Noncoronary Cusp Of Aortic Valve Research Articles

LACTOBACILLUS ENDOCARDITIS, A SINISTER CONSEQUENCE OF AN INNOCUOUS BACTERIUM

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Lactobacillus species are gram positive rods that are part of the normal flora in gastrointestinal, oropharyngeal and genital tracts. Rarely they are implicated as causative agents of endocarditis in patients who are immunocompromised, undergo dental procedures, use probiotics or have a valvulopathy or prosthetic device. We describe the case of lactobacillus jensenii causing aortic valve endocarditis in an immunocompetent patient with a bicuspid aortic valve. It is important to recognize lactobacillus species as an emerging cause of endocarditis. Treatment involves a synergistic combination of penicillin and gentamicin. CASE PRESENTATION: 55 years old female with past medical history of bicuspid aortic valve presented to the emergency department with chief complaint of fever of 3 weeks' duration. COVID-19 testing was negative. Her medical history was significant for bicuspid aortic valve with aortic regurgitation and hyperlipidemia. Vitals signs were significant for a fever of 103 F. Physical exam was remarkable for a diastolic murmur heard best in the left third intercoastal space. Labs showed a normal blood count, and electrolytes. Patient's blood and urine cultures were obtained, and they were sent home with an oral antibiotic only to be called two days later for a positive blood culture. Blood cultures initially grew gram positive bacilli and patient was started on vancomycin and piperacillin-tazobactam pending final cultures. Due to her history of bicuspid aortic valve, endocarditis was suspected, and patient underwent transesophageal echocardiogram (TEE) which showed a 10-millimeter vegetation attached to the non-coronary cusp of aortic valve. Blood cultures came back positive for lactobacillus jensenii. Patient satisfied the Duke's criteria for endocarditis and was switched to penicillin and gentamicin. Further history did not elicit further risk factors of lactobacillus endocarditis including probiotic use, recent dental work, and immunodeficiency. Patient completed six weeks of antibiotics and had negative final blood cultures. DISCUSSION: This case highlights the importance of lactobacillus species to be a causative factor of endocarditis in patients with a predisposing risk factor. These risk factors include, in order of decreasing frequency, valvulopathy, dental procedures, probiotic use and immunosuppression. It is important to consider lactobacilli as a causative agent of infection if they are isolated on routine blood cultures in predisposed patients with a compatible clinical picture. TEE should be done if endocarditis is suspected. Lactobacilli are highly sensitive to penicillin G and synthetic penicillins. However, they are usually resistant to vancomycin. This is important as vancomycin is an integral regimen of most initial sepsis regimens. CONCLUSIONS: . REFERENCE #1: Campagne, J., J. F. Guichard, M. C. Moulhade, H. Kawski, and F. Maurier. "Lactobacillus endocarditis: a case report in France and literature review." IDCases 21 (2020): e00811. REFERENCE #2: Prendergast, B. D. "Diagnostic criteria and problems in infective endocarditis." Heart 90, no. 6 (2004): 611-613. DISCLOSURES: No relevant relationships by Muhammad Hasib Khalil, source=Web Response

Native aortic valve thrombosis confined to noncoronary cusp of aortic valve

Antiphospholipid syndrome (APLS) carries numerous cardiovascular complications due to recurrent arterial and venous thromboembolism. However, thrombosis of native aortic valve in primary APLS is a ...

A Rare Case of Nephrotic Syndrome in Cardiac Patients

AbstractIntroduction: Renal disease due to infective endocarditis (IE) is well established, with the earliest reports of glomerular lesions published over 100 years ago. Although initially believed to be primarily embolic it later became clear that over 80% of cases represented focal, segmental, or diffuse proliferative glomerulonephritis (GN) with prominent endo-capillary proliferation and occasional infiltrating leukocytes. However, the literature describing nephritis associated with IE still relies heavily on autopsy studies conducted in the pre- and early post-antibiotic era or small renal biopsy studies from the 1970s. Over the past decades, IE outcomes have not improved, and infection rates are steadily increasing.Case Report: This thirty seven year old female patient came to OPD with chief complaints of facial puffiness, abdominal distension, swelling of feet, numbness of head since one month duration. She also complained of shortness of breath (SOB) which was insidious onset and gradually progressive NYHA Class 2. She was non-diabetic and non-hypertensive. She was anemic with bilateral pitting edema. She also had significant thyromegaly. Her cardiovascular examination revealed a regular, normo-volemic pulse at a rate of 120 bpm, blood pressure of 170/100 mm of Hg. On auscultation, both heart sounds were normally audible with early diastolic high pitched murmur heard best in left 2ndintercostal space during expiration. 2-dimensional echocardiography showed mild Aortic regurgitation with vegetation on the aortic valve. Her routines showed she was anemic, proteinuric (2400mg in 24 hr urine) with hypo-albuminemia (albumin:1.4g/l), hypothyroid, and hyperlipidemic (total cholesterol:408mg/dl). Her renal parameters were suggestive of pre-renal azotemia with serum urea of 40mg/dl. These findings led to a diagnosis of nephrotic syndrome. Her blood and urine culture showed negative findings. She underwent renal biopsy. Electron microscopic study of a renal biopsy specimen was suggestive of Focal Segmental Glomerulosclerosis. Her collagen profile was not suggestive of any collagen vascular disease.She was started on immunosuppressive therapy for recurrent relapses. She had an episode of short duration weakness of left upper limb from which she recovered spontaneously within 10 minutes. Two-dimensional echocardiography and Transesophageal echocardiography showed healed vegetation over non-coronary cusp of aortic valve. Nephrologist opinion was taken regarding the nephrotic syndrome and healed vegetation over non-coronary cusp.Conclusion: Nephrotic syndrome being immunodeficient state may lead to infective endocarditis in underlying valvular predisposing condition. Complementary to this subacute endocarditis may lead to nephrotic range proteinuria due to deposition of complements in glomeruli leading to massive proteinuria in some patients.In this case, the patient presented with nephrotic syndrome with recurrent remissions and relapses which are quite a rare entity and further cases have to be studied regarding the implications of this complication in the management of nephrotic syndrome and infective endocarditis.

Systemic lupus erythrematosus; its implication in cardiac surgery: Institutional case report

Introduction Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. According to the literature, the prevalence of cardiovascular involvement in patients with systemic lupus erythematosus (SLE) has been estimated to be more than 50%. Valvular involvement is the most frequent cardiac manifestation in SLE. Functionally, valvular regurgitation hasbeen reported to occur in up to 74% of patients. Meanwhile valvular endocarditis is a frequent manifestation of SLE, and the mitral valve is most frequently affected. However, any valve or multivalvular affection may occur. Valvular lesions resulting from lupus can cause severe mitral regurgitation (MR). The most classic cardiac valvular abnormality in patientswith SLE is known as Libman–Sacks endocarditis, which consists of noninfective, verrucousvegetations(marantic endocarditis). They occur most frequently onthe mitral valve. Most of the valves that have vegetations are usually associated with diffuse thickeningor regurgitation. However, although cardiac involvement in patients with SLE has been recognized since the early 20th, But cardiac surgery was infrequently performed in patients with SLE, and its clinical outcome was reported only in small series. Also the impact of SLE on provision of anesthesia has never beeninvestigated, and the lack of evidence combined with theheterogeneity of disease manifestations makes it difficult toestablish definitive management protocols. That’s why, We herein describe a 22 years old female patient with SLE,with end stage renal diseaserequiring peritoneal dialysis. presented to our hospital (Al-Demerdash, Ain Shams University Hospital), with signsof congestiveheart failure such as dyspnea on exertion andorthopnea, paroxysmal nocturnal dyspnea, and fatigue, refractory to medical management.Her therapy for SLE required longterm prednisolonand hydroxychloroquine. Physical examination revealed no facial malar rash or generalized discoid rashes. The breath sounds were diminished at the lower lung zones. Cardiac auscultation showed regular heart beat with a heart rate of 102 beats/min, a grade III/VI systolic murmur at the left lower sternal border and the apex, and a pericardial friction rub. Palpation of the abdomen showed hepatomegaly. The extremities were notable for mild pitting edema. There was no clubbing, cyanosis or deformity of joints. Preoperative data Complete blood count revealed Hg 9.9 g/dl, WBC 11.100/ul, Platelet 247,000/ul. Bleeding Profile showed PT 16.4 sec, INR 1.45, PTT 44 sec. biochemistry work-up showed, Glucose 75 mg/dl, Creat 2.9 mg/dl with hemodialysis session, ALT 15U/l, AST 20U/l. Preoperative transesophageal Echocardiography showed: A large mass is attached to the atrial surface of the anterior mitral leaflet measuring 6 × 7 mm. the mass perforates the leaflet causing severe mitral regurgitation. And, another large mass measuring 6 × 9 mm attached to the non-coronary aortic valve cusp with 2 small masses attached to each of the other two leaflets causing severe aortic regurgitation.EF 60%,RVSP 50 mmHg. So the patient was scheduled for double valve replacement. Although valve repair and bioprosthetic valve replacement are not the best solution, since accelerated native valve and bioprosthetic valve calcification tend to occur because of the high calcium turnover. Also Porcine valves have become affected by valvulitiswith perforation of valve cusps. But, our cardiac surgical team decided to replace mitral and aortic valve with bioprothetic valve, as they believe that Anticoagulation may present higher risks in our young patient who require prolonged steroid use and who have end stage renal failure, the resultant dependence on dialysis. Also previous reports described patients with SLE who underwent mitral valve replacement, had a number of complications, and died secondary to anticoagulation. Also, because ofsuccessful placement of the porcine Carpentier-Edwards bioprosthesis in patients with SLE has been reported before. Finally weaning from cardiopulmonary bypass was uneventful (adrenaline 50 n/kg/min). The patient’s recovery from surgery was uncomplicated, and she was discharged on the 6th postoperative day. In conclusion, although the postoperative complication is common, cardiac operation could be performed in patients with SLE.

Aortic insufficiency due to ventricular septal defect (Laubry–Pezzi syndrome)

A 15-year-old boy showed progressive aortic valve regurgitation during follow-up of supracristal ventricular septal defect. This anatomic arrangement is consistent with the Laubry-Pezzi syndrome in which prolapse of a non-coronary aortic valve cusp due to Venturi's effect results in progressive aortic valve insufficiency.

Cardiac gated computed tomography used to confirm iatrogenic aortic valve leaflet perforation after mitral valve replacement.

Aortic insufficiency from iatrogenic valve perforation from nonaortic valve operations is rarely reported despite the prevalence of these procedures. Rapid diagnosis of these defects is essential to prevent deterioration of cardiac function. In this paper, we describe a young man who reported to our institution after two open cardiac surgeries with new aortic regurgitation found to be due to an iatrogenic perforation of his noncoronary aortic valve cusp. This defect was not appreciated by previous intraoperative transesophageal echocardiography and was inadequately visualized on follow-up transthoracic and transesophageal echocardiograms. In contrast, cardiac gated computed tomography clearly visualized the defect and its surrounding structures. This case highlights the utility of cardiac gated computed tomography for cases of suspected valvular perforation when echocardiography is not readily available or inadequate imaging is obtained.

Multimodality Imaging in the Diagnosis of Coexisting Left Atrial Myxoma and Aortic Valve Papillary Fibroelastoma

We present the case of a 77-year-old Cambodian woman with a 3-day history of dyspnea on exertion. Physical examination revealed a murmur of mitral regurgitation and decompensated heart failure. The ECG was remarkable for atrial fibrillation with rapid ventricular response. Transthoracic echocardiography showed severe left atrial dilation, a large (5×8 cm) mobile mass attached to the anterior left atrial wall, and several small, mobile aortic masses on the noncoronary cusp of the aortic valve (Figure 1 and online-only Data Supplement Movie I). Figure 1. Transthoracic echocardiogram shows small, mobile aortic masses on noncoronary cusp of aortic valve (blue arrow) and large mobile mass attached to the anterior left atrial wall (red arrow). LV indicates left ventricle; LA, left atrium; AO, aorta. Three-dimensional transesophageal echocardiography showed a large multilobular mass being displaced by the central jet of moderate to severe mitral regurgitation during systole and prolapse of the mass through the mitral valve during diastole (Figures 2 and 3 and online-only Data Supplement Movies II and III). The atrial mass was attached with a stalk to the anterior atrial wall and appeared lobulated and deformable, consistent with the …

A rare complication from transseptal puncture-persistent aorto-right atrial shunt and puncture of noncoronary cusp of aortic valve

v A 62-year-old lady presented with symptomatic persistent atrial fibrillation. An attempt at left atrial ablation (LAA) was abandoned following difficulty in performing transseptal puncture under fluoroscopic guidance alone and concern that the puncture had caused right atrial puncture into the pericardial space. Echocardiography at the time demonstrated a small rim of pericardial fluid that was managed conservatively. Left ventricular pressure readings noted at the time were felt to represent the catheter having crossed the mitral valve following left atrial puncture during this compli-

A fibrous band associated with the non-coronary aortic valve cusp in a dog

A fibrous band connecting the middle of the free edge (nodulus Arantii) of the non-coronary aortic valve cusp to the ascending aorta just above the level of the non-coronary sinus of Valsalva was observed in an asymptomatic, 11-year-old, male Border Collie. The fibrous band was unrelated to the cause of the death in this dog. Such fibrous bands are usually reported in humans with congenital bicuspid aortic valves. To our knowledge, this is the first report of a fibrous band in the aortic valve in a domestic animal.

Catheter Ablation of Peri‐AV Nodal Atrial Tachycardia from the Noncoronary Cusp of the Aortic Valve

Atrial tachycardias (AT) originating from the anteroseptal region of the aortic root, near the atrioventricular node can be challenging to eliminate safely by catheter ablation. In this study, we examine the characteristics of anteroseptal ATs in a cohort of patients at our centers, and demonstrate the long-term efficacy and safety of targeting the arrhythmias from within the base of the noncoronary aortic valve cusp (NCC). From among a cohort of 54 patients with symptomatic focal AT undergoing invasive electrophysiological evaluation, the point of earliest right atrial (RA) activation was at the peri-AV nodal region in 10 patients, just postero-superior to the His-bundle. Before further mapping, RA lesions placed in two patients were unsuccessful in eliminating the arrhythmia. Because of its proximity to the interatrial septum, the base of the NCC was mapped using a retrograde aortic approach, and revealed a point of early activation without the presence of a His potential. The arrhythmia terminated with <10 seconds of radiofrequency or cryothermal energy delivery and was successfully eliminated in 7 of 10 patients. Transient termination or acceleration of the AT was noted in the other three patients, prompting successful ablation from a left atrial septal position or a reattempt from a para-Hisian RA position. All patients have been arrhythmia free during follow-up (41 +/- 12 months). Catheter ablation from within the base of the NCC represents a safe and effective means to eliminate focal AT arising from the peri-AV nodal region.

Transpecies heart valve transplant: advanced studies of a bioengineered xeno-autograft

Background. Tissue engineering approaches utilizing biomechanically suitable cell-conductive matrixes should extend xenograft heart valve performance, durability, and growth potential to an extent presently attained only by the pulmonary autograft. To test this hypothesis, we developed an acellular, unfixed porcine aortic valve-based construct. The performance of this valve has been evaluated in vitro under simulated aortic conditions, as a pulmonary valve replacement in sheep, and in aortic and pulmonary valve replacement in humans. Methods. SynerGraft porcine heart valves (CryoLife Inc, Kennesaw, GA) were constructed from porcine noncoronary aortic valve cusp units consisting of aorta, noncoronary aortic leaflet, and attached anterior mitral leaflet (AML). After treatment to remove all histologically demonstrable leaflet cells and substantially reduce porcine cell-related immunoreactivity, three valve cusps were matched and sewn to form a symmetrical root utilizing the AML remnants as the inflow conduit. SynerGraft valves were evaluated by in vitro hydrodynamics, and by in vivo implants in the right ventricular outflow tract of weanling sheep for up to 336 days. Cryopreserved allograft valves served as control valves in both in vitro and in vivo evaluations. Valves were also implanted as aortic valve replacements in humans. Results. In vitro pulsatile flow testing of the SynerGraft porcine valves demonstrated excellent valve function with large effective orifice areas and low gradients equivalent to a normal human aortic valve. Implants in sheep right ventricular outflow tracts showed stable leaflets with up to 80% of matrix recellularization with host fibroblasts and/or myofibroblasts, and with no leaflet calcification over 150 days, and minimal deposition at 336 days. Echocardiography studies showed normal hemodynamic performance during the implantation period. The human implants have proven functional for over 9 months. Conclusions. A unique heart valve construct has been engineered to achieve the equivalent of an autograft. Short-term durability of these novel implants demonstrates for the first time the possibility of an engineered autograft.

A safe, rapid method of transfemoral retrograde left ventricular catheterization in valvular aortic stenosis.

We report our experience with the use of a standard left Amplatz coronary catheter and a guidewire to cross the aortic valve in 34 patients being evaluated for valvular aortic stenosis. A number of 2 Amplatz left coronary catheter inserted via the femoral artery was positioned above the noncoronary aortic valve cusp with the tip aligned toward the aortic valve. This catheter allowed a soft-tipped, Teflon-coated guidewire to be guided through the aortic valve orifice. The catheter was then advanced over the guidewire into the left ventricle. This technique was successful within six minutes in 32 of 34 patients (94%). The stenotic aortic valve was crossed in less than two minutes in 15 patients (42%) and in less than four minutes in 31 (91%). The aortic valve was not crossed in two patients. Twenty-one patients (62%) had an aortic valve area of less than 0.75 cm2. There were no complications. We conclude that this technique provides a method for safe, rapid transaortic left ventricular catheterization in patients with aortic stenosis of all degrees of severity.