Embolic Phenomena Research Articles

Clinical, echocardiographic, and pathologic characteristics of patients with pathology-proven nonbacterial thrombotic endocarditis

Abstract Background Non-bacterial thrombotic endocarditis (NBTE) is a non-infectious condition characterized by thrombotic and/or inflammatory depositions involving the cardiac valves. It is a challenging diagnosis of exclusion. Purpose This study aimed to better characterize patients with pathologically proven NBTE and assess its clinical, echocardiographic characteristics and prognostic implications. Methods We retrospectively identified patients with pathology-proven NBTE at a single center. Patients with positive preoperative blood cultures, a history of active or treated infective endocarditis, or identification of valvular organisms by special stains were excluded from the study. Patients with pathology reports of valve perforation or chordal rupture were also excluded because of the high likelihood of an infectious etiology for these lesions. Results A total of 53 patients with NBTE (median age 57 years; 61% females) were identified. In this cohort, 22% had a history of malignancy, 30% had connective tissue disease, 32% had coronary artery disease, and 11% prior history of NBTE. Neurological events accounted for 18 (34%) of the presenting symptoms (TIA n=17, CVA n=9), while new valvular dysfunction in 7 (13%) and fever in 8 (15%) of patients. Five patients (9%) had NBTE involving more than one valve. NBTE involved the mitral valve in 64%, aortic valve in 38% prosthetic/mechanical valve in 11%, and tricuspid valve in 5%. NBTE was identified at the time of autopsy in 34% of patients. NBTE recurred in 3 patients during follow-up. Excluding patients diagnosed at the time of autopsy, 9% of patients died within 1 year of NBTE diagnosis. Conclusion NBTE was diagnosed pathologically in the presence of hyper-inflammatory states due to critical illness or immunological diseases. It was predominantly on the left side of the heart and was associated with embolic phenomena, either clinically or on imaging. Patients diagnosed with antemortem with NBTE have a high mortality in the first year (9%).

Lingual artery thrombosis as a presentation of infective endocarditis in a pregnant patient; a case report

Abstract Background Infective endocarditis during pregnancy is a rare condition that compromises the health of both the mother and the fetus, presenting high rates of morbidity and mortality. The clinical manifestations of this disease are varied, with embolic phenomena being a frequent presentation. Case summary We report the case of a 37-year-old patient, at 29 weeks of pregnancy, with no known cardiovascular history, who presented with 48 hours of sudden mandibular and lingual pain. The study showed acute thrombosis of the right lingual artery and the rest of the right external carotid artery. In this context, searching for the origin of the embolism, acute mitral valve endocarditis was diagnosed, which was effectively treated with antibiotic therapy and biological mitral valve replacement, as well as early cesarean delivery. Discussion We report the first case where lingual artery thrombosis was the key diagnostic feature of infective endocarditis.

Infective Endocarditis by Listeria Species—A Systematic Review

Infective endocarditis (IE) is a disease associated with significant morbidity and mortality. It is more commonly caused by Gram-positive cocci, but Gram-positive bacilli may seldom cause the disease. Listeria monocytogenes is an aerobic Gram-positive coccobacillus and a foodborne and opportunistic pathogen most commonly causing gastrointestinal infections, even though bacteremia, sepsis, meningitis, and fetal infections may also occur. Listeria IE has rarely been described, with most reports being case reports or case series. Thus, the characteristics of this disease remain largely unknown. This systematic review aimed to present all published Listeria IE studies and describe their characteristics. A search of PubMed, Scopus, and the Cochrane Library for studies providing information on epidemiology, clinical findings, treatment, and outcome of Listeria IE cases was performed. A total of 54 studies containing data from 62 patients were included. Among all patients, 64.5% were male; the median age was 69 years. Among all patients, 54.8% had a history of a prosthetic valve. The aortic valve was the most commonly affected, followed by the mitral. Fever, heart failure, and embolic phenomena were the most commonly encountered clinical findings. The only isolated species was L. monocytogenes. Antimicrobial resistance was relatively low for aminopenicillins and aminoglycosides, the most commonly used antimicrobials for treating L. monocytogenes IE. Surgery was performed in 27.4% of patients. Mortality was 37.1%. Patients who survived were more likely to have had a prosthetic valve, to have necessitated transesophageal echocardiography for the diagnosis, to have mitral valve IE, and to have had surgical management; however, no factor was identified in a multivariate logistic regression model as an independent factor for overall mortality.

From flank pain to splenic abscess: a complex case of infective endocarditis with literature review

BackgroundInfective endocarditis (IE) is a severe condition characterized by inflammation of the heart endocardium and valves, commonly caused by Gram-positive bacteria. Complications such as embolic phenomena and organ abscesses can arise, necessitating timely diagnosis and intervention.Case presentationWe report the case of a 20-year-old female with a history of cerebral and splenic infarctions due to IE. The patient presented with left-sided flank pain, urinary burning, and fever. Examination revealed mitral and aortic valve involvement, splenomegaly, and neurological deficits. Despite initial antibiotic therapy, the patient developed a splenic abscess and drug-induced neutropenia. She required aortic valve replacement and was successfully managed with a multidisciplinary approach.ConclusionMultidisciplinary management, including timely surgical intervention and advanced imaging, is essential for favorable outcomes in IE patients. This case underscores the importance of early detection and tailored treatment strategies in managing severe complications associated with IE.

Trash Feet and Mesenteric Ischemia as a Rare Manifestation of a Complicated Abdominal Aortic Aneurysm: A Case Report.

Abdominal aortic aneurysms and atheromatous plaques are well-established potential culprits in the development of cholesterol embolization. This embolic phenomenon can result in the occlusion of peripheral arteries in the forefoot or toes, commonly referred to as "trash foot". A 61-year old patient exhibited severe symptoms and signs of lower limb and mesenteric ischemia, represented clinically by abdominal pain, hematochezia, and bilateral plantar necrotic lesions, attributed to embolization from a previously unknown large infrarenal abdominal aortic aneurysm. Diagnosis was confirmed by performing angio-CT of the abdomen, an angiologic examination, as well as colonoscopy. The patient underwent open surgical repair of the aortic aneurysm and received intravenous prostanoids, resulting in a successful outcome with resolution of bowel ischemia and complete recovery of bilateral foot lesions with no tissue loss. Cholesterol embolization syndrome seldom manifests with its complete clinical spectrum. Identifying and addressing the underlying cause is crucial, with a focus on potential abdominal aortic aneurysms. A combined approach involving surgical repair and prostanoid therapy may offer a viable option for patients experiencing severe manifestations.

Large ventricular myxoma causing inflow and outflow obstruction of the right ventricle; A Case Report

BackgroundMyxomas are the most common primary benign heart tumors, typically found in the left atrium, with only 2–4% occurring in the right ventricle. Clinical presentations vary widely, including congestive heart failure and systemic embolic phenomena. This case report describes a rare right ventricular myxoma causing both inflow and outflow obstruction, presenting as progressive exertional dyspnea.Case PresentationA 23-year-old male presented with two weeks of worsening exertional dyspnea. He was stable but tachypneic with a systolic murmur over the tricuspid area. Elevated erythrocyte sedimentation rate (ESR) and C-Reactive protein (CRP) were noted, while other lab tests were normal. Imaging, including echocardiography and chest tomography scan (CT) revealed a 4 × 3.8 × 4.6 cm mass in the right ventricle extending to the pulmonary trunk. Surgical resection via right ventriculotomy was performed, and histopathology confirmed myxoma. The patient recovered uneventfully.ConclusionRight ventricular myxomas, though rare, can cause significant obstruction and present with diverse symptoms. Timely diagnosis using imaging techniques like echocardiography is crucial. Surgical resection remains the definitive treatment, offering excellent outcomes and low recurrence rates. Early intervention is vital to prevent serious complications and ensure favorable patient prognosis.

Echocardiographic predictors and associated outcomes of multiple vegetations in infective endocarditis: A pilot study.

Infective endocarditis (IE) is a life-threatening infection with an annual mortality of 40%. Embolic events reported in up to 80% of patients. Vegetations of > 10 mm size are associated with increased embolic events and poor prognosis. There is a paucity of literature on the association of multiple vegetations with outcome. To study the echocardiographic (ECHO) features and outcomes associated with the presence of multiple vegetations. In this retrospective, single-center, cohort study patients diagnosed with IE were recruited from June 2017 to June 2019. A total of 84 patients were diagnosed to have IE, of whom 67 with vegetation were identified. Baseline demographic, clinical, laboratory, and ECHO parameters were reviewed. Outcomes that were studied included recurrent admission, embolic phenomenon, and mortality. Twenty-three (34%) patients were noted to have multiple vegetations, 13 (56.5%) were male and 10 (43.5%) were female. The mean age of these patients was 50. Eight (35%) had a prior episode of IE. ECHO features of moderate to severe valvular regurgitation [odds ratio (OR) = 4], presence of pacemaker lead (OR = 4.8), impaired left ventricle (LV) relaxation (OR = 4), and elevated pulmonary artery systolic pressure (PASP) (OR = 2.2) are associated with higher odds of multiple vegetations. Of these moderate to severe valvular regurgitation (P = 0.028), pacemaker lead (P = 0.039) and impaired relaxation (P = 0.028) were statistically significant. These patients were noted to have an increased association of recurrent admissions (OR = 3.6), recurrent bacteremia (OR = 2.4), embolic phenomenon (OR = 2.5), intensive care unit stay (OR = 2.8), hypotension (OR = 2.1), surgical intervention (OR = 2.8) and device removal (OR = 4.8). Of this device removal (P = 0.039) and recurrent admissions (P = 0.017) were statistically significant. This study highlights the associations of ECHO predictors and outcomes in patients with IE having multiple vegetations. ECHO features of moderate to severe regurgitation, presence of pacemaker lead, impaired LV relaxation, and elevated PASP and outcomes including recurrent admissions and device removal were found to be associated with multiple vegetations.

AN OUT OF HOSPITAL CARDIAC ARREST SURVIVOR WITH PRESUMED EMBOLIC MYOCARDIAL INFARCTION: ROLE OF MULTI–MODALITY IMAGING

Abstract Background Myocardial infarction with non–obstructive coronary arteries (MINOCA) refers to a puzzling clinical entity that is characterized by symptoms suggestive of acute coronary syndrome, demonstrates troponin elevation with inconclusive coronary angiogram. The underlying pathophysiologic mechanisms include atherosclerotic cause or non–atherosclerotic causes, such as coronary dissection or coronary embolus. A standardized approach that includes multimodality imaging is necessary to determine underlying aetiology and direct appropriate treatment. Case Summary A 57–year–old male was admitted to our hospital after experiencing cardiac arrest after physical exercise (swimming) treated immediately with cardiac pulmonary resuscitation and two defibrillator–delivered electrical shocks for shockable rhythm before return of spontaneous circulation. Relevant abnormal bloods included a hs–Troponin I elevation. Invasive coronary angiography demonstrated non–obstructed coronary arteries. Subsequent cardiac magnetic resonance imaging (MRI) demonstrated akinesia and an area of subendocardic late gadolinium enhancement in the inferior–lateral wall. This pattern was in keeping with an ischaemic cause, as a recent embolic myocardial infarction. Further investigations, including contrast bubble echocardiogram, were performed in order to identify a cause and source of the embolic infarction and led to the diagnosis of tunnel–like patent foramen ovale with right to left shunting, then confirmed on trans–oesophageal echocardiogram. The patient was treated as myocardial infarction most likely due to embolic phenomena in the presence of a PFO. Therefore, a transvenous ICD was implanted for secondary prevention and the patient underwent percutaneous closure of the PFO. Discussion and Conclusion MINOCA can occur in 5–15% of all acute coronary syndromes and represents a working diagnosis. It is important to identify the underlying aetiology of their presentation to appropriately manage them. In particular, where cardiac MRI demonstraded LGE areas ichaemic patterns, myocardial infarction due to secondary embolism should be considered and the next step in clinical management is to identify potential sources of emboli performing further assessments. Multi–modality imaging with cardiac MRI and echocardiogram (transthoracic, contrast bubble and trans–oesophageal) is important in correctly identifying any source of emboli and the diagnosis of any intra–cardiac shunt.

Ultrasound monitoring to detect embolic phenomena in the inferior vena cava during hip arthroplasty

Introduction and objectivesEmbolic phenomena frequently occur during hip joint replacement surgery, and may lead to haemodynamic instability in frail patients. Transoesophageal ultrasound monitoring is rarely available in non-cardiac operating theatres, and cannot be performed in awake patients under spinal anaesthesia. The main objectives of this prospective exploratory study were to determine the feasibility of using an alternative ultrasound approach to monitor the inferior vena cava during hip replacement surgery, and to determine the intra and interobserver reliability of the ultrasound findings. MethodWe conducted a prospective exploratory study in 20 patients undergoing cemented hip arthroplasty in the supine position under spinal anaesthesia and sedation. The inferior vena cava was assessed through a subcostal window at 10 intraoperative time points, and the findings were rated on a qualitative embolism severity scale. The ultrasound images were evaluated by 2 independent observers. ResultsAn adequate subcostal window was obtained in 90% of cases. Intra- and inter-observer reliability was high (kappa index >0.80, p < 0.001). Nearly all (95%) patients presented some degree of embolism, which was severe in 50% of cases. ConclusionsOur study suggests that ultrasound assessment of embolic phenomena in the inferior vena cava through a subcostal window is feasible in 90% of cases. The qualitative embolic severity rating scale is highly reproducible and has high intra- and inter-observer reliability.

Transcranial Doppler emboli monitoring for stroke prevention after flow diverting stents.

Flow diverting stents (FDS) are increasingly used for the treatment of intracranial aneurysms. While FDS can provide flow diversion of parent vessels, their high metal surface coverage can cause thromboembolism. Transcranial Doppler (TCD) emboli monitoring can be used to identify subclinical embolic phenomena after neurovascular procedures. Limited data exists regarding the use of TCDs for emboli monitoring in the periprocedural period after FDS placement. We evaluated the rate of positive TCDs microembolic signals and stroke after FDS deployment at our institution. We retrospectively evaluated 105 patients who underwent FDS treatment between 2012 and 2016 using the Pipeline stent (Medtronic, Minneapolis, MN, USA). Patients were pretreated with aspirin and clopidogrel. All patients were therapeutic on clopidogrel pre-operatively. TCD emboli monitoring was performed immediately after the procedure. Microembolic signals (mES) were classified as "positive" (<15 mES/hour) and "strongly positive" (>15 mES/hour). Clinical stroke rates were determined at 2-week and 6-month post-operatively. A total of 132 intracranial aneurysms were treated in 105 patients. TCD emboli monitoring was "positive" in 11.4% (n=12) post-operatively and "strongly positive" in 4.8% (n=5). These positive cases were treated with heparin drips or modification of the antiplatelet regimen, and TCDs were repeated. Following medical management modifications, normalization of mES was achieved in 92% of cases. The overall stroke rates at 2-week and 6-months were 3.8% and 4.8%, respectively. TCD emboli monitoring may help early in the identification of thromboembolic events after flow diversion stenting. This allows for modification of medical therapy and, potentially, preventionf of escalation into post-operative strokes.

Infective Endocarditis by Capnocytophaga Species-A Narrative Review.

Bacteria belonging to the genus Capnocytophaga are thin, capnophilic, Gram-negative bacilli with tapered ends that include nine species that are isolated from the mouth of humans and animals and, from a phylogenetical perspective, they belong to the family Flavobacteriaceae. Two more species, namely C. endodontalis and C. stomatis have been recovered from a periapical abscess and human and animal infections, respectively. Capnocytophaga spp. can cause serious and potentially life-threatening infections in humans, such as bacteremia and meningitis, most commonly in the context of penetrating trauma as a result of contact with animals, especially after animal bites. Other invasive diseases such as osteomyelitis, septic arthritis, and infective endocarditis (IE) may also occur more rarely. The aim of this study was to review all previously described cases of IE by Capnocytophaga spp. and provide information about the epidemiology, microbiology, antimicrobial susceptibility, clinical characteristics, treatment, and outcomes of this infection. A narrative review based on a search in PubMed, the Cochrane Library, and Scopus was performed. Studies published until 11 September 2023 providing relevant data for IE caused by Capnocytophaga spp. in humans were included. A total of 31 studies containing data from 31 patients were included. A history of dog bites was present in 10 out of 26 patients (38.5%). A prosthetic valve was present in 3 patients (9.7%). The most commonly infected valve was the aortic valve, followed by the tricuspid valve. Fever, embolic phenomena, paravalvular abscess, and sepsis were the most common clinical presentations. Beta-lactams and aminoglycosides were the antimicrobials most commonly used. Surgery was performed in 20 patients (64.5%). Overall mortality reached 16.1%.

Monitorización sonográfica de la vena cava inferior para la valoración de fenómenos embólicos durante la artroplastia de cadera

Introduction and objectivesEmbolic phenomena frequently occur during hip joint replacement surgery, and may lead to haemodynamic instability in frail patients. Transoesophageal ultrasound monitoring is rarely available in non-cardiac operating theatres, and cannot be performed in awake patients under spinal anaesthesia. The main objectives of this prospective exploratory study were to determine the feasibility of using an alternative ultrasound approach to monitor the inferior vena cava during hip replacement surgery, and to determine the intra- and interobserver reliability of the ultrasound findings. MethodWe conducted a prospective exploratory study in 20 patients undergoing cemented hip arthroplasty in the supine position under spinal anaesthesia and sedation. The inferior vena cava was assessed through a subcostal window at 10 intraoperative time points, and the findings were rated on a qualitative embolism severity scale. The ultrasound images were evaluated by 2 independent observers. ResultsAn adequate subcostal window was obtained in 90% of cases. Intra- and inter-observer reliability was high (kappa index>0.80, p<0.001). Nearly all (95%) patients presented some degree of embolism, which was severe in 50% of cases. ConclusionsOur study suggests that ultrasound assessment of embolic phenomena in the inferior vena cava through a subcostal window is reliable in 90% of cases. The qualitative embolic severity rating scale is highly reproducible and has high intra- and inter-observer reliability.

A299 ACUTE TUMOUR RUPTURE POST-TRANSARTERIAL CHEMOEMBOLIZATION IN A PATIENT WITH HEPATOCELLULAR CARCINOMA

Abstract Background Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, with increasing worldwide incidence. Transarterial chemoembolization (TACE) is an interventional radiological (IR) therapy used largely in intermediate stage HCC, which can provide successful bridge or downstaging to liver transplantation and increased survival rates. Tumour rupture is a very rare complication of TACE, with an estimated incidence of 0.68%. Potential risk factors include tumour size ampersand:003E 10 cm, and location of lesions in the right lobe or near the liver capsule. However, the pathophysiology of post-TACE tumour rupture is still not fully understood. Aims We aim to describe a case of HCC tumour rupture that occurred in the first 30 hours post-TACE. We also aim to highlight the extent of multiorgan ischemia associated with this tumour-related arterial bleed. Methods A PubMed literature review was done to ensure that post-TACE tumour rupture was a rare and sparsely reported event. Subsequently, inpatient notes, laboratory and imaging data were obtained from the patient's medical record in an anonymized manner. Results A 66-year-old male with alcohol-related liver cirrhosis (MELDNa 7; Child-Pugh Class A) was diagnosed with a 3.3 cm HCC, spanning segments 5 and 8. Six months later, after multidisciplinary discussion, he underwent successful elective TACE of a segment 8 artery that was supplying the HCC, as a bridge to liver transplantation. The next day, he developed diffuse abdominal pain, emesis, tachycardia, and abdominal firmness and tenderness. Labs showed a 45 g/L drop in hemoglobin (121 g/L to 76 g/L), leukocytosis (27.0 x109/L), and an elevated lactate (4.4 mmol/L). Computed tomography (CT) scan confirmed tumour rupture, with moderate-to-large hemoperitoneum with active bleeding from the embolized region of the HCC, and associated gas. Emergent IR-guided embolization was performed to the bleeding segment 8 artery. CT scan two days later revealed interval ischemic infarction of the spleen, pancreatic tail, and stomach. This widespread ischemia was suspected to be due to hypovolemic hypoperfusion vs. post-TACE embolic phenomena. Aggressive supportive measures, antibiotics, and anticoagulation were implemented. Due to tumour rupture, the patient was deemed no longer a suitable candidate for liver transplantation. Futility of definitive management was discussed, and the patient opted for medical care without resuscitation. After optimization of nutritional and physical functioning parameters, he was discharged home with medical management for pain and ascites. Conclusions Post-TACE tumour rupture is a rare occurrence for which the pathophysiology is not fully understood. This case provides an important reminder of this potential adverse event. Early detection and management are imperative to facilitating a favourable outcome in this life-threatening condition. Funding Agencies None

Mortality trends during the first three waves of the COVID-19 pandemic at an urban district hospital in South Africa: A retrospective comparative analysis

Background. Severe acute respiratory syndrome coronavirus 2 (SARS‐COV‐2) is the virus responsible for the COVID‐19 (C19) pandemic. South Africa (SA) experienced multiple periods of increased transmission. Tertiary, regional and central hospitals were overwhelmed, resulting in low acceptance rates. Objectives. To compare mortality trends of patients who died in hospital from SARS‐CoV‐2 infection during the first three waves of infection as defined by the National Institute of Communicable Diseases of South Africa. Methods. This was a retrospective cohort study at a district level hospital of 311 adults who died within the first three waves of COVID‐19. The study analysed case and crude fatality rates, baseline characteristics, symptomatology, clinical presentation and management of patients. Results. Waves 1, 2 and 3 yielded case fatality rates of 14.5%, 27.6% and 6.3%, respectively, and crude fatality rates of 16.7%, 33.0% and 12.2%, respectively. Black Africans were less likely to die during the third wave (odds ratio (OR) 0.54; 95% confidence interval (CI) 0.31 ‐ 0.94). Patients in the second wave had clinical frailty scores of &lt;5 (OR 2.51; 95% CI 1.56 ‐ 4.03). Obesity was most prevalent in the second wave (OR 1.87; 95% CI 1.01 ‐ 3.46), and dyslipidaemia (OR 3.03; 95% CI 1.59 ‐ 5.77) and ischaemic heart disease (OR 3.77; 95% CI .71 ‐ 8.33) were most prevalent during the third wave. Severe ground glass appearance was most common during the second wave (OR 2.37; 95% CI 1.49 ‐ 3.77). Renal impairment was most prevalent during the first wave (OR 3.28; 95% CI 1.59 ‐ 6.77), and thrombo‐ embolic phenomena were less common during wave three (OR 0.12; 95% CI 0.02 ‐ 0.91). Conclusion. The Beta variant was the most virulent, with the highest case and crude fatality rates in wave 2.

Clinicopathological differences between Bartonella and other bacterial endocarditis-related glomerulonephritis - our experience and a pooled analysis.

Although Staphylococcus aureus is the leading cause of acute infective endocarditis (IE) in adults, Bartonella spp. has concomitantly emerged as the leading cause of "blood culture-negative IE" (BCNE). Pre-disposing factors, clinical presentation and kidney biopsy findings in Bartonella IE-associated glomerulonephritis (GN) show subtle differences and some unique features relative to other bacterial infection-related GNs. We highlight these features along with key diagnostic clues and management approach in Bartonella IE-associated GN. We conducted a pooled analysis of 89 cases of Bartonella IE-associated GN (54 published case reports and case series; 18 published conference abstracts identified using an English literature search of several commonly used literature search modalities); and four unpublished cases from our institution. Bartonella henselae and Bartonella quintana are the most commonly implicated species causing IE in humans. Subacute presentation, affecting damaged native and/or prosthetic heart valves, high titer anti-neutrophil cytoplasmic antibodies (ANCA), mainly proteinase-3 (PR-3) specificity, fastidious nature and lack of positive blood cultures of these Gram-negative bacilli, a higher frequency of focal glomerular crescents compared to other bacterial infection-related GNs are some of the salient features of Bartonella IE-associated GN. C3-dominant, but frequent C1q and IgM immunofluorescence staining is seen on biopsy. A "full-house" immunofluorescence staining pattern is also described but can be seen in IE -associated GN due to other bacteria as well. Non-specific generalized symptoms, cytopenia, heart failure and other organ damage due to embolic phenomena are the highlights on clinical presentation needing a multi-disciplinary approach for management. Awareness of the updated modified Duke criteria for IE, a high index of suspicion for underlying infection despite negative microbiologic cultures, history of exposure to animals, particularly infected cats, and use of send-out serologic tests for Bartonella spp. early in the course of management can help in early diagnosis and initiation of appropriate treatment. Diagnosis of IE-associated GN can be challenging particularly with BCNE. The number of Bartonella IE-associated GN cases in a single institution tends to be less than IE due to gram positive cocci, however Bartonella is currently the leading cause of BCNE. We provide a much-needed discussion on this topic.

Cerebral Protection in Trans-Catheter Aortic Valve Replacement: Review and Contemporary Assessment of Randomized Trial Data.

As the population has aged and as aortic valve therapies have evolved, the use of trans-catheter aortic valve replacement (TAVR) has grown dramatically over the past decade. A well-known complication of percutaneous cardiac intervention is embolic phenomena, and TAVR is among the highest risk procedures for clinical and subclinical stroke. As indications for TAVR expand to lower-risk and ultimately younger patients, the long-term consequences of stroke are amplified. Cerebral embolic protection (CEP) devices have taken a on unique preventative role following the Food and Drug Administration approval of the SentinelTM Cerebral Protection System (CPS). More recently, the PROTECTED TAVR study has spurred extensive debate in the neuro-cardiac community. In this review we describe the contemporary literature regarding stroke risk associated with TAVR, the history and role of CEP devices, a PROTECTED TAVR sub-group analysis, and implications for next steps in the field. Lastly, we explore the unique need for CEP in a younger TAVR population, as well as directions for future research.

Infective Endocarditis by Lactobacillus Species-A Narrative Review.

Bacteria of the genus Lactobacillus are microaerophilic or aerotolerant anaerobic Gram-positive non-spore-forming rods. They are considered essential members of the human gut microbiome; however, recent studies have revealed that these microorganisms are less predominant in the gut microbiome than initially thought. Lactobacillus spp. is mainly known for its use as a probiotic in foods and supplements to prevent and treat specific issues such as infectious diseases, irritable bowel syndrome, and diabetes mellitus. However, Lactobacillus spp. may occasionally cause infections such as bacteremia or infective endocarditis (IE). The present study aimed to review all cases of IE by Lactobacillus spp. and describe the epidemiology, microbiology, clinical characteristics, treatment, and outcomes of this infection by collecting relevant data from studies existing in Pubmed and Scopus until 28 September 2023. A total of 77 studies containing data for 82 patients were included. The median age was 56 years, and 69.6% were male. A prosthetic valve was present in 16% of patients, and 17.3% had previously been on probiotics. The aortic valve was the most commonly involved intracardiac site, followed by the mitral valve. Fever, embolic phenomena, sepsis, and heart failure were the most common clinical presentations. Aminoglycosides and penicillin were the most commonly used antimicrobials for definitive treatment. Surgery was performed in 53.7% of patients. Overall mortality was 17.1%. IE in prosthetic valves and presentation with shock were independently associated with overall mortality.

Pancreatic cancer with multiple liver metastasis complicating multi organ infarcts from Marantic endocarditis and Trousseau’s syndrome

Background: Marantic endocarditis and Trousseau’s syndrome are historically linked with pancreatic cancer. The patient had catastrophic embolic events which caused multi organ infarct due to underlying advanced pancreatic cancer. Doctors should be aware of early signs and symptoms of pancreatic cancer and conduct necessary clinical assessments and investigations that can prevent any severe complications. Case Presentation: A middle-aged healthy gentleman who presented with left-sided weakness, slurred speech, left-sided sensory neglect, mild headache, and fever. CT head showed acute right-sided temporal ischemic changes with subsequent magnetic resonance imaging (MRI) head showed multiple infarcts in the brain. A transesophageal echocardiogram reported possible MV vegetation. MRI of the liver was done due to deranged LFTs which showed multiple liver metastasis with a primary mass in the tail of the pancreas. Left leg ultrasound Doppler showed a large left leg deep vein thrombosis involving the femoral vein as he complained of left leg pain for 2 months and went to GP with right leg pain 3 months ago which was treated as a right ankle sprain. The clinical events explained that most likely he developed Trousseau’s syndrome 3 months ago and the embolic phenomena were due to rare Marantic endocarditis (Non-bacterial thrombotic endocarditis) secondary to pancreatic cancer. Ultrasound-guided biopsy of liver metastasis was planned, but sadly the patient passed away the next day. Conclusion: The diagnosis of early pancreatic cancer with imaging poses a challenge sometimes, therefore the pancreatic protocol of CT or MRI is the first line of investigation. Moreover, the cause of unprovoked thrombo-embolism should be investigated to rule out any underlying malignancy.

Pancreatic cancer with multiple liver metastasis complicating multi organ infarcts from Marantic endocarditis and Trousseau’s syndrome.

Background Marantic endocarditis and Trousseau’s syndrome are historically linked with pancreatic cancer. The patient had catastrophic embolic events which caused multi organ infarct due to underlying advanced pancreatic cancer. Doctors should be aware of early signs and symptoms of pancreatic cancer and conduct necessary clinical assessment and investigations which can prevent any severe complications. Case presentation A middle-aged healthy gentleman who presented with left sided weakness, slurred speech, left sided sensory neglect, mild headache and fever. CT head showed acute right sided temporal ischaemic changes with subsequent MRI head showed multiple infarcts in the brain. Transoesophageal echocardiogram reported possible MV vegetation. MRI of the liver was done due to deranged LFTs which showed multiple liver metastasis with primary mass in the tail of pancreas. Left leg ultrasound doppler showed a large left leg deep vein thrombosis involving femoral vein as he complained of left leg pain for 2 months and went to GP with right leg pain 3 months ago which was treated as right ankle sprain. The clinical events explained that most likely he developed Trousseau&amp;apos;s syndrome 3 months ago and the embolic phenomena was due to rare Marantic endocarditis (Non-bacterial thrombotic endocarditis) secondary to pancreatic cancer. Ultrasound guided biopsy of liver metastasis was planned, but sadly the patient passed away the next day. Conclusion The diagnosis of early pancreatic cancer with imaging poses a challenge sometimes, therefore the pancreatic protocol of CT or MRI is the first line investigation. Moreover, the cause of unprovoked thrombo-embolism should be investigated to rule out any underlying malignancy.

Infective Endocarditis by Clostridioides and Clostridium Species-A Narrative Review.

Bacteria of the genus Clostridium are anaerobic Gram-positive spore-forming bacilli that include more than 200 species. Some of them are known to cause invasive infections and diseases caused by the production of toxins. Some of the diseases that are mediated by toxins are colitis in patients with specific risk factors, such as previous administration of antimicrobials or foodborne botulism. Invasive diseases include bacteremia, infective endocarditis (IE), clostridial myonecrosis (gas gangrene), and other diseases that involve the destruction of soft tissue due to the local production of toxins. The present study aimed to review all cases of IE by Clostridioides and Clostridium species and describe the epidemiology, clinical characteristics, treatment, and outcomes of these infections. A narrative review was performed based on a search in PubMed and Scopus for studies published until 11 September 2023, providing such data of IE caused by Clostridioides and Clostridium species in humans. A total of 20 studies containing data for 21 patients were included. A prosthetic valve was present in 5 patients (23.8%). The aortic valve was the most commonly involved, followed by the mitral valve. Fever, sepsis, and embolic phenomena were the most common clinical presentations. Beta-lactams and metronidazole were the most commonly used antimicrobials. Surgery was performed in nine patients (45%). Mortality reached 33.3%. IE in multiple valves was associated with increased mortality. Despite the heterogeneous genetic and molecular characteristics that necessitate the taxonomic change of some of this genus's previous members, the clinical syndrome of IE caused by these bacteria seems to have similar characteristics.