Rapid Development of Primary Right Atrial Angiosarcoma.

Cardiac angiosarcomas are rare and generally followed by a high level of metastasis with poor median survival outcomes. Echocardiograms, CT scans, and MRIs are the standard methods for finding sites of cardiac tumors; however, immunohistochemical confirmation is necessary for a definitive diagnosis of angiosarcoma. A 58-year-old male presented to the emergency room with one week of dyspnea on moderate exertion accompanied by chest pain and alleviated with rest. A workup done to evaluate mass found a single 5 x 3.5 x 4.8 cm mass heavily vascularized by the right coronary artery and left circumflex involving the free wall of the right atrium with no extension to the tricuspid valve. Surgical resection was performed, and immunohistochemistry was consistent with a primary cardiac angiosarcoma. An exudative fluid analysis on pericardial and pleural fluid analysis may warrant screening for malignancy more frequently in concurrence with a patient's history and presentation. Although the time from onset of symptoms to diagnosis of cardiac angiosarcoma is not well established, further investigation of such correlation may offer insight into survival post-treatment.

Purely Endoscopic Supracerebellar Infratentorial Approach to the Pineal Region in Pediatric Population.

Pineal lesions represent less than 1% of all brain tumors (Villani et al., Clin Neurol Neurosurg 109:1-6, 2007). The abysmal location and critical neurovascular structures remain a surgical challenge, despite the advent of microneurosurgery. The classical wide surgical suboccipital craniotomy with the supracerebellar infratentorial approach, described by Sir Victor Horsley (Victor, Proc R Soc Med 3:77-78, 1910), is infamous for its considerable surgical morbidity and mortality. This was later upgraded microneurosurgically by Stein to improve surgical outcomes (Stein, J Neurosurg 35:197-202, 1971).Ruge et al. reported the first purely endoscopic fenestration of quadrigeminal arachnoid cysts via this corridor (Ruge et al., Neurosurgery 38:830-7, 1996). A cadaver-based anatomical study by Cardia et al. demonstrated the viability for endoscope-assisted techniques (Cardia et al., J Neurosurg 2006;104(6 Suppl):409-14). However, the first purely endoscopic supracerebellar infratentorial (eSCIT) approach to a pineal cyst was performed in 2008 by Gore et al. (Gore PA et al., Neurosurgery 62:108-9, 2008).Unlike transventricular endoscopy, eSCIT approach poses no mechanical risk to the fornices and can be utilized irrespective of ventricular size. More vascular control and resultant reduction in uncontrolled hemorrhage improve the feasibility of attaining complete resection, especially around corners (Zaidi et al,, World Neurosurg 84, 2015). Gravity-dependent positioning and cerebrospinal fluid (CSF) diversion aid cerebellar relaxation, creating the ideal anatomical pathway. Also, angle of the straight sinus, tentorium, and tectal adherence can often influence the choice of approach; thus direct endoscopic visualization not only counteracts access to the engorged Galenic complex but also encourages sharp dissection of the arachnoid (Cardia et al., J Neurosurg 104:409-14, 2006). These tactics help provide excellent illumination with magnification, making it less fatiguing for the surgeon (Broggi et al., Neurosurgery 67:159-65, 2010).The purely endoscopic approach thwarts the dreaded risk of air embolisms, via simple copious irrigation from a small burr hole (Shahinian and Ra, J Neurol Surg B Skull Base 74:114-7, 2013). The tiny opening and closure are rapid to create, and the smaller wound decreases postoperative pain and morbidity. Recent literature supports its numerous advantages and favorable outcomes, making it a tough contender to traditional open methods.

A Rare Case of Bivalvular Infective Endocarditis With Left Atrial Mural Endocarditis.

Infective endocarditis (IE) is a life-threatening cardiac infection usually associated with cardiac valves. Left atrial (LA) mural endocarditis is rarely seen and occurs in isolation or in conjunction with mitral valve endocarditis. We present a case of a 61-year-old male with no prior cardiac history who presented with melena and fevers. Blood cultures were positive for Enterococcus faecalis. Transesophageal echocardiogram (TEE) demonstrated aortic and mitral valve vegetations with several small echo densities present on the left atrial wall. These findings were further assessed with a computed tomography angiogram of the heart and cardiac magnetic resonance imaging Ti600 sequence. The patient was treated with intravenous antibiotics and underwent aortic and mitral valve replacement with resection of numerous small fungating masses on the left atrium. There are currently no formal guidelines in place for managing mural endocarditis. However, conducting a multidisciplinary evaluation by an endocarditis team could aid in achieving earlier and more precise diagnoses of the underlying condition and its complications. This approach could also ensure consistent antibiotic therapy and appropriate timing for surgical intervention.

Combining 2D Planimetry and Yeo's Index Can Help Accurately Identify Patients with Severe Rheumatic Mitral Stenosis-A Perspective from a 3D Assessment Using Transoesophageal Echocardiography.

BACKGROUND: Yeo's index is a novel measure of the severity of rheumatic mitral valve stenosis (MS). It is derived from the product of the mitral leaflet separation index and dimensionless index. This study aims to validate Yeo's index using a transesophageal echocardiogram (TEE) three-dimensional (3D) mitral valve area (MVA) as a comparator and to compare the concordance of existing echocardiographic measures of the MVA with TEE 3DMVA. METHODS AND RESULTS: We studied 111 patients with rheumatic MS who underwent both transthoracic echocardiography (TTE) and a TEE assessment of MS severity. Yeo's index, the MVA determined by 2D planimetry, pressure half-time (PHT) and continuity equation (CE) measured on TTE were compared with the TEE 3DMVA. With a linear correlation, Yeo's index showed the best correlation with TEE 3DMVA (r2 = 0.775), followed by 2D planimetry (r2 = 0.687), CE (r2 = 0.598) and PHT (r2 = 0.363). Using TEE 3DMVA as comparator, Yeo's index (ρc = 0.739) demonstrated the best concordance, followed by 2D planimetry (ρc = 0.632), CE (ρc = 0.464) and PHT (ρc = 0.366). When both Yeo's index and 2D planimetry suggested significant MS, the positive predictive value was high (an AUC of 0.966 and a PPV of 100.00% for severe MS, and an AUC of 0.864 and a PPV of 85.71% for very severe MS). When both measures suggested the absence of significant MS, the negative predictive value was also high (an AUC of 0.940 and an NPV of 88.90% for severe MS, and an AUC of 0.831 and an NPV of 88.71% for very severe MS). CONCLUSIONS: Yeo's index performed well in identifying severe MS when compared with TEE 3DMVA and may be a useful adjunct to existing methods of measuring MS severity. Combining it with 2D planimetry could further enhance its accuracy.

Is it a thrombus or a tumor? An imaging dilemma for clinicians.

Atrial fibrillation, the most common cardiac arrhythmia in the Western world, confers a 5-fold increase in stroke, mainly due to thrombus formation in the left atrial appendage. Early rhythm control is often beneficial in reducing adverse cardiovascular events in higher-risk populations. Here, we present a patient who was found to have a 1 cm stalk-like lesion in the left atrial appendage on transesophageal echocardiogram prior to electrical cardioversion. Using multiple cardiac imaging modalities, including cardiac magnetic resonance imaging and computed tomography, the mass was eventually determined to be a chronic resolving thrombus.

Edoxaban Improved End-QRS Notches and Early Repolarizations.

Cardiac computed tomography (CT) images sometimes show a donut-like oval structure on the antero-superior wall of the left atrium (LA). What is a donut? Left atrium diverticula (LADs) are common, but there are many unknown features of LADs. The direct effects of pulmonary vein thrombi (PVTs) on the heart are poorly understood. Herein, we report a case report in which we describe the different effects of edoxaban on LA thrombi, the LAD, coronary artery collaterals, early repolarizations, and end-QRS notches using cardiac CT and transesophageal echocardiography (TEE). First, we showed that there was a LAD on the anterior wall of the LA where the LA thrombi from the right lower pulmonary vein (RLPV) thrombi were connected. To our knowledge, this is the first report to reveal LAD's annular transformation and the beneficial effect of edoxaban on the end-QRS notch.

Intraoperative Catastrophic Acute Pulmonary Embolism: A Case Report.

This case report describes a 75-year-old female with a medical history including recurrent bowel obstruction due to sigmoid stricture, atrial fibrillation managed with rivaroxaban, a 50-year one pack-per-day smoking history, hypertension, hyperlipidemia, peripheral vascular disease with bilateral iliac stents (2015), stage III chronic kidney disease, and renal artery stenosis with bilateral stenting. She was transferred from outside hospital for an elective sigmoidectomy with ileorectal anastomosis following several recent admissions due to bowel obstruction that had been managed non-operatively. She was deemed optimized for surgery by the primary care team; however, during induction, she developed pulseless ventricular tachycardia requiring extensive resuscitative efforts. Intraoperative findings revealed biventricular failure and a clot in the right pulmonary artery. Despite aggressive treatment, including veno-arterial extracorporeal membrane oxygenation (VA ECMO), the patient's condition deteriorated, and life support was ultimately withdrawn. This case highlights the challenges of managing complex surgical patients and underscores the importance of multidisciplinary care in such cases.

Culture-Negative Neutrocytic Ascites in a Patient With Cardiac Ascites From End-Stage Heart Failure.

There are two significant groups of infection regarding ascitic fluid: spontaneous bacterial peritonitis (SBP) and culture-negative neutrocytic ascites (CNNA). SBP and CNNA typically occur in patients with cirrhosis. A 46-year-old male with end-stage biventricular heart failure presented with a heart failure exacerbation. He was treated with intravenous diuretics with the improvement of hypervolemia. He remained hospitalized to undergo an evaluation for tricuspid valve repair, but given the severity of his bi-ventricular heart failure, he underwent a heart transplant evaluation. As part of the work-up, he underwent an abdominal ultrasound that was significant for severe ascites but did not note an abnormal hepatic architecture suggestive of cirrhosis. A liver biopsy was then performed, which confirmed no evidence of cirrhosis. His hospitalization was complicated by refractory cardiac ascites, which required a bi-weekly paracentesis. The serum albumin-ascites gradient (SAAG) from his initial paracentesis was 1.4, indicating the etiology was from portal hypertension. The total protein was greater than 2.5 in multiple studies, so the etiology was less concerning for cirrhosis and secondary to his heart failure. About two weeks into his hospital course, he developed a leukocytosis but remained hemodynamically stable and asymptomatic from an infectious standpoint. Analysis of his ascitic fluid initially was negative for infection, but he later developed an elevated total neutrophil count on a subsequent ascitic fluid analysis study. The body fluid culture remained negative for bacterial growth. Hepatology was consulted, and he met the criteria for CNNA, so treatment with ceftriaxone was initiated. After initiating antibiotics, his leukocytosis and elevated ascitic fluid total neutrophil count resolved. Ascitic infections such as CNNA generally occur in patients with liver cirrhosis but may occur in patients without cirrhosis, as observed in our patient. This case highlights that patients with cardiac ascites can develop ascitic fluid infections that may have an impact on their mortality. The precipitating factor that enabled the patient to develop CNNA is unclear but may be related to the translocation of bacteria during his congestive heart failure exacerbation. Although uncommon in a patient with cardiac ascites, an early diagnosis of CNNA and the initiation of antibiotics can be important in preventing patient mortality.

Percutaneous closure of incomplete surgical left atrial appendage ligation: success begins with the decision to try.

The authors present a case of percutaneous closure of an incomplete surgical left atrial appendage (LAA) ligation with a new device LAmbre (Lifetech ScientificCo Ltd).

Tricuspid mass-curious case of Li-Fraumeni syndrome: A case report.

BACKGROUND: Li-Fraumeni syndrome (LFS) is a rare autosomal dominant cancer-predisposing syndrome, which can manifest as a polymorphic spectrum of malignancies. LFS is associated with an early onset in life, with the majority of cases occurring prior to the age of 46. Notwithstanding the infrequency of primary cardiac tumors, it behooves clinicians to remain vigilant in considering the differential diagnosis of such tumors in LFS patients who present with a cardiac mass. This is due to the markedly elevated risk for malignancy in this particular population, far surpassing that of the general populace. CASE SUMMARY: Herein, we present a case of a 30-year-old female with LFS who was found to have a tricuspid valve leaflet mass. CONCLUSION: This case exemplifies valuable learning points in the diagnostic approach for this exceptionally rare patient population.

Recognition and management of left atrial dissection during mitral repair.

BACKGROUND: Left atrial dissection (LAtD) is a rare but potentially life-threatening complication of mitral valve surgery. Its management is not well stablished in the literature. However, early recognition through intraoperative TEE and attention to changes in the left atrial free wall during saline leak testing can lead to avoidance of severe complications. CASE PRESENTATION: We report a case of LAtD detected by intraoperative transesophageal echocardiogram (TEE) following mitral valve repair for primary mitral valve regurgitation secondary to degenerative mitral valve disease with MAZE IV procedure for atrial fibrillation. LAtD was noted on TEE as an expanding double density along the wall of the left atrium with a jet originating at the posterior annulus flowing into the LAtD which was repaired. Separation from bypass following LAtD repair was complicated by severe biventricular dysfunction requiring significant inotropic support and placement of an intra-aortic balloon pump (IABP). Patient's post-operative course was further complicated by right sided heart failure requiring placement of a right sided impella which was subsequently removed on POD 4. Patient was discharged home on POD 17. Transthoracic echo at 1 month, 3 months demonstrated resolution of the LAtD. A follow up echo at 4 years showed complete resolution of the LAtD with an intact mitral repair, trace mitral regurgitation, and a mean gradient across the repair of 3 mm Hg. CONCLUSIONS: Left atrial dissection is a rare but serious complication of mitral valve surgery. We provide a review of the current literature regarding LAtD, emphasizing the need to consider this complication early during mitral surgery to allow for uncomplicated repair.

Enterococcus faecalis Endocarditis of All Four Native Valves: A Case Report.

Enterococcus faecalis is commonly implicated in Infective Endocarditis (IE), resulting in remarkable morbidity and mortality. We present an unusual case documenting the clinical course and outcome of an elderly female patient who developed quadruple valve endocarditis due to Enterococcus faecalis infection. She presented with altered mental status, resulting in hospitalization, and was found to have bacteremia complicated by endocarditis, epidural abscess, discitis, and splenic infarction. Urinalysis was consistent with bacterial infection two days before being admitted to the hospital. Unfortunately, despite aggressive therapeutic regimens, the patient died.  This is one of the few documented endocarditis cases involving all heart valves. It reviews the importance of maintaining a high index of clinical suspicion for assessing IE, with a low threshold for performing a transesophageal echocardiogram as a diagnostic tool.

Native Aortic Valve Endocarditis Secondary to Gastric Antral Vascular Ectasia Manipulation During Endoscopic Argon Plasma Coagulation.

Gastric antral vascular ectasia (GAVE) is an uncommon cause of upper gastrointestinal (GI) bleeds. Due to the high vascularity of the region, transient bacteremia due to manipulation of the GI tract can very rarely cause the translocation of bacteria. We present a rare case in which endoscopic manipulation to treat GAVE led to native valve infective endocarditis (IE). Our patient had a prior history of GAVE and presented with worsening dizziness and shortness of breath (SOB). After an esophagogastroduodenoscopy (EGD) and subsequent argon plasma coagulation (APC) for active preantral bleeding, the patient was noted to have repeated fevers, a new cardiac murmur, and positive blood cultures for Staphylococcus epidermidis, leading to a diagnosis of native infective endocarditis. With high clinical suspicion and early recognition of a new cardiac murmur, a transesophageal echocardiogram (TEE) was key in identifying vegetation. This case highlights the importance of combining history, a physical exam, and diagnostic lab tests and imaging to identify endocarditis. Management included two months of intravenous (IV) vancomycin and repeat TEE for close monitoring of vegetation improvement.

Aortic Regurgitation After Right Coronary Cusp Injury During Percutaneous Coronary Intervention.

Injury of a coronary cusp of the aortic valve is a rare complication that can occur during coronary angiography. It usually occurs from multiple attempts with different catheters to access the ostia of the right coronary artery, but it has also occurred accessing the ostia of the left coronary artery. We present the case of a patient who underwent coronary angiography with suspected coronary cusp injury that remained asymptomatic but was found to have severe aortic regurgitation during coronary artery bypass graft surgery (CABG) one week later, requiring an aortic valve replacement.

Endoleak in covered CP stent causes procedural failure during transcatheter closure of sinus venosus defects.

Transcatheter sinus venosus defect closure uses a long covered stent of appropriate length and diameter across the cavoatrial junction after balloon interrogation. The fabric in the covered stent creates a roof for the right upper pulmonary vein that closes the interatrial communication and redirects the vein into the left atrium behind the stent. A fabric tear in the covered stent may cause endoleak that will result in residual flows across the struts of the covered stent, causing procedural failure. This report highlights the identification of fabric leak by angiography and transesophageal echocardiography and steps to overcome this complication by the placement of another overlapping covered stent.

Endocarditis Infecciosa Mural Apical del Ventrículo Izquierdo: Presentación de caso clínico y revisión bibliográfica / Infectious Apical Mural Endocarditis of the Left Ventricle: Clinical case presentation and bibliographic review

RESUMEN La endocarditis mural es una forma infrecuente de infección intracardiaca que afecta al endocardio no valvular que pue- de presentarse con complicaciones similares a la endocarditis infecciosa valvular. Se recomienda la ecocardiografía para confirmar el diagnóstico cuando exista un alto índice de sospecha. Con respecto al tratamiento, existe evidencia limitada acerca de las estrategias terapéuticas en la endocarditis mural, sin embargo en la mayoría de casos reportados se recomienda iniciar antibioticoterapia dirigida asociado a una intervención quirúrgica precoz. A continuación, se presenta un caso clínico de un paciente masculino de 74 años con fenómenos embólicos sistémicos, en quien se documenta por ecocardiograma transesofágico una endocarditis mural en ápex del ventrículo izquierdo asociado a una bacteriemia por Staphylococcus aureus. Este caso pone de manifiesto la importancia de una valoración ecocardiográfica detallada de las válvulas y cámaras cardíacas ante la sospecha de una endocarditis infecciosa.

ABSTRACT Mural endocarditis is an uncommon form of intracardiac infection affecting the non valvular endocardium that can present with complications similar to valvular infective endocarditis. Echocardiography is recommended to confirm the diagnosis when there is a high index of suspicion. Regarding treatment, there is limited evidence about therapeutic strategies in mural endocarditis, however in most reported cases it is recommended to initiate targeted antibiotic therapy associated with early surgical intervention. The following is a clinical case of a 74-year-old male patient with systemic embolic phenomena, in whom a transesophageal echocardiogram documented mural endocarditis in the apex of the left ventricle associated with Staphylococcus aureus bacteremia. This case highlights the importance of a detailed echocardiographic assessment of the cardiac valves and chambers when infective endocarditis is suspected.

Lactobacillus rhamnosus Infective Endocarditis in an Elderly Male.

Lactobacilli are facultative anaerobic, gram-positive, rod-shaped bacteria found in the normal flora of the oral cavity and the gastrointestinal and genitourinary tracts. This report presents a case of Lactobacillus rhamnosus infective endocarditis and provides echocardiographic evidence of its pathogenic potential. Furthermore, we provide an account of the first successful treatment with daptomycin to our knowledge. Additionally, we examine the limited literature available on this microbiological entity and attempt to relate this data to our case.