Streptococcus Mitis Endocarditis Associated with Early Gastric Carcinoma.

We report a case of Streptococcus mitis endocarditis associated with early gastric carcinoma. A 71-year-old man who had been diagnosed with aortic regurgitation (AR) two years previously was referred for valve surgery and evaluation of elevated inflammatory markers. Four months previously, atrophic gastritis, early gastric adenocarcinoma, and colon polyp had been identified in the patient during endoscopy. However, Helicobacter pylori testing was negative. On admission, he had no dental diseases or recent oral procedures. Echocardiography demonstrated severe AR and mobile vegetation on the aortic valve. Magnetic resonance imaging revealed cerebral embolism and spondylodiscitis. Blood cultures grew Streptococcus mitis. At surgery, destruction of the left cusp with vegetation and a perforation of the non-coronary cusp were found; in addition, aortic valve replacement was performed. Although the association between Streptococcus bovis bacteremia and colon neoplasm is well recognized, the association between Streptococcus mitis endocarditis and gastrointestinal carcinoma should also be kept in mind.

Rothia Aeria Endocarditis Complicated with Multiple Systemic Embolisms.

Rothia aeria is part of the normal flora in the human oral cavity and rarely causes serious systemic infection in healthy hosts. We report a case of infective endocarditis of the mitral valve due to Rothia aeria. A 53-year-old man suffered a cut on his left thumb. At the time, the patient licked the wound as a conventional way to accelerate its cure. Thereafter, he developed a recurrent fever, which was temporarily lysed with treatment using an intravenous antibiotic, over a period of 2 months after the injury. On admission, the patient had no dental caries and denied any dental procedures before onset of the fever. Auscultation revealed a systolic cardiac murmur. Echocardiography showed torn chordae of the posterior mitral leaflet with a small vegetation and severe mitral regurgitation. Two sets of blood cultures were positive for Rothia aeria. Computed tomography revealed splenic and left renal infarctions but no cerebral infarction. After resolution of the inflammation by 6 weeks of penicillin treatment, mitral valve repair was successfully performed.

Acute Mitral Regurgitation After Blunt Chest Trauma: A Case Report.

Myocardial contusion is the most common cardiac injury from blunt chest trauma (BCT), whereas isolated valve injury is uncommon. We report a case of acute mitral regurgitation (MR) due to isolated valve injury after BCT. A 60-year-old man received an impact on his left chest by a car wheel three weeks prior to visiting our hospital. At the time a diagnosis of contusion of the chest wall without rib and sternal fractures was made. Thereafter, the patient had progressive worsening of heart failure symptoms. Eventually he developed dyspnea on slight exertion but echocardiographic evaluation was not performed at the time of diagnosis or during the three weeks prior to admission. At admission a holosystolic murmur was heard. Transthoracic echocardiography revealed prolapse of the posterior mitral leaflet due to torn chordae tendineae with severe MR and normal left ventricular wall motion. At surgery, torn chordae tendineae and a leaflet tear of the posterior leaflet were detected, and mitral valve repair was achieved without residual MR. Pathological examination of the torn chordae showed no findings of endocarditis or myxomatous degeneration. Echocardiography may play an important role for accurate and prompt diagnosis of cardiac lesions in patients with recent or a history of high-energy BCT.

Anomalous Aortic Origin of the Right Coronary Artery Incidentally Detected In a Patient with Degenerative Mitral Valve Disease.

Anomalous aortic origin of a coronary artery from the opposite sinus of Valsalva is known as a cause of sudden cardiac death. However, it is often asymptomatic and incidentally diagnosed during evaluation for other cardiac diseases. We report a case of anomalous aortic origin of the right coronary artery (RCA) from the left sinus of Valsalva (ARCA) detected incidentally in a patient with degenerative mitral regurgitation (MR). A 47-year-old man, who had no history of myocardial ischemic symptoms on exertion, was admitted for sudden orthopnea. ECG revealed no ischemic changes and arrhythmias. Echocardiography demonstrated MR due to torn chordae of the posterior mitral leaflet. Computed tomography (CT) revealed the RCA arising from the left sinus of Valsalva at an acute angle and taking an interarterial course between the great arteries. The proximal RCA showed a circular shaped cross-section on CT, suggesting no presence of an intramural segment. Considering refractory heart failure and no history of myocardial ischemic symptoms on exertion as well as the findings of the CT angiography, urgent mitral valve repair was undertaken without surgical intervention for the anomalous RCA, and without evaluating myocardial ischemia. The patient recovered uneventfully. Postoperatively, myocardial perfusion scintigraphy demonstrated no exercise-induced myocardial ischemia. Patients with ARCA who are asymptomatic and whose coronary course is not intramural can be managed without surgical intervention for an anomalous coronary artery.

Retinal pigment epithelium atrophy after epiretinal membrane and internal limiting membrane peeling: case reports.

Objective: To describe the development of retinal pigment epithelium (RPE) atrophy after uncomplicated pars plana vitrectomy (PPV) with epiretinal membrane (ERM) and/or internal limiting membrane (ILM) peeling in 2 patients. Cases description: Case 1: A 79-years-old female with diagnosis of a full-thickness macular hole in her right eye (OD) with best corrected visual acuity (BCVA) of: 20/100 and left eye (OS): 20/70. After surgery she developed large RPE hyperplasia and presented hand movement that did not improve with pinhole. Case 2: A 69-years-old female patient who had ERM in her OS with BCVA of 20/30 in both eyes (OU). PPV was assisted with brilliant blue (BB) to better visualize the ILM. During follow-up visits we evidenced RPE atrophy in the zone where peeling was done. In the last control after 2-years, her visual acuity was 20/40 that did not improve with pinhole. Discussion: There are three possible mechanisms to explain this complication: toxic damage, mechanical trauma during the membrane removal with forceps, or a combination of both. In our cases, a combination of them is probably the cause of the presence of RPE atrophy. Conclusion: Vitrectomy with membrane removal is successful in most cases with low rate of complications. Because RPE atrophy is infrequent, our suggestion is to continue performing this technique and if possible, it should be done without dye staining to minimize risks. Abbreviations: ERM = epiretinal membrane, ILM = internal limiting membrane, MH = macular hole, RPE = Retinal pigment epithelium, OD = right eye, BCVA = Best corrected visual acuity, OS = left eye, OU = both eyes, IOL = intraocular lens, OCT = Optical coherence tomography, BB = Brilliant blue, TB = Trypan blue, ICG = indocyanine green.

Pregnancy-unrelated spontaneous rupture of a right ovarian artery aneurysm.

Spontaneous rupture of an ovarian artery aneurysm is extremely rare. It can lead to retroperitoneal hemorrhage that is often life-threatening. We report a case of pregnancy-unrelated spontaneous rupture of a right ovarian artery aneurysm in a multiparous woman. A 29-year-old woman, gravida 3, para 3, whose latest pregnancy involved uneventful gestation and delivery 2 years previously, was admitted for right flank pain. The urine test result for pregnancy was negative. Computed tomography revealed a large retroperitoneal hematoma and right ovarian artery aneurysm with contrast extravasation. After selective angiography, embolization of the right ovarian artery was successfully achieved using microcoils. Diagnostic angiography with subsequent transcatheter arterial embolization is an effective and less invasive technique for the management of ovarian artery aneurysm.

Aortic valve replacement for dextrocardia with situs inversus totalis.

Dextrocardia is a rare congenital cardiac positional anomaly. A 74-year-old woman was referred for aortic regurgitation (AR). Chest X-ray revealed a mildly enlarged heart that directed to the right side. Transthoracic echocardiography showed AR due to cusp prolapse with a dilated left ventricle and reduced wall motion. Computed tomography demonstrated the heart and great vessels in a mirror image of their normal positions. A median sternotomy performed by the surgeon standing on the right side of the patient. After establishing a cardiopulmonary bypass, the surgeon moved to the left side of the patient, and then performed aortic valve replacement.

Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist.

OBJECTIVES: Most Japanese hospitals need to keep to higher Staphylococcus aureus bacteremia (SAB) quality-of-care indicators (QCIs) and create strategies that can maximize the effect of these QCIs with only a small number of infectious disease specialists. This study aimed to evaluate the clinical outcomes of patients with SAB before and after the enhancement of the mandatory infectious disease consultations (IDCs). METHODS: This retrospective study was conducted at a tertiary care hospital in Japan. The primary outcome was the 30-day mortality between each period. A generalized structural equation model was employed to examine the effect of the mandatory IDC enhancement on 30-day mortality among patients with SAB. RESULTS: A total of 114 patients with SAB were analyzed. The 30-day all-cause mortality differed significantly between the two periods (17.3% vs. 4.8%, P = 0.02). Age, three-QCI point ≥ 1, and Pitt bacteremia score ≥ 3 were the significant risk factors for 30-day mortality. The intervention was also significantly associated with improved adherence to QCIs. CONCLUSION: Mandatory IDCs for SAB improved 30-day mortality and adherence to QCIs after the intervention. In Japan, improving the quality of management in patients with SAB should be an important target.

Repeated Peripheral Embolisms associated with Chronic Aortic Dissection.

A male patient developed acute type B aortic dissection (AD) extending to the right external iliac artery (EIA) and left common femoral artery at the age of 56 years. Two months after the diagnosis of AD, he developed right renal infarction suggesting embolism, as the right renal artery arose from a false lumen containing a mural thrombus. Seven years later, at the age of 63 years, the patient was readmitted for acute onset of intermittent claudication in the right leg. On admission, arterial pulses distal to the right femoral artery were absent. The right ankle-brachial pressure index (ABI) was 0.66, while the left ABI was 1.06. Computed tomography (CT) confirmed chronic type B AD and revealed a localized occlusion of the right EIA and disappearance of a small protruding thrombus in the false lumen that was found on the previous CT, suggesting a second embolism. Since recovery of antegrade blood flow was insufficient after catheter embolectomy, femorofemoral bypass was performed with resolution of ischemic symptoms. Postoperatively, the ABI recovered to 0.99 in the right and 1.12 in the left, and CT showed a patent bypass graft and restoration of blood flow to the right leg. This case indicates that embolism should be recognized as one of the possible causes of acute organ ischemia in patients with AD, even in patients with chronic AD.

Infectious disease consultations and newly diagnosed cancer patients: A single-center retrospective observational study.

Noninfectious diseases may be diagnosed during infectious disease (ID) consultations. Among non-IDs, cancer diagnosis is important; however, epidemiological data describing the relationship between ID consultations and newly diagnosed cancer patients are scarce. This study described the frequency and tendency of new cancer diagnoses in patients after ID consultation.This retrospective study included adult inpatients who underwent ID consultations between October 2016 and March 2018. The demographic data and clinical manifestations of each case are described.Among the 380 inpatients who underwent ID consultations, 6 (1.6%) received a new cancer diagnosis after ID consultation. Among the initial most likely diagnoses, 3 patients were diagnosed with IDs and 3 were diagnosed with non-IDs. The initial most likely ID diagnosis was important for new cancer diagnoses (P = .004, odds ratio: 11.1, 95% confidence interval: 2.11-57.2); diagnostic errors, as judged by the physicians, occurred in 2 of the 6 cases.While the frequency of establishing new diagnoses during ID consultations is low, coexisting infection and cancer is possible. ID specialists should identify any patterns related to new cancer diagnosis in patients to prevent diagnostic error and improve the quality of diagnosis.

Meteorological and chronobiological factors and the occurrence of acute aortic dissection.

Although a number of studies have demonstrated seasonal variations in acute cardiovascular events, the association between winter and low temperatures and the incidence rate of acute aortic dissection has not been fully elucidated. In this study, we investigated the association between meteorological and chronobiological factors and the occurrence of acute aortic dissection classified by the Stanford type, sex and age. We retrospectively collected 131 patients who had been admitted consecutively to our institution with acute aortic dissection, including 58 type A patients and 73 type B patients, from January 2013 to December 2017. The meteorological data were downloaded from the homepage of the Japan Meteorological Agency. The daily incidence of aortic dissection was higher in winter (10.2%) than in fall (5.3%) (P = 0.04), and a significant winter peak was also observed in the sub-groups of males and type B, while there were no significant differences in the proportions of type A, female, and ≤ 70- and > 70-year-old patients. The maximum, mean and minimum temperatures on the days with aortic dissection were significantly lower than on the days without aortic dissection. Divided into four seasons, lower temperatures were found only in spring. The most significant and greatest difference was observed between the maximum temperature on the day of aortic dissection and that at 2 days earlier. The multivariate logistic regression analysis showed that the difference in the maximum temperature between the day of and 2 days before the incident (odds ratio 0.91; 95% confidence interval 0.87-0.96; P < 0.01) as well as the maximum temperature (odds ratio 0.97; 95% confidence interval 0.95-0.99; P = 0.02) were significantly associated with the incidence of aortic dissection. Cold weather and a sudden decrease in temperature might trigger aortic dissection, although the influence might differ among sub-groups.

Initial medical management in acute type A aortic dissection patients with a thrombosed false lumen in the ascending aorta combining intramural hematoma and retrograde dissection from the descending to the ascending aorta.

BACKGROUND: The feasibility of medical management for select patients with acute type A aortic dissection has been reported from a few institutions. In this study, we retrospectively investigated the safety and feasibility of our conservative approach for patients with type A aortic dissection in daily practice. METHODS: From January 2013 to December 2017, 131 consecutive patients were admitted to our institution for acute aortic dissection, including 58 patients of type A. Initial medical management was attempted in select patients who were clinically stable and had a thrombosed false lumen of the ascending aorta without ulcer-like projections in the ascending aorta. RESULTS: Except for nine patients contraindicated for surgery, urgent surgery was performed in 26 patients (SRG group), while 23 patients (MED group) were treated with the initial medical management. The maximum diameter of the ascending aorta was significantly larger in the SRG group than in the MED group. In the MED group, the heart rate and blood pressures were well-controlled at admission to the intensive-care unit, and the systolic blood pressure was further reduced at 24 h after. The in-hospital mortality rates of the MED and SRG groups were 0% and 15%, respectively. During the follow-up period, the survival rate was significantly higher in the MED group than in the SRG group, and the aortic event-free survival at one year was 80%. CONCLUSIONS: The initial medical management for select patients with a thrombosed false lumen in the ascending aorta was a safe and feasible strategy in real-world practice.

Aortic Dissection Associated with Autosomal Dominant Polycystic Kidney Disease

A 78-year-old man who had been diagnosed with autosomal dominant polycystic kidney disease (ADPKD) and hypertension presented with chest pain. His family history was positive for ADPKD. Chest computed tomography (CT) revealed a type A aortic dissection with thrombotic occlusion of a false lumen and an ulcer-like projection in the ascending aorta, an aneurysm of the ascending aorta, and pericardial effusion. Abdominal CT showed multiple renal and hepatic cysts. At surgery, aortic dissection with thrombotic occlusion of the false lumen and an intimal tear in the distal ascending aorta were observed. Hemiarch replacement including the intimal tear was performed. The patient is doing well without requiring dialysis and without recurrence of aortic dissection or aneurysm under strict antihypertensive therapy 3 years after the operation. Pathological examination of aortic wall specimens revealed no degenerative abnormality. ADPKD should be kept in mind as one of the causative disorders of aortic dissection.

Pericardial injury from chest compression: a case report of incidental release of cardiac tamponade.

BACKGROUND: Although chest compression is a standard technique in cardiopulmonary resuscitation, it is well recognized that manual chest compression causes various internal injuries, of which major injuries are often fatal. Similarly, when cardiac tamponade occurs in patients with type A acute aortic dissection, many patients die before reaching the hospital. We report a rare case in which chest compressions caused pericardial laceration that may have inadvertently played a life-saving role in releasing cardiac tamponade induced by acute aortic dissection. CASE PRESENTATION: A 67-year-old woman developed cardiac arrest soon after complaining of epigastric pain, and after successful resuscitation by manual chest compression, she was transferred to our hospital. On arrival, the patient was 14 on the Glasgow Coma Scale. An ECG showed a normal sinus rhythm, and no arrhythmias or signs of myocardial ischemia were observed. A chest X-ray revealed left pleural effusion, while cardiomegaly and pneumothorax were not identified. Computed tomography revealed type A aortic dissection, mild pericardial effusion, and massive left pleural effusion. No pulmonary embolus was found on the CT. After drainage of bloody effusion from the left pleural space, an emergency operation was begun. During surgery, a pericardial laceration with communication to the left pleural space and a hemothorax were found; however, no cardiac injury was identified. No other intra-thoracic injuries or rupture of the aortic dissection causing the hemothorax were detected. Hemiarch replacement was performed without difficulty, but the patient died of multi-organ failure 30 days after surgery. CONCLUSIONS: We report a case of pericardial injury without skeletal fracture caused by chest compression. The pericardial laceration may have inadvertently served to release the cardiac tamponade induced by the acute aortic dissection, resulting in the hemothorax, and provided time to receive surgery.

Infective Endocarditis Associated with Atopic Dermatitis.

We report a case of aortic valve infective endocarditis (IE) in a 24-year-old man with atopic dermatitis (AD). He had a history of balloon valvuloplasty for a stenotic bicuspid aortic valve, and had dental caries but no invasive dental procedure before the onset of IE. On admission, skin lesions of AD with itching and scratches were found on the neck, trunk, and extremities. Echocardiography showed a vegetation on the aortic valve with mild steno-regurgitation, but extension of IE to the annulus was not detected. Magnetic resonance imaging identified fresh cerebral infarction without neurological dysfunction, leading us to suspect an embolism. Blood cultures grew methicillin-sensitive Staphylococcus aureus. During emergency surgery, a vegetation attached to the conjoined cusp was observed, and the aortic valve was replaced with a mechanical valve. The patient recovered uneventfully without any complications such as recurrent IE or mediastinitis. We also review previously reported cases of IE associated with AD.

Coexistence of Right Ventricular Myxoma and Atrioventricular Septal Defect.

Although a small number of atrial myxomas are found in association with congenital cardiac defects, ventricular myxomas coexisting with congenital cardiac anomalies are extremely rare. We report a case of right ventricular (RV) myxoma coexistent with atrioventricular septal defect in an adolescent. Echocardiography showed an RV mass, a small ostium primum atrial septal defect, and a cleft of the left atrioventricular valve. Magnetic resonance imaging revealed a mass, suggesting a myxoma. The mass was excised simultaneously with repair of the anomalies and was histologically confirmed as a myxoma.

Intra-Atrial Excision of the Left Atrial Appendage: A Simple and Easy Technique.

In patients with atrial fibrillation, closure of the left atrial appendage (LAA) is recommended to prevent thromboembolic events, however, conventional exclusion or excision techniques have potential drawbacks such as persistent blood flow into the appendage and a residual stump. We propose a simple and easy technique for LAA closure consisting of intra-atrial excision of the LAA, which is invaginated into the left atrium (LA), and direct suture closure of the orifice from inside the LA. In this technique, complete elimination of the LAA was achieved without leaving a residual stump because the LAA was excised at the orifice and was closed at the base of the LAA.

Usefulness of three-dimensional transesophageal echocardiography for diagnosis of hemolytic anemia due to inverted internal felt strip after surgery for aortic dissection.

Felt strips are widely used for reinforcement of the aortic stump in surgery for aortic dissection (AD). Postoperative hemolytic anemia (HA) due to an inverted internal felt strip at the aortic stump fixation for AD is extremely rare. A 70-year-old woman underwent ascending aorta replacement for acute type A AD, where both proximal and distal anastomotic sites were reinforced with Teflon felt strips. A week later, macroscopic hematuria and HA emerged. Three-dimensional transesophageal echocardiography (3D-TEE) demonstrated that the proximal inner felt strip turned up and protruded into the aortic inner lumen. At redo surgery, which was performed 2 weeks after the initial surgery, the findings of 3D-TEE were confirmed, and the inverted internal felt strip was replaced with a bovine pericardial strip. The findings of HA disappeared immediately after the second surgery. 3D-TEE is a very informative, valuable modality for accurate diagnosis that leads to a safe surgery.

A Case of Femoral Arterial Bleeding by an Unknown Origin Metastatic Groin Lymph Nodes Carcinoma.

We report a case of femoral arterial bleeding complicated with hemorrhagic shock caused by bacterial infection attributed to an inguinal lymph node metastasis of carcinoma of unknown primary. Because of severe preoperative condition, a venous patch plasty of ruptured artery, and omentopexy for the groin was performed as a less invasive surgery. But the recurrence of bleeding was occurred postoperatively. A staged operation, hemostasis with a venous patch plasty at a first stage, and an extra-anatomical bypass soon after improvement of shock condition in a second stage, can be one of surgical procedures to save the lives and salvage limbs.

Isolated Tricuspid Valve Endocarditis Caused by Infection of an Implanted Central Venous Access Port Device.

A 70-year-old man was referred to our hospital for an intermittent high fever attributed to subcutaneous pocket infection of an implanted central venous access port device caused by methicillin-resistant staphylococcus aureus and subsequent bloodstream infection. Echocardiography revealed a large vegetation on the posterior tricuspid leaflet, annular dilatation and moderate-to-severe tricuspid regurgitation. Valve surgery was performed for persistent infection despite 8 weeks of antibiotics therapy. At operation, vegetations and torn chordae tendineae were found on the posterior tricuspid leaflet. After total resection of the posterior tricuspid leaflet, bicuspidalization valvuloplasty with prosthetic ring annuloplasty was achieved without relapse of the infection or residual regurgitation.