve vegetation, acute severe aortic regurgitation, and shock. Discussion: Acute coronary syndrome is usually an early and uncommon complication of IE and the risk of embolism decreases after antibiotic therapy is initiated. Due to the low incidence of coronary events in IE, only case reports have been published. Most patients with septic pulmonary embolism have a presentation similar to that for pneumonia. The diagnosis is therefore often delayed, which consequently influences prognosis. Our case report presents an example of IE-related multiple systemic embolization with poor patient outcome due to delayed diagnosis.

Tropheryma Whipplei Endocarditis: A Diagnosis In Hindsight

Description of case: We report a case of Tropheryma whipplei endocarditis, a rare cause of bloodculture-negative infective endocarditis (BCNIE). Due to its rarity and lack of availability of diagnostic tests in district hospitals, the diagnosis remains challenging. The objective of this case report is to increase physician awareness of this pathogen. A 61-year-old man presented to the Emergency Department with central chest pain at rest. A 12-lead ECG demonstrated ST- segment depression in V4-V6 leads, and his serial troponin levels were raised. He was commenced on treatment for acute coronary syndrome and transferred to the Coronary Care Unit. An echocardiogram showed a 15mm x 15mm vegetation in the aortic valve with mild aortic regurgitation. His initial microbiology workup, which included two sets of blood cultures (pre-antibiotics), MRSA screen & COVID-19 PCR, was negative. He was transferred to a cardiothoracic centre four days later. Pre-operative CT coronary angiogram showed severe three vessel coronary artery disease. He underwent triple coronary artery by-pass grafts and tissue aortic valve replacement. During early post-op recovery, he had fever episodes and an elevated C-reactive protein of 280 mg/L but normal white cell counts. He was treated with intravenous Tazocin for hospital-acquired pneumonia and discharged on doxycycline. Two weeks post-discharge, he had a positive 16S/18S PCR for Tropheryma whipplei on molecular analysis of the aortic valve. He was treated for Whipples endocarditis with a 4-week course of IV Ceftriaxone, followed by a 12-month course of oral Cotrimoxazole. The patient has reported doing well since the surgery. Discussion(s): Molecular assay with PCR of the heart valve is the mainstay of diagnosing Whipple's endocarditis. There have been 5 previously reported cases of Whipple's endocarditis in the United Kingdom in our knowledge. It is likely under-reported because of a reliance on tissue diagnosis. Preceding intestinal manifestations and arthralgia should raise its clinical suspicion for timely workup. Physician awareness of Whipple's Endocarditis is paramount in investigating for this pathogen.

Application of Novel Technologies in Cardiac Electrotherapy to Prevent Complications.

(1) Background: Cardiac electrotherapy is developing quickly, which implies that it will face a higher number of complications, with cardiac device-related infective endocarditis (CDRIE) being the most frequent, but not the only one. (2) Methods: This is a retrospective case study followed by a literature review, which presents a patient with a rare but dangerous complication of electrotherapy, which could have been prevented if modern technology had been used. (3) Results: A 34-year-old female was admitted with suspicion of CDRIE based on an unclear echocardiographic presentation. However, with no signs of infection, that diagnosis was not confirmed, though an endocardial implantable cardioverter-defibrillator (ICD) lead was found folded into the pulmonary trunk. The final treatment included transvenous lead extraction (TLE) and subcutaneous ICD (S-ICD) implantation. (4) Conclusions: With the increasing number of implantations of cardiac electronic devices and their consequences, a high index of suspicion among clinicians is required. The entity of the clinical picture must be thoroughly considered, and various diagnostic tools should be applied. Lead dislocation into the pulmonary trunk is an extremely rare complication. Our findings align with the available literature data, where asymptomatic cases are usually effectively treated with TLE. Modern technologies, such as S-ICD, can effectively prevent lead-related problems and are indicated in young patients necessitating long-term ICD therapy.

Corynebacterium amycolatum infective endocarditis in a patient with severe COVID-19: a case report.

Objective. To present a case of successful treatment of a secondary bacterial infection caused by non-diphtheritic corynebacterium in a patient with severe COVID-19 and known beta-lactam intolerance. Materials and methods. A clinical case of infective endocarditis (IE) caused by Corynebacterium amycolatum in a 74-year-old patient hospitalized with severe COVID-19 is presented. Comorbidity (secondary immune deficiency due to active malignancy, chemotherapy courses;previous heart disease) and the need for immunosuppressive therapy were triggers for infection caused by a rare Gram-positive bacterium which is usually considered as clinically non-significant. The choice of empiric antimicrobial treatment was limited by the patient's history of beta-lactam intolerance. Results. A multidisciplinary approach to medical care of the patient and alertness to secondary infections helped to diagnose IE in a timely manner and to choose effective antimicrobial therapy. Combination therapy with vancomycin and amikacin helped to make blood flow free from infection. The further switch to oral doxycycline in outpatient settings resulted in the patient recovery from the infection. Conclusions. Under conditions of limited choice of drug therapy, it is critical to have access to modern microbiological diagnostics which make it possible to diagnose rare pathogens. A dialogue between treating physician and clinical pharmacologist helps to choose an empirical and targeted antimicrobial therapy with the best efficacy-safety ratio. There is a need to be alert to secondary infections, including those of atypical locations and courses and caused by rare or opportunistic pathogens.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

What Is the Optimal Pk/Pd Target for Beta-Lactam Therapy of Infective Endocarditis? A Systematic Review

Aim: To elucidate the factors that influence beta-lactam pharmacokinetic (PK) and pharmacodynamic (PD) variability in infective endocarditis (IE) and to examine optimal PK/PD target parameters for therapy. Background(s): Beta-lactam antibiotics are the mainstay of therapy for most bacterial causes of IE. Traditionally considered as agents with a broad therapeutic index there has been increasing recognition that standard doses may be subtherapeutic or toxic in critically ill patients. Optimising therapy for efficacy requires an established PK/PD target associated with clinical and microbiological cure. Method(s): Clinical and laboratory in vivo animal or human studies examining PK and/or PD of beta-lactam antibiotics in IE were eligible. Ovid MEDLINE, Embase and Cochrane Central Registry were searched using defined terms. Two authors reviewed s and full texts using Covidence software. Result(s): 62 articles were selected for review and synthesis. We identified 45 animal studies investigating the broad categories of beta-lactam diffusion into vegetations, PK/PD determinants of outcome, mode of antibiotic delivery and synergistic impact of agents. 17 human case studies/series totalling 347 participants reported antibiotic serum concentrations and clinical outcomes. Findings generally supported the importance of time-dependent killing for beta-lactams but heterogeneous data limited the determination of an optimal PK/PD target for IE treatment. Conclusion(s): Beta-lactam PK and PD in endocarditis is variable and specific to the particular antibiotic-organism combination. Timedependent killing is important, consistent with non-endocarditis studies, but there is little agreement on optimal drug exposure. Clinical studies examining various PK/PD targets in endocarditis patients are required to further inform drug selection and dosing.Copyright © 2023 Southern Society for Clinical Investigation.

Paravalvular aortic abscess with aorto-left atrial fistula in infective endocarditis of the native aortic valve: a case report

Introduction: Infective endocarditis (IE) is a life-threatening disease with poor prognosis and high mortality if not diagnosed promptly and intervened early1. Perianullary extension accounts for nearly 40% of all native valves IE, most commonly the aortic valve, but formation of an intracardiac fistula occurs in less than 1% of all cases2. Case report: We report the case of a 64-year-old man admitted to the intensive care unit because of acute respiratory failure with high fever, high inflammatory blood reactants and electrolyte disbalance. He had previously been extensively evaluated for microcytic anemia due to hemorrhoids, and had also suffered from epilepsy since his youth. A series of blood cultures were obtained and Streptococcus oralis was positive. Because of systolic-diastolic murmur and second-degree atrioventricular conduction disturbance on electrocardiography, transthoracic echocardiography (TTE) was performed. TTE showed the aortic valve with a hyperechogenic mass and severe aortic regurgitation with a jet directed toward the septum and moderate aortic stenosis. However, a 1.5 x 2.2 cm hyperechogenic mass was noted in the right atrium adjacent to the aortic annulus (Figure 1). Transesophageal echocardiography (TOE) showed a deformed aortic valve with three degenerative leaflets and hyperechogenic mobile vegetations, a circumferential abscess of the aortic annulus with extension of infection toward the right atrium just above the tricuspid septal leaflet and extension of infection toward the left atrium with formation of a fistula detected by color Doppler flow (Figure 2). The patient was treated with vancomycin and benzilpenciline and referred to cardiac surgery, where the aortic valve was replaced with a biological prosthesis and the aortic root was patched. The postoperative course was complicated by the COVID-19 infection. A series of control blood cultures were sterile. After two months of treatment, the patient was discharged home with normal TTE function of the biological aortic valve (Figure 3). Conclusion: TTE and TOE are invaluable for rapid and accurate diagnosis of the anatomic involvement of IE and its extent, leading to appropriate treatment and thus a better prognosis. [ FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Infective endocarditis and COVID-19: the impact of SARS-CoV-2 infection on diagnostics, course, and prognosis.

Aim. To study the impact of coronavirus disease 2019 (COVID-19) pandemic on hospitalization rates, diagnosis, and outcomes of infective endocarditis (IE) with a subanalysis of IE course in combination with COVID-19. Material and methods. This prospective cohort study included 168 patients with definite or probable IE (DUKE 2015) hospitalized in the V. V. Vinogradov City Clinical Hospital from July 2017 to July 2022. All patients underwent a conventional examination in accordance with current clinical guidelines. We studied clinical, paraclinical and etiological parameters, as well as outcomes. Two clinical observations of the combination of IE and COVID-19 are presen-ted. Results. When assessing the local registry of patients with IE, a trend towards an increase in hospitalizations rate of IE in 2021-2022 was shown, with a decrease during the period of long-term lockdowns in Moscow and a subsequent surge after their cancellation. Patients with IE during the COVID-19 pandemic had a more favorable clinical profile, a 2-fold increase in IE diagnosis (due to late hospitalization), frequent detection of Staphylococcus aureus MSSA (32,6%), and frequent surgical treatment (up to 87,6% with a combination of IE and COVID-19), as well as high in-hospital mortality, but without a tendency to increase (30,4%). Clinical observations of IE and COVID-19 combination are presented, which demonstrates the contribution of COVID-19 as the only risk factor for native tricuspid valve IE in a patient without predisposing causes, as well as a factor in the unfavorable prognosis for native aortic valve IE after the addition of COVID-19, which led to lethal outcome. Conclusion. The present study demonstrates the profile of patients with IE and COVID-19 depending on the epidemiological situation of COVID-19 and the association with SARS-CoV-2 infection. The data obtained make it possible to discuss the potential relationship between COVID-19 and IE. The "endocarditis team" determines the timely implementation of surgery and the absence of an increase in inhospital mortality, regardless of the epidemiological situation.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Streptococcus oralis pulmonic valve endocarditis: a case report and review of the literature.

BACKGROUND: Several factors increase the risk of right-sided endocarditis. The tricuspid valve is usually involved in right-sided endocarditis cases. Infective endocarditis of the pulmonic valve is rare, and few cases of pulmonic valve endocarditis were reported previously. CASE PRESENTATION: Here we describe a case of a 81-year-old Middle Eastern male patient, admitted to our hospital three times in a period of 2 months for fever and cough. He had Streptococcus oralis bacteremia with vegetation that was on the pulmonic valve. We diagnosed him with pulmonic valve endocarditis, and he was treated successfully with intravenous antibiotics. CONCLUSION: It is important to keep high suspicion for isolated pulmonic valve endocarditis in patients with respiratory symptoms. Adequate dental care is important in patients with risk factors for infective endocarditis.

Transcatheter aortic valve implantation-related infective endocarditis: experience from an Irish tertiary referral centre.

BACKGROUND: Transcatheter aortic valve implantation-related infective endocarditis (TAVI-IE) is a well-recognised and serious complication following TAVI. The purpose of this study was to describe the clinical characteristics, microorganism spectrum, and outcomes of TAVI-IE in an Irish context. METHODS: A prospective registry was used to assess the baseline demographics, procedural variables, and clinical outcomes of patients undergoing TAVI between 2009 and 2020 at two tertiary referral Irish Hospitals. RESULTS: A total of 733 patients underwent TAVI during the study period. During a follow-up duration of 1,949 person-years (median 28 months), TAVI-IE occurred in 17 (2.3%) patients. The overall incidence was 0.87 per 100 person-years and the median time from TAVI to presentation with IE was 7 months [IQR: 5-13 months]. In those who developed TAVI-IE, the mean age was 78.7 years, 70.5% were male, and there was a trend towards more permanent pacemaker implantations post-TAVI (17.6% vs. 5.86%; p = 0.08). The dominant culprit microorganisms were streptococci (41.1%) and four (23.5%) cases were attributed to dental seeding. Major complications of TAVI-IE included one (5.8%) stroke, one (5.8%) in-hospital death, and two (11.7%) urgent surgical aortic valve replacements. The Kaplan-Meier estimate of survival at 1-year was 82% (95% CI = 55-95). CONCLUSIONS: This Irish cohort of TAVI-IE exhibited a similar incidence and time to presentation compared to prior international registries; however, the 1-year mortality rate was comparatively lower. The need for rigorous dental clearance pre-TAVI and maintenance of dental health post-TAVI is underscored by the high prevalence of oral streptococcus species in this cohort.

Infective endocarditis and COVID-19: the impact of SARS-CoV-2 infection on diagnostics, course, and prognosis.

Aim. To study the impact of coronavirus disease 2019 (COVID-19) pandemic on hospitalization rates, diagnosis, and outcomes of infective endocarditis (IE) with a subanalysis of IE course in combination with COVID-19. Material and methods. This prospective cohort study included 168 patients with definite or probable IE (DUKE 2015) hospitalized in the V. V. Vinogradov City Clinical Hospital from July 2017 to July 2022. All patients underwent a conventional examination in accordance with current clinical guidelines. We studied clinical, paraclinical and etiological parameters, as well as outcomes. Two clinical observations of the combination of IE and COVID-19 are presen-ted. Results. When assessing the local registry of patients with IE, a trend towards an increase in hospitalizations rate of IE in 2021-2022 was shown, with a decrease during the period of long-term lockdowns in Moscow and a subsequent surge after their cancellation. Patients with IE during the COVID-19 pandemic had a more favorable clinical profile, a 2-fold increase in IE diagnosis (due to late hospitalization), frequent detection of Staphylococcus aureus MSSA (32,6%), and frequent surgical treatment (up to 87,6% with a combination of IE and COVID-19), as well as high in-hospital mortality, but without a tendency to increase (30,4%). Clinical observations of IE and COVID-19 combination are presented, which demonstrates the contribution of COVID-19 as the only risk factor for native tricuspid valve IE in a patient without predisposing causes, as well as a factor in the unfavorable prognosis for native aortic valve IE after the addition of COVID-19, which led to lethal outcome. Conclusion. The present study demonstrates the profile of patients with IE and COVID-19 depending on the epidemiological situation of COVID-19 and the association with SARS-CoV-2 infection. The data obtained make it possible to discuss the potential relationship between COVID-19 and IE. The "endocarditis team" determines the timely implementation of surgery and the absence of an increase in inhospital mortality, regardless of the epidemiological situation.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Infective endocarditis and COVID-19: the impact of SARS-CoV-2 infection on diagnostics, course, and prognosis.

Aim. To study the impact of coronavirus disease 2019 (COVID-19) pandemic on hospitalization rates, diagnosis, and outcomes of infective endocarditis (IE) with a subanalysis of IE course in combination with COVID-19. Material and methods. This prospective cohort study included 168 patients with definite or probable IE (DUKE 2015) hospitalized in the V. V. Vinogradov City Clinical Hospital from July 2017 to July 2022. All patients underwent a conventional examination in accordance with current clinical guidelines. We studied clinical, paraclinical and etiological parameters, as well as outcomes. Two clinical observations of the combination of IE and COVID-19 are presen-ted. Results. When assessing the local registry of patients with IE, a trend towards an increase in hospitalizations rate of IE in 2021-2022 was shown, with a decrease during the period of long-term lockdowns in Moscow and a subsequent surge after their cancellation. Patients with IE during the COVID-19 pandemic had a more favorable clinical profile, a 2-fold increase in IE diagnosis (due to late hospitalization), frequent detection of Staphylococcus aureus MSSA (32,6%), and frequent surgical treatment (up to 87,6% with a combination of IE and COVID-19), as well as high in-hospital mortality, but without a tendency to increase (30,4%). Clinical observations of IE and COVID-19 combination are presented, which demonstrates the contribution of COVID-19 as the only risk factor for native tricuspid valve IE in a patient without predisposing causes, as well as a factor in the unfavorable prognosis for native aortic valve IE after the addition of COVID-19, which led to lethal outcome. Conclusion. The present study demonstrates the profile of patients with IE and COVID-19 depending on the epidemiological situation of COVID-19 and the association with SARS-CoV-2 infection. The data obtained make it possible to discuss the potential relationship between COVID-19 and IE. The "endocarditis team" determines the timely implementation of surgery and the absence of an increase in inhospital mortality, regardless of the epidemiological situation.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Streptococcus Anginosus Causing Infective Endocarditis - a Rare Case of Multiple Splenic Infarctions

Background Information on infective endocarditis (IE) caused by the Streptococcus anginosus (S. anginosus) group is scarce. We present a case of IE with multiple splenic septic infarcts that was further complicated by renal involvement and osteomyelitis, caused by S. anginosus in a patient with diabetes. Case 58-year-old male with diabetes presented with fever and bilateral flank pain. His CT showed splenomegaly with multiple splenic infarctions and symmetric bilateral perinephric stranding indicative of nephritis. His Labs showed leukocytosis and two blood culture sets grew S.anginosus. Transesophageal echocardiogram confirmed vegetations on aortic valve (1.3 x 1.0 cm)(Image A, red arrow) and mitral valve (1.4 x 1.0 cm)(Image B, blue arrow). Lumbar spine MRI showed L2-3 vertebral osteomyelitis. [Formula presented] Decision-making Due to patient's normal oxygen saturation and clear lung auscultation and imaging, COVID-19 was ruled out. The etiology of his fever was diagnosed as S. anginosus IE, as evidenced by his vegetations and positive cultures. The patient started on IV antibiotics and IV fluids and was transferred to another facility to receive aortic and mitral bioprostheses. Conclusion This, to the best of our knowledge, is the first documented case of S. anginosus with splenic and renal involvement. The presence of multiple splenic infarcts in immunocompromised patients, in this case in someone with diabetes, should raise suspicion for the presence of vegetations and the diagnosis of S. anginosus IE.Copyright © 2023 American College of Cardiology Foundation

COVID-19: How Nuclear Medicine Can Provide A Differential Diagnosis In A Very Dubious Case

Background: We present the case of a 55-year-old woman, admitted to the Infectious Disease Department of Policlinico Umberto I, Rome, in mid-March 2020, with suspicion of COVID-19 infection. Objective(s): The rRT-PCR was negative, and the following CT scan, performed to exclude false-neg-ative results and help diagnosis, was inconclusive. Method(s): It was decided to submit the patient to a 99mTc-HMPAO-labelled leukocyte scan. Result(s): This exam led to the diagnosis of infective endocarditis. Conclusion(s): In the present pandemic scenario, 99mTc-HMPAO-labelled leukocyte scan represents a reliable imaging technique for differential diagnosis with COVID-19 in patients with confusing clinical signs, possible false-negative rRT-PCR results, and inconclusive CT scan.Copyright © 2021 Bentham Science Publishers.

Looks Like a Vegetation but It Is Not Endocarditis

Background Myxomas are the second most common primary cardiac tumor (PCT) but overall have a low incidence rate. They usually arise from the interatrial septum whereas infective endocarditis (IE) vegetations frequently develop where there is turbulent blood flow, i.e., on the atrial side of the atrioventricular valves. Case A 75 year old male presented with fatigue, shortness of breath (SOB), myalgias and lower extremity edema for 2 weeks. His vital signs were stable and he was afebrile. Blood cultures were negative, WBC was normal, COVID-19 test was negative, and troponin was mildly elevated. TEE showed an ejection fraction of 20% with a large mitral valve (MV) mass (Figure 1A,B). Decision-making The mass was surgically resected and the MV was replaced (Figure 1C). On pathologic evaluation, the mass was confirmed to be a myxoma. The patient was later discharged without complication. Conclusion Clinical features of myxoma can overlap with IE including fever, malaise, SOB, and other signs of valvular obstruction or embolization. About 5% of myxomas originate from the MV and the differential diagnosis for an intra-atrial mass should include IE, PCT, metastatic tumors, and intracardiac thrombus. On echocardiography, myxomas appear irregularly frond-like or grape-cluster in shape. They are typically nonhomogeneous and can have areas of calcifications (Figure 1A). Both TEE and TTE are the mainstay for diagnosis of intracardiac masses and TEE specifically assists in guiding surgical excision. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Outcome of Tunneled Cuffed Catheter as Hemodialysis Access;a Single Centre Experience in a Tertiary Care Centre in Eastern India

Introduction: Although AVFs are preferred vascular access for hemodialysis, tunneled cuffed catheters(TCC) are increasingly being used as dialysis access in certain clinical situations such as in AVF failure or lack of suitable vessels for AVF creation or bridge to living donor transplant. Aim and objective of this study was to study the characteristics of the population having benefited from tunneled cuffed catheters, to identify the different indications as well as the complications secondary to tunneled cuffed catheters in hemodialysis patients and to determine the catheter and patient survival rate and the factors associated with complications and survival. Method(s): This was an retrospective Observational study done after institutional ethics committee approval. All data was captured using standard proforma. The data was tabulated using MS excel and all results projected in form of bar graphs, pie charts, histograms or tables. Kaplan- meier analysis was used for survival. All patients included in the study consented for the procedure as well as collection of data. 527 TCC placement were done in 498 patients by nephrologists without fluoroscopy in a percutaneous fashion between jan 2021 to march 2022. Minimum follow up was 12 months. 37 patients lost to follow up. Result(s): 316 (68.5%) were males and mean age was 48.3+/-12.6 years. Staggered tip MAHURKAR MaxidTM Covidien, was used in every patient. Most common native kidney disease was cresentic GN 176(38.1%). Most common Site of TCC was right internal jugular 88.9%(441/496), followed by left internal jugular 10.48%(52/496), femoral TCC done in 0.6%. Mean blood flow achieved was 311+/- 32ml/min. Most common indication of TCC placement was starting of HD after 1/2 temporary access- 162(32.66%), followed by awaiting Maturation of autogenous AVF 66 (13.3%) and awaiting living-related transplantation 54(10.88%). Total catheter related infective episodes (CRBSI) were 229 (1.07 episodes/1000catheter days),Exit site infection was in 57 cases (0.26 /1000 catheter days), Tunnel infection was in 51(0.19/1000 catheter days), Infective endocarditis was seen in 3 cases. Catheter loss due to CRBSI was 23 (12.16%). Most common organism was Enterococci (29.7%), followed by s.aureus (24.32%). Most common immediate complication was tunnel bleeding (5.9% ), followed by improper tip position 4.68%. Late complications due to TCC thrombosis/ fibrin sheath was 74(15.07%). Recanalisation with urokinase was successful in 36.84%. Central venous stenosis was in 26 cases. successful recanalisation after central venoplasty was 16/19 (84.21%). Mean catheter survival was 201.9 +/- 114.9 days (3day to 12 months). Catheter survival at the end of 3 months was 75.76%, at 6 months 63.4%, at 12months 32.17%. Patient survival at 6 months was 86.7%, at 12 months- 77.5%. Most common cause of death was unrelated to TCC - cardiovascular cause (77.6%). Direct TCC related death was in 5 cases. Most common cause of catheter drop out was patient death (33.03%), followed by maturation of AVF (22.82%), catheter thrombosis/fibrin sheath (22.2%). [Formula presented] Conclusion(s): Though AVF is the best access, for late unplanned HD initiation in many CKD patients, TCC insertion becomes next best option. In access crisis patients, TCC may remain one feasible option for bridge to available live donor transplant. With strict asepsis protocol and technical aptitude TCC placement is safe with few side effects. No conflict of interestCopyright © 2023

Grayken lessons: the role of an interdisciplinary endocarditis working group in evaluating and optimizing care for a woman with opioid use disorder requiring a second tricuspid valve replacement.

BACKGROUND: Injection drug use-related endocarditis is increasingly common among hospitalized patients in the United States, and associated morbidity and mortality are rising. CASE PRESENTATION: Here we present the case of a 34-year-old woman with severe opioid use disorder and multiple episodes of infective endocarditis requiring prosthetic tricuspid valve replacement, who developed worsening dyspnea on exertion. Her echocardiogram demonstrated severe tricuspid regurgitation with a flail prosthetic valve leaflet, without concurrent endocarditis, necessitating a repeat valve replacement. Her care was overseen by our institution's Endocarditis Working Group, a multidisciplinary team that includes providers from addiction medicine, cardiology, infectious disease, cardiothoracic surgery, and neurocritical care. The team worked together to evaluate her, develop a treatment plan for her substance use disorder in tandem with her other medical conditions, and advocate for her candidacy for valve replacement. CONCLUSIONS: Multidisciplinary endocarditis teams such as these are important emerging innovations, which have demonstrated improvements in outcomes for patients with infective endocarditis and substance use disorders, and have the potential to reduce bias by promoting standard-of-care treatment.

A Fatal Case of Native Valve Endocarditis with Multiple Embolic Phenomena and Invasive Methicillin-Resistant Staphylococcus aureus Bacteremia: A Case Report from the Maldives.

Infective endocarditis (IE) is a life-threatening condition caused by infection within the endocardium of the heart and commonly involves the valves. The subsequent cascading inflammation leads to the appearance of a highly friable thrombus that is large enough to become lodged within the heart chambers. As a result, fever, fatigue, heart murmurs, and embolization phenomena may be seen in patients with IE. Embolization results in the seeding of bacteria and obstruction of circulation, causing cell ischemia. Of concern, bacteria with the potential to gain pan-drug resistance, such as methicillin-resistant Staphylococcus aureus (MRSA), are increasingly being identified as the causative agent of IE in hospitals and among intravenous drug abusers. We retrospectively reviewed de-identified clinical data to summarize the clinical course of a patient with MRSA isolated using an automated blood culture system. At the time of presentation, the patient showed a poor consciousness level, and the calculated Glasgow scale was 10/15. A high-grade fever with circulatory shock indicated an occult infection, and a systolic murmur was observed with peripheral signs of embolization. This case demonstrated the emerging threat of antimicrobial resistance in the community and revealed clinical findings of IE that may be helpful to clinicians for the early recognition of the disease. The management of such cases requires a multi-specialty approach, which is not widely available in small-island developing states such as the Maldives.

A case of Kytococcus schroeteri prosthetic valve endocarditis in a patient with COVID-19 infection.

64 years old male presented fever, gastrointestinal symptoms, COVID-19 infection with bioprosthetic mitral in situ, cardio embolic stroke 2 years ago. The 2 D ECHO showed a vegetation indicating infective endocarditis. Three paired blood cultures grew Kytococcus schroeteri. The organism was sensitive to Vancomycin, Teicoplanin, Gentamycin and Linezolid. Patient had multiorgan dysfunction which further deteriorated into failure, disseminated intravascular coagulation resulting into death of the patient.