Isolated Flailed P3 Scallop of the Mitral Valve Leaflet in the Setting of Newly Diagnosed Heart Failure With Preserved Ejection Fraction.

Mitral valve prolapse (MVP) is characterized by typical fibromyxomatous changes in the mitral leaflet tissue with superior displacement of one or both leaflets into the left atrium. An echocardiogram is a fundamental study required for the diagnosis of MVP with a flail leaflet and grading of mitral regurgitation (MR) severity. Most patients with MVP have a risk of cardiovascular morbidity and mortality similar to that of the general population, though moderate to severe MR and left ventricular (LV) ejection fraction less than 50% have been postulated to increase the risk of adverse cardiac events. In this case report, we present an isolated flailed P3 scallop of the mitral valve leaflet leading to severe MR and acute congestive heart failure. A 54-year-old African-American male with a medical history of hypertension, hyperlipidemia, and transient ischemic attack, presented to the emergency department (ED) for evaluation of dyspnea on exertion. The patient reported that his dyspnea started one week prior to ED visit and was associated with intermittent chest pain. He also endorsed mild orthopnea and lightheadedness, though he denied any syncopal event. Vital signs were found within normal limits on arrival. He clinically appeared to be volume overloaded which improved quickly with IV furosemide. Transesophageal echocardiogram (TEE) with 3D image acquisition showed significant for hyper-dynamic LV function and evidence of isolated flailed P3 scallop of the mitral valve (MV) leaflet resulting in a severe eccentric, anteriorly directed MR jet. The MV leaflets did not appear thickened, and there was no evidence of mitral or aortic stenosis. Cardiac catheterization showed multivessel disease for which the patient underwent coronary artery bypass grafting and MV repair. This patient presented with new-onset congestive heart failure secondary to severe MR associated with undiagnosed MVP. Commonly, the middle scallop (P2) of the posterior leaflet is more prone to prolapse due to its redundancy and variable thickness with the impact of greater systolic pressure. However, in this case of acute severe MR, we identified an isolated flail of the P3 segment. We believe that this rare TEE finding was associated with a torn chordae or ruptured papillary muscle secondary to ischemic disease as the posteromedial papillary muscle has a single blood supply and is particularly prompted to injury from myocardial infarction.

Aorto-right ventricular fistula: a rare complication of Abiotrophia Endocarditis.

A 41-year-old African male presented with worsening dyspnea and cachexia concerning for congestive heart failure. Transesophageal echocardiogram revealed a large mass attached to the aortic valve leaflet, mass attached to the flail anterior mitral valve leaflet, severe pulmonary hypertension and dilatation of the aortic root along with fistula between the right coronary aortic cusp and the right ventricular (RV) outflow tract. Blood cultures grew Abiotrophia Defectiva (AD) sensitive to vancomycin. Patient underwent emergent surgical closure of aorto RV fistula and aortic root replacement along with pulmonary and mitral valve replacement. Endocarditis caused by AD has been reported to result in heart failure, septic embolization and destruction of the valve despite use of appropriate antibiotics. To our knowledge, this is the only case of AD endocarditis without any identified entrance route; requiring replacement of pulmonary, mitral and aortic valve due to extensive valvular damage and large vegetations.

Impact of Switching From Prasugrel to Clopidogrel Shortly After a Percutaneous Coronary Intervention Without a Loading Dose of Clopidogrel.

OBJECTIVE: To determine the safety and efficacy of administering prasugrel at the time of percutaneous coronary intervention (PCI), and switching to clopidogrel, without reloading. BACKGROUND: Prasugrel has faster onset of action and appears to be of greater benefit than clopidogrel, particularly early after PCI. However, long-term prasugrel increases bleeding. Many physicians at Geisinger Medical Center (GMC) administer prasugrel before PCI and switch to clopidogrel afterward. The safety and efficacy of this strategy has not been studied. METHODS: We performed a retrospective study using electronic medical records and identified patients at GMC who underwent PCI between February 1, 2009 and January 31, 2012 and received a loading dose of prasugrel with a subsequent switch to clopidogrel, without reloading. The primary endpoint was major adverse cardiovascular event (MACE), defined as death, myocardial infarction (MI), stroke, or stent thrombosis, 7 days after the first dose of clopidogrel. Secondary endpoints included MACE at 30 days, individual MACE components at 7 and 30 days post procedure, and bleeding as defined by the Bleeding Academic Research Consortium (BARC) at 1 day and 30 days. RESULTS: A total of 151 patients met inclusion criteria. One patient suffered a MACE on day 7 (0.7%; 95% confidence interval, 0.03%-3.33%). One patient had an MI between 8-30 days. Two patients had BARC bleeding (type 2 and type 3b) 30 days post PCI. CONCLUSIONS: In this small, retrospective analysis, the results of loading patients with prasugrel for PCI and switching them to clopidogrel without a loading dose appear to be encouraging.