Giant Right Coronary Artery Aneurysm Incidentally Found During Stroke Evaluation Through Echocardiography.

Giant coronary artery aneurysms (CAAs) are rare forms of coronary artery disease. An 82-year-old man presented to the hospital with generalized weakness, arm numbness, and dizziness and was found to have a multi-infarct stroke. A transthoracic echocardiogram was obtained to determine a possible cardiovascular etiology of his stroke. However, it did not reveal thrombi or vegetation; instead, it showed a ring-like structure adjacent to the tricuspid valve that appeared to be a large right atrial cyst. A transesophageal echocardiogram was performed localizing the ring-like mass near the tricuspid annulus. Cardiac catheterization revealed aneurysms of the coronary arteries with complete distal occlusion of the left anterior descending artery (LAD), an aneurysmal left circumflex, and a right coronary artery with a very large aneurysm without signs of thrombus or flow-limiting lesion. CAAs are usually found through cardiac catheterization. Echocardiography may be a novel way of identifying CAAs.

Burkholderia cepacia: A Rare Source of Endocarditis.

A 37-year-old male with a past medical history of previous mitral valve replacement due to bacterial endocarditis and intravenous (IV) drug use was found to have Burkholderia cepacia bacteremia. Transesophageal echocardiogram revealed large mitral and tricuspid valve vegetations. Medical management was initially attempted but his bacteremia persisted, and he required urgent prosthetic mitral valve replacement and native tricuspid valve replacement. Prosthetic valve endocarditis has been associated with surgery in 48.9% of patients and a mortality of 22.8%. In patients with prosthetic valve endocarditis due to B. cepacia, valve replacement occurred in approximately 61.5% of patients and mortality is estimated to be 33.3%. To our knowledge, this is one of only a few prosthetic valve endocarditis cases caused solely by B. cepacia and our case is the first to affect multiple valves including prosthetic and native valves.

Triple Threat: Triple Pathogen Endocarditis.

Polymicrobial endocarditis is rare but is seen in those with risk factors like diabetes mellitus, structural heart disease, congenital heart defects, prosthetic devices, and intravenous drug use. We report the case of a 30-year-old woman with a past medical history of chronic Hepatitis C and IV drug use who presented with a one-week history of generalized weakness, subjective fevers, lower extremity abscesses, and occasional chest pain. Blood cultures were positive for Streptococcus anginosus, Gemella hemolysans, and Pseudomonas aeruginosa. A transthoracic echocardiogram revealed a very large tricuspid valve vegetation and severe tricuspid regurgitation. Her course was complicated by a complete heart block, septic pulmonary emboli, acute hypoxic respiratory failure, and cardiogenic shock meeting the criteria for early surgical intervention. She underwent an emergency tricuspid valve replacement and pacemaker implantation. During the operation, it became evident that her valve was destroyed with vegetation. A week after the operation, her ejection fraction had improved to 50% and she only exhibited mild tricuspid valve regurgitation. Six weeks later, she was in a stable condition and presented for follow-up. Surgery is necessitated in nearly 50% of Gemella endocarditis cases, 62% of cases with S. anginosus group, and approximately 56% of P. aeruginosa cases. To our knowledge, this is the only case of polymicrobial endocarditis caused by G. hemolysans, S. anginosus, and P. aeruginosa.

Are Shorter Durations of Dual Antiplatelet Therapy Acceptable Following Percutaneous Coronary Intervention?

Much debate has centered on whether or not the standard 12-month duration of dual antiplatelet therapy (DAPT) is still necessary postpercutaneous coronary intervention, given recent improvements in stent technology. The benefits of shorter (3-6 months) durations of DAPT include a potential lower risk for bleeding and less patient drug cost and pill burden. Although randomized clinical trials have shown noninferiority for shorter versus longer DAPT regimens in many regards, some endpoints (e.g., myocardial infarction) may still occur less frequently with longer DAPT regimens, particularly in higher risk populations (e.g., acute coronary syndromes). Bleeding risk is either comparable or less with shorter versus longer DAPT regimens. Given the lack of unequivocal data regarding the equality of shorter versus longer DAPT regimens in all patients, there is a growing consensus that an individualized approach is advisable for determining DAPT duration postpercutaneous coronary intervention. Clinical decision aids and updated clinical practice guidelines are available that consider risk:benefit ratios and clinical trial data to assist the clinician in developing a personalized DAPT regimen.