Clinical outcomes of severe tricuspid valve infective endocarditis related to intravenous drug abuse - a case series.

BACKGROUND: Right-sided infective endocarditis (IE) related to intravenous drug use (IVDU) can follow an acute fulminant course. However, there is limited information on its longer-term clinical outcomes. AIM AND METHODS: We assessed a cohort of consecutive patients who presented with IVDU complicated by severe tricuspid valve regurgitation to determine their presentation, treatment, and long-term outcomes. In this study, severe tricuspid regurgitation (TR) was defined by the European Association of Cardiovascular Imaging criteria at initial presentation to the hospital. RESULTS: Thirty-three patients with a mean age of 35 ± 18 years (72% males) presented with IVDU associated with severe TR. At the initial presentation, 15 patients were in septic shock and required inotropes. 26 patients had septic pulmonary emboli; 10 patients had associated metastatic systemic sites of infection of which 5 patients had central nervous system (CNS) involvement. Three patients were in disseminated intravascular coagulation (DIC) and 1 patient had multi-organ failure (MOF), but not requiring dialysis or mechanical ventilation. Most patients had large tricuspid valve vegetations of >20mm. Eleven patients underwent surgery with 18% perioperative mortality. The Median follow-up was 6.4 years (0.5-11.4). Recurrent IE occurred in one-third of patients, the overall incidence of heart failure and Atrial fibrillation (AF) on follow-up was low in all 3 groups. Five-year survival was 94%. CONCLUSION: Acute severe TR following associated endocarditis IVDU results in a fulminant initial presentation, but a longer-term prognosis is good with surgical and medical treatment.

Simultaneous cardiocerebral infarctions: a five-year retrospective case series reviewing natural history.

Introduction: Concurrent cardiocerebral infarction (CCI), a rare condition defined as simultaneous occlusions in the cerebrovascular and coronary vessels, has high mortality but very limited literature on optimum treatment methods. A better understanding of the natural history and effect of treatment would improve patient outcomes. Methods: Using our prospective stroke database from 2014 to 2018, ten consecutive patients with CCI were identified (incidence = 0.29%). We recorded patient demographics, cardiovascular risk factors, cardiac and cerebral occlusions, circumstances of admission and management of each patient. Patient notes and imaging findings were reviewed to determine the underlying cause of CCI. Results: Median National Institute of Health Stroke Scale score was 15 (range 4-27). Mean patient age was 59 years and 90% were men. Two patients were treated with intravenous tissue plasminogen activator (IV tPA) only and three underwent endovascular treatment in both the cerebral and coronary vessels sequentially. One patient underwent percutaneous coronary intervention (PCI) only and two underwent PCI after IV tPA therapy. Two patients were conservatively treated due to poor premorbid status. At the three-month follow-up, five patients had excellent functional outcomes (modified Rankin Scale 0-1) while three died. Conclusion: CCI is a rare but devastating clinical scenario, with high incidence of morbidity and mortality. Treatment strategy can impact patient outcome, and further research is warranted on the ideal acute and post-reperfusion treatments for CCI. In this series, IV tPA at stroke doses appeared to be the preferred initial step for its treatment, with subsequent coronary or cerebral endovascular therapy, if necessary.

Chronic thromboembolic pulmonary hypertension: a review.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension resulting from obstruction of the pulmonary artery by fibrotic thromboembolic material, usually initiated by recurrent or incomplete resolution of pulmonary embolism. This distinct form of pulmonary hypertension is classified under Group 4 of the World Health Organization classification. Further investigations are usually initiated, with transthoracic echocardiography followed by right heart catheterisation and pulmonary angiography as the gold standard. Definitive treatment is usually in the form of surgical pulmonary endarterectomy. Inoperable CTEPH is medically treated with pharmacological agents such as phosphodiesterase Type 5 inhibitors, endothelin receptor antagonists, soluble guanylate cyclase stimulators and prostacyclin. Recent developments have made balloon pulmonary angioplasty a viable option as well.