Association of right ventricular dysfunction and pulmonary hypertension with adverse 30-day outcomes in COVID-19 patients.

BACKGROUND: Cardiac manifestations in COVID-19 are multifactorial and are associated with increased mortality. The clinical utility and prognostic value of echocardiography in COVID-19 inpatients is not clearly defined. We aim to identify echocardiographic parameters that are associated with 30-day clinical outcomes secondary to COVID-19 hospitalization. METHODS: This retrospective cohort study was conducted in a large tertiary hospital in New York City during the COVID-19 pandemic. It included 214 adult inpatients with a laboratory-confirmed diagnosis of COVID-19 by reverse transcriptase polymerase chain reaction assay (RT-PCR) for SARS-CoV-2 on nasopharyngeal swab and had a transthoracic echocardiogram performed during the index hospitalization. Primary outcome was 30-day all-cause inpatient mortality. Secondary outcomes were 30-day utilization of mechanical ventilator support, vasopressors, or renal replacement therapy. RESULTS: Mild right ventricular systolic dysfunction (odds ratio (OR): 3.51, 95% confidence interval (CI): 1.63-7.57, p = 0.001), moderate to severe right ventricular systolic dysfunction (OR: 7.30, 95% CI: 2.20-24.25, p = 0.001), pulmonary hypertension (OR: 5.39, 95% CI: 1.96-14.86, p = 0.001), and moderate to severe tricuspid regurgitation (OR: 3.92, 95% CI: 1.71-9.03, p = 0.001) were each associated with increased odds of 30-day all-cause inpatient mortality. Pulmonary hypertension and moderate to severe right ventricular dysfunction were each associated with increased odds of 30-day utilization of mechanical ventilator support and vasopressors. CONCLUSIONS: Right ventricular dysfunction, pulmonary hypertension, and moderate to severe tricuspid regurgitation were associated with increased odds for 30-day inpatient mortality. This study highlights the importance of echocardiography and its clinical utility and prognostic value for evaluating hospitalized COVID-19 patients.

Venous Stent Migrating to the Right Heart Causing Severe Regurgitation.

Venous stent migration to the cardiopulmonary system is a rare but serious complication. Cardiopulmonary involvement has various presentations such as valvulopathy, acute heart failure, arrhythmias, endocarditis, and tamponade. The presenting symptoms depend on the eventual location of the stent in the heart or lungs, size of the stent, and valve involvement. Extracardiac dislodgement can be managed by catheter-directed extraction or proper deployment within the containing vessel or surgical extraction. Intracardiac stents may require open surgery to prevent life-threatening complications. We present an asymptomatic patient with stent migration that lead to severe tricuspid regurgitation and required tricuspid valve replacement.

Isolated Pulmonic Valve Endocarditis.

BACKGROUND Infective endocarditis (IE) has a high mortality rate, even when treated with appropriate antibiotic therapy and surgical intervention. Right-sided endocarditis is in itself rare, with some studies reporting an incidence of 5-10%. The majority of these cases involve the tricuspid valve, and isolated pulmonary valve endocarditis (PVE) is an extremely rare entity affecting less than 2% of patients with infective endocarditis. Identification and early management are crucial to prevent long-term complications and reduce mortality. CASE REPORT We present a patient with a history of essential hypertension and no underlying valvular disease, who underwent dental cleaning and subsequently developed low-grade fever, myalgia, and malaise. This occurred during the flu season, and was initially diagnosed and treated as flu, without any improvement. The patient was later found to be bacteremic with S. mitis, with no identifiable source, and a normal transthoracic echocardiogram (TTE). He was later hospitalized, had a transesophageal echocardiogram, and was found to have a large pulmonic valve vegetation. CONCLUSIONS This case presents an interesting and rare finding of endocarditis, isolated to the pulmonic valve, in an otherwise healthy individual with no predisposing risk factors. The lack of peripheral stigmata, as well as an unremarkable initial outpatient TTE, made the diagnosis more difficult. It should also be noted that current guidelines do not specifically address right-sided endocarditis, and do not specify the role of surgical intervention.

Aortic valve fibroelastoma: a rare cause of stroke.

The prevalence of primary cardiac tumours varies from 0.02% to 0.45%. Cardiac papillary fibroelastoma (CPF) is a rare tumour diagnosed incidentally on imaging. The clinical manifestations result from thromboembolisation and include transient ischaemic attack, stroke and sudden cardiac death. We present a patient aged 57 years with CPF arising from the aortic valve. The patient presented with right hemiparesis due to acute stroke. He received tissue plasminogen activator with complete resolution of neurological symptoms. Echocardiography revealed a broad-based, gelatinous, non-mobile mass on the left aortic cusp. The tumour was excised sparing the aortic valve. The patient recovered rapidly without any complications. The histopathological examination confirmed the diagnosis of CPF. A review of the literature suggests that CPF is a rare but treatable cause of stroke. The course is not clear and there are no tumours or patient-related characteristics which could predict the risk of thromboembolisation. Surgical treatment is definite and is relatively safe.

Severe Bioprosthetic Mitral Valve Stenosis and Heart Failure in a Young Woman with Systemic Lupus Erythematosus.

A 23-year-old African American woman with a past medical history of systemic lupus erythematous (SLE), secondary hypertension, and end stage renal disease (ESRD) on hemodialysis for eight years was stable until she developed symptomatic severe mitral regurgitation with preserved ejection fraction. She underwent a bioprosthetic mitral valve replacement (MVR) at outside hospital. However, within a year of her surgery, she presented to our hospital with NYHA class IV symptoms. She was treated for heart failure but in view of her persistent symptoms and low EF was considered for heart and kidney transplant. This was a challenge in view of her history of lupus. We presumed that her stenosis of bioprosthetic valve was secondary to lupus and renal disease. We hypothesized that her low ejection fraction was secondary to mitral stenosis and potentially reversible. We performed a dobutamine stress echocardiogram, which revealed an improved ejection fraction to more than 50% and confirmed preserved inotropic contractile reserve of her myocardium. Based on this finding, she underwent a metallic mitral valve and tricuspid valve replacement. Following surgery, her symptoms completely resolved. This case highlights the pathophysiology of lupus causing stenosis of prosthetic valves and low ejection cardiomyopathy.

Lemierre's Syndrome: A Rare Case of Pulmonic Valve Vegetation.

Lemierre's syndrome is an uncommon complication of pharyngitis commonly associated with an anaerobic gram negative bacterium, Fusobacterium necrophorum. The syndrome usually affects young healthy adults with the mean age of 20 and is characterized by recent pharyngitis followed by ipsilateral internal jugular vein thrombosis and septic thromboembolism. The treatment is at least 6 weeks of antibiotics; the role of anticoagulation is unclear. The following presentation is a case of Lemierre's syndrome in a 23-year-old healthy individual who is infected by a rare species: Fusobacterium nucleatum. The case is complicated by septic emboli to the lungs and impressive seeding vegetation to the right ventricular outflow tract (RVOT) at the pulmonic valve of the heart.