Prosthetic Valve Research Articles

Background: Non-ST-elevation myocardial infarction (NSTEMI) typically results from plaque rupture leading to obstructive coronary artery disease. However, embolic thrombi originating from cardiac structures, such as prosthetic valves, can rarely cause NSTEMI. Recognizing these uncommon embolic sources is vital for accurate diagnosis and management. Case Presentation: An 82-year-old female with severe aortic stenosis previously treated by transcatheter aortic valve replacement (TAVR), paroxysmal atrial fibrillation with a Watchman device, hypertension, diabetes, and heart failure with preserved ejection fraction presented with persistent chest discomfort and palpitations. Coronary angiography revealed a thrombus extending from the distal left main artery into the ostial left circumflex artery, successfully treated via aspiration thrombectomy and balloon angioplasty [Figure 1]. Transesophageal echocardiography (TEE) did not detect atrial thrombi. However, cardiac computed tomography (CT) identified thrombi on the prosthetic aortic valve leaflets, confirming the valve as the embolic source [Figure 2]. Discussion: This case emphasizes that NSTEMI may result from embolic thrombus, not solely from plaque rupture. Prosthetic valves, such as those used in TAVR, are rare but recognized sources of coronary embolism. Although TEE is frequently used, it has limitations in thrombus detection; thus, cardiac CT remains the preferred imaging modality for accurate evaluation. While coumadin is traditionally recommended for anticoagulation, Direct oral anticoagulants (DOACs) are emerging alternatives, though further studies are required to establish their efficacy. Conclusion: Clinicians should consider prosthetic valve-associated thromboembolism in NSTEMI cases post-TAVR. Cardiac CT is the optimal diagnostic tool, and future research should clarify the role of NOACs in managing prosthetic valve thrombosis.

Background: Infective endocarditis (IE) due to Gemella species is extremely rare and typically associated with dental disease, mucosal disruption, or valvular pathology. To our knowledge, this is the first reported case of Gemella morbillorum IE involving a transcatheter aortic valve replacement (TAVR) prosthesis. This case underscores the importance of recognizing uncommon pathogens in prosthetic valve endocarditis (PVE), even in the absence of typical infection sources. Case: A 70-year-old man with a remote history of lymphoma (treated with abdominal tumor resection and radiation) and severe aortic stenosis status post-TAVR presented with a 1.2 cm vegetation on the bioprosthetic valve. One month prior, he had Gemella bacteremia, treated with IV vancomycin and oral minocycline. Although clinically improved, repeat transesophageal echocardiography (TEE) revealed a new valve vegetation (Figure 1A). Blood cultures were negative, and he remained afebrile and hemodynamically stable. He denied recent dental work. Maxillofacial CT showed no dental infection. Abdominal imaging revealed a stable soft tissue mass in the posterior mediastinum, consistent with residual changes from his prior lymphoma. His abdominal surgery and radiation likely led to long-term mucosal barrier injury, predisposing to translocation of Gemella, a GI tract commensal. With recent bacteremia, a new valve vegetation, and a prosthetic valve, PVE was diagnosed. He received six weeks of IV vancomycin and ultimately underwent surgical TAVR explant and valve replacement (Figure 1B). Discussion: TAVR-related PVE is rare (0.5–1.5% annually) and typically involves Staphylococcus or Enterococcus. Gemella morbillorum is an exceptionally uncommon cause, with only isolated reports of IE involving surgically implanted valves and none in TAVR recipients. Misidentification as viridans streptococci may delay diagnosis. TAVR imaging is also challenging due to prosthetic shadowing. This case is unique in its presentation of culture-negative TAVR PVE caused by Gemella morbillorum. The patient's prior oncologic treatment likely disrupted mucosal integrity, enabling bacterial translocation. This report highlights the need to consider rare pathogens like Gemella morbillorum in PVE, particularly in patients with prior mucosal compromise or immunosuppression.

Description of Case: A 63-year-old woman with nonischemic cardiomyopathy (CM) with recovered ejection fraction (EF), severe bicuspid aortic valve (AV) stenosis post-transcatheter aortic valve replacement (TAVR) and prior methamphetamine use presented with chest pain, troponin >6000 ng/L, and anterolateral (V2-V6) ST elevation, T wave inversion, and Q waves. She was transferred for possible late or completed STEMI. Echocardiogram showed reduced ejection fraction (25% from 55%), mid-apical wall akinesis to dyskinesis, and a hyperdynamic base. Continuous wave doppler through the AV revealed a mean gradient of 44 mmHg (previously 11 mmHg) raising concern for valve dysfunction. Coronary angiography revealed nonobstructive coronary artery disease. Left heart catheterization via a 55 cm femoral sheath using an end-hole catheter with slow pullback in the left ventricle (LV) demonstrated a significant LV-aortic gradient at the apex that progressively diminished and resolved near the left ventricular outflow tract (LVOT) below the aortic valve, confirming dynamic LVOT obstruction. Cardiac magnetic resonance imaging (MRI) showed patchy late gadolinium enhancement (LGE), raising concern for myocarditis versus stress CM due to methamphetamine exposure. The patient improved with medical therapy and was discharged in stable condition. Discussion: The dynamic LVOT obstruction in this case resulted from hyperdynamic basal contraction against an akinetic apex, causing mid-cavity collapse and a falsely elevated transvalvular gradient, mimicking prosthetic valve stenosis. This underrecognized mechanism can mislead post-TAVR assessments, especially in the setting of catecholamine excess or myocardial inflammation. Initial concern for valve failure or infarction was redirected by invasive hemodynamics and multimodal imaging. Recognition of this physiology avoided unnecessary intervention and guided therapy. Traditionally, the absence of LGE supported stress CM, but recent studies show stress CM can present with LGE. This overlap underscores the evolving understanding of myocardial injury and highlights that myocarditis can mimic stress CM when LGE is present. This case emphasizes the importance of invasive pressure assessment, multimodal imaging, and diagnostic flexibility in evaluating post-TAVR patients with suspected acute coronary syndrome.

Background: Cardiac devices such as prosthetic valves, coronary bypass grafts, and implantable hardware have improved survival but are associated with increased infection risk. Infective endocarditis (IE) remains a life-threatening complication of device-related infections. Despite advances in antimicrobial strategies and perioperative protocols, long-term national trends in endocarditis-related mortality with cardiac device complications remain under-characterized. Methods: Using the CDC WONDER Multiple Cause of Death database (1999–2023), we identified decedents aged 15–84 years in whom infective endocarditis (ICD-10: I33.0, I33.9, I38) and cardiac device complications (ICD-10: T82.0, T82.2, T82.6, T82.7) were listed as contributing causes of death. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated using the 2000 U.S. standard population. Joinpoint regression (v5.4.0) identified inflection points in trends and calculated Annual Percent Change (APC). Results: From 1999 to 2023, a final model with two joinpoints was identified. Between 1999 and 2006, AAMRs increased significantly with an APC of +8.00% (95% CI: 2.06 to 14.29; p = 0.01). This was followed by a sharp decline from 2006 to 2011 (APC = –10.30%; 95% CI: –20.90 to +1.72; p = 0.086). Between 2011 and 2023, mortality trends plateaued, with a modest but non-significant rise (APC = +0.71%; 95% CI: –1.57 to +3.06; p = 0.52). Overall, mortality rates stabilized over the last decade despite the earlier fluctuations. Conclusion: The trajectory of endocarditis-related mortality in patients with cardiac device complications reveals a critical inflection in modern cardiovascular care. The initial rise mirrors a surge in device utilization without parallel infection safeguards. The subsequent decline suggests early wins from antimicrobial stewardship and surgical protocol refinement. However, the post-2011 plateau, despite advances in materials and perioperative care, signals a stagnation point, not success. This stagnation likely reflects unresolved mechanistic challenges such as biofilm resilience, hematogenous microbial seeding, and late-onset device colonization. These findings position infective endocarditis as a high-fidelity surrogate for late device-related mortality burden. Urgent innovation is needed: biocompatible surface technologies, sustained post-implantation surveillance, and precision infection diagnostics must now lead the next phase of device-era infection prevention.

Introduction: End-stage kidney disease (ESKD) patients on dialysis are particularly vulnerable to developing cardiac implantable electronic device-related infective endocarditis (CIED-IE), which carries significant morbidity and mortality. Outcomes of these patients are not well known. Research Questions: To compare outcomes of CIED-IE among patients with ESKD, chronic kidney disease (CKD), and those without CKD (no-CKD), using a nationally representative database. Methods: The National Readmission Database (2016–2022) was used to identify patients with CIED-IE using ICD-10-CM codes. Those with prosthetic valves were excluded. Patients were categorized into ESKD, CKD, and no-CKD groups. Results: We identified 22,172 patients hospitalized with CIED-IE: 1,979 (8.9%) with ESKD, 5,573 (25.1%) with CKD, and 12,233 (55.2%) without CKD. ESKD patients were younger (mean age: ESKD 66.3, CKD 76.5, no-CKD 69.9 years; P<0.001) and had a lower proportion of males (ESKD 62.6%, CKD 68.9%, no-CKD 64.1%; P<0.001). ESKD patients had the highest in-hospital mortality (ESKD 16.5%, CKD 12.0%, no-CKD 8.3%; P<0.001) and 3-month post-discharge mortality (ESKD 8.9%, CKD 3.7%, no-CKD 2.4%; P<0.001). The lead extraction rate within 3 months of CIED-IE diagnosis was highest in patients without CKD (no-CKD 24.3%, CKD 20.6%, ESKD 17.6%; P<0.001). ESKD patients also had the highest 3-month readmission rate (ESKD 52.5%, CKD 43.5%, no-CKD 37.7%; P<0.001). Stroke rates were low and showed no significant differences across groups during hospitalization (no-CKD: 0.9%, CKD: 1.2%, ESKD: 1.7%; P=0.0959) or within 3 months post-discharge (no-CKD: 0.9%, CKD: 1.0%, ESKD: 1.1%; P=0.9209). Conclusions: ESKD patients with CIED-IE experienced significantly worse outcomes, including higher in-hospital mortality, post-discharge mortality, and readmission rates, compared to those with CKD or no-CKD. ESKD patients were also the least likely to undergo lead extraction within 3 months of CIED-IE diagnosis. Stroke incidence did not significantly differ between groups during hospitalization or after discharge.

Background: Loeys-Dietz syndrome (LDS) and vascular Ehlers-Danlos syndrome (vEDS) are rare connective tissue disorders characterized by arterial fragility and early-onset vascular events. Stroke risk is elevated in both conditions, but data on stroke subtypes and anticoagulation use remain limited. Understanding the relationship between stroke mechanisms, arrhythmias, and antithrombotic therapy is crucial in these genetically vulnerable populations. Aim: To assess the prevalence and subtypes of stroke in patients with LDS and vEDS. Methods: A retrospective chart review was conducted across three Mayo Clinic sites. Patients with LDS and vEDS were identified using an electronic data extraction tool, followed by manual chart review for diagnostic confirmation. Stroke subtypes, ischemic, dissection-related, and hemorrhagic, were classified based on imaging findings and clinical documentation. Data on atrial arrhythmias, valve replacement status, and anticoagulation use (including warfarin and apixaban) were systematically collected and analyzed. Results: In the LDS cohort, 12 of 94 patients (12.8%) experienced a stroke: 8 ischemic (8.5%), 3 dissection-related (3.2%), and 1 hemorrhagic (1.1%). Atrial fibrillation or flutter was present in 7 patients (58.3%), 6 of whom had ischemic strokes. Among the stroke patients, 9 (75%) had prosthetic valves, 6 mechanical and 3 bioprosthetic, and 4 (33.3%) were on warfarin at the time of the event. In the vEDS cohort, 22 of 132 patients (16.7%) had strokes: 13 ischemic (9.8%) and 9 dissection-related (6.8%). No hemorrhagic strokes were observed. Atrial fibrillation or flutter was documented in 12 patients (54.5%), with 10 experiencing ischemic and 2 dissection-related strokes. Of these, 5 (22.7%) were on apixaban, 3 (13.6%) on warfarin, and 4 (18.2%) were not anticoagulated. None of the vEDS stroke patients had mechanical valves. Conclusion: Ischemic stroke is the most frequent cerebrovascular event in both LDS and vEDS, but dissection-related strokes are more common in vEDS. Atrial arrhythmias often precede ischemic events, yet anticoagulation use varies widely. One-third of dissection-related strokes occurred despite antithrombotic therapy, raising concerns about current management strategies. These findings support the need for syndrome-specific guidelines for stroke prevention, arrhythmia management, and anticoagulation in LDS and vEDS patients.

Background: Warfarin remains essential for preventing thrombosis in patients with mechanical heart valves. However, its narrow therapeutic index and susceptibility to drug interactions demand careful monitoring. We present a case of subacute mechanical aortic valve thrombosis likely precipitated by a warfarin–trazodone interaction. Case Presentation: A 58-year-old man with a history of bicuspid aortic stenosis requiring mechanical valve replacement—previously stable on chronic warfarin therapy (5 mg daily)—presented to the ED with three days of worsening dyspnea, cough, and upper back pain. Upon arrival, he was hypertensive, hypoxic, and in respiratory distress, exhibiting cold extremities, bilateral crackles, and an audible mechanical valve click. Labs revealed an INR of 1.3 (previously therapeutic), lactate 9.0 mmol/L, troponin 233 ng/L, and BNP 6812 pg/mL. CTA showed possible multifocal pneumonia. Initially, he was diagnosed with septic shock and ARDS, requiring vasopressors and BiPAP. Shortly after, he suffered a cardiac arrest, requiring intubation and vasopressor escalation. Transthoracic echocardiography (TTE) revealed a peak gradient of 3.7 m/s and mean gradient of 28 mmHg across the prosthetic valve. Urgent transesophageal echocardiography (TEE) showed severely restricted leaflet motion with torrential aortic regurgitation—highly suggestive of valve thrombosis. Due to prohibitive surgical risk, thrombolysis with alteplase (25 mg over 6 hours) was administered. Repeat TEE demonstrated improved leaflet motion (velocity 2.2 m/s, mean gradient 17.6 mmHg), LVEF of 25%, and new severe mitral regurgitation. He was stabilized on milrinone and extubated by hospital day five. Despite restarting warfarin—at doses up to 30 mg daily (three times his prior regimen)—therapeutic INR was not achieved until 10 days later. Further interrogation revealed, thirteen days prior to ED visit, he was started on trazodone 50 mg. No other interacting medications or hepatic dysfunction were identified. Trazodone was identified as the likely culprit and had been discontinued. His INR subsequently normalized. Discussion: Trazodone may reduce warfarin efficacy, leading to subtherapeutic INR and valve thrombosis in mechanical valve patients. While the exact mechanism is unclear, proposed theories include CYP2C9 induction, increased warfarin clearance, or protein-binding displacement. This case highlights the need for close INR monitoring when initiating trazodone in patients on warfarin.

Introduction: Hypo-attenuated leaflet thickening (HALT) is a type of thrombotic lesion that has been identified frequently in recent times owing to the widespread use of transcatheter aortic valve implantation. However, few studies have investigated HALT after surgical aortic valve replacement (SAVR). This study investigates the incidence of HALT after SAVR with Inspiris Resilia valve and the associated postoperative outcomes. Hypothesis: HALT impact early clinical outcomes or increase the incidence of thromboembolic events. Methods: SAVR was performed using Inspiris Resilia valves in 183 patients between August 2020 and January 2025. The present study included 121patients (66.1%) who underwent cardiac CT one week after surgery. HALT was defined as the presence of one or more leaflets with HALT of the prosthetic aortic valve during the early left ventricular diastolic phase ( Fig 1A-B) . Heparin administration was started post-op (APTT 1.5–2×), followed by warfarin (PT-INR 1.6–2.2). 121 patients were divided into the HALT (n=27) and non-HALT (n-94) groups. Results: The overall incidence of HALT after SAVR was 22.3%. Anticoagulant and antiplatelet therapy (APT) at the time of HALT diagnosis was as follows: warfarin (WF) alone (n=11), WF + single APT (n=8), single APT (n=5), dual APT (n=2), and none (n=1). Compared with the non-HALT group (N=94), the HALT group (N=27) was significantly older (76.2 vs. 73.0 years; p =0.003) and had a smaller body surface area (1.46 vs. 1.58 m 2 ; p =0.002). No significant differences were found in other baseline characteristics, intraoperative factors, ICU stay, and postoperative course ( Fig 2) . The rate of postoperative anticoagulant and APT use also did not differ significantly. The postoperative echocardiographic data are shown in the figure ( Fig 3 ). Echocardiographic findings showed significant differences in AVA (1 week postoperatively), peak pressure gradient, and AVAi (3 months) were observed between the two groups; however, there was no evidence that HALT affected acute prosthetic valve function, and no cases exhibited a mean pressure gradient >20 mmHg. No in-hospital deaths or thromboembolic events in either group. No strokes in HALT group; two in non-HALT ( p =0.445). Conclusions: HALT was observed after SAVR using stented bioprosthetic valves, even under optimal anticoagulation management. HALT did not affect acute prosthetic valve function, early postoperative outcomes, or neurological events.

Background: Antiphospholipid syndrome (APS) predisposes patients to thrombosis and cardiac valve lesions (e.g., Libman-Sacks endocarditis). These vegetations, though sterile, may serve as a nidus for infection. The risk of infective endocarditis (IE) and other serious infections in APS patients within large populations remains poorly quantified, representing a key knowledge gap. Research Questions/Hypothesis: To quantify the risk of the primary outcome, IE, and secondary outcomes of MRSA sepsis and MSSA sepsis, associated with APS using a large, nationally representative inpatient database. Methods/Approach: This retrospective cross-sectional study utilized the Nationwide Inpatient Sample (NIS) database from 2016 to 2020. Hospitalized patients aged 18-75 with APS were compared to those without APS. Patients with major pre-existing risks for IE or significant confounders (e.g., prosthetic valves, specific congenital/rheumatic heart diseases, ESRD) were excluded. Multivariable logistic regression was used to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs), adjusting for age, sex, race/ethnicity, hospital region, primary payer, median household income, and Systemic Lupus Erythematosus (SLE) status. Results/Data: A total of 297,459 patients met inclusion criteria; 223 hospitalizations (0.075%) had an APS diagnosis. APS patients were significantly younger (mean age 46.9 ± 14.4 vs. 50.8 ± 14.6 years, p<0.001) and more often female (72.6% vs. 40.0%, p<0.001). Unadjusted analyses revealed higher IE prevalence in APS (8.5% vs. 4.3%, p = 0.002), MRSA sepsis (14.3% vs. 8.9%, p = 0.004), and MSSA sepsis (15.2% vs. 9.6%, p = 0.004). In multivariable analysis, APS was significantly associated with over double the odds of IE (aOR 2.03; 95% CI 1.22–3.37; p = 0.007). APS also conferred increased risks of MRSA sepsis (aOR 1.75; 95% CI 1.18–2.58; p=0.005) and MSSA sepsis (aOR 1.86; 95% CI 1.28–2.70; p=0.001). In-hospital mortality within the IE cohort was not significantly different (0.2% vs. 0.1%, p = 0.543). Conclusion(s): APS emerged as a significant independent risk factor for IE, MRSA, and MSSA sepsis in this nationwide analysis. These findings suggest a broader vulnerability to infection in APS, highlighting the critical need for increased clinical suspicion, vigilant monitoring, and potentially tailored prophylactic or treatment approaches for severe infections in these patients.

Background: Fungal endocarditis is uncommon, making up an estimated 1-3% of cases. Risk factors for this are prosthetic heart valves, prior heart surgery, and IV drug use. Fungal seeding of CIED is even more rare, and often leads to fatal outcomes. The majority of the species involved are Candida . Pichia kudriavzevii , formerly known as Candida krusei , is a rare non-Candida species of yeast that is most frequently seen in immunocompromised patients and is associated with a high mortality rate. Known risk factors for P. kudriavzevii include underlying gastrointestinal disease or cancer, hematologic malignancies, organ transplant, corticosteroid use, and recent use of antibiotic or antifungal therapies. We present the case of P. kudriavzevii fungemia leading to seeding of ICD. Case Report: A 66-year-old male with past medical history of uncontrolled type 2 diabetes mellitus, non-ischemic cardiomyopathy with dual chamber ICD, and atrial fibrillation s/p re-do CTI and PVI ablation 2 months prior presented to the ED with abdominal pain, vomiting, and dysuria. He was afebrile and hemodynamically stable. Workup revealed WBC count of 28.6, blood glucose of 361. CT imaging of the abdomen and pelvis was unremarkable. He was admitted for sepsis secondary to suspected UTI and was started on ceftriaxone. Blood cultures drawn on admission resulted showing Pichia kudriavzevii and Lactobacillus gasseri . Urine cultures resulted showing showing P. kudriavzevii . The patient was then started on micafungin. Initial TTE did not reveal vegetations, LVEF noted to be 55%. A TEE was ordered as the patient was having persistent unexplained leukocytosis, and this revealed a vegetation on the ICD lead in the right atrium. Given the patient’s fungemia with evidence of endovascular seeding and vegetations, in the context of now recovered LVEF, the patient underwent complete extraction of his ICD. Conclusions: This case is unique in that the patient seemingly has no major risk factors for P. kudriavzevii fungemia. He does not have history of prior fungal infections or UTIs, recent anti-fungal or antibiotic use, or immunocompromised status. The patient did undergo a recent CTI and PVI ablation, however the source of infection was proven to be urinary. His uncontrolled diabetes mellitus may have been a contributing factor. A multidisciplinary approach involving infectious disease and cardiology is critical in reducing the risk of adverse outcomes in these patients.

Here is a rare and diagnostically challenging case of infective endocarditis (IE) involving the Chiari network in a 47-year-old female with a complex cardiac and social history. She had a history of intravenous drug use (IVDU), prior methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia involving the mitral valve (MV), and methicillin-resistant Staphylococcus aureus (MRSA) endocarditis requiring tricuspid valve (TV) replacement with a CorMatrix bioprosthesis. She presented with a 3-day history of fever, progressive right groin pain and swelling, and worsening dyspnea. On admission, she was afebrile but hypotensive and had tachycardia. On examination, she had a loud holosystolic murmur in the left lower sternal border, a pulsatile right groin mass with a bruit, alongside multiple healed track marks on her lower extremities. Blood work was notable for leukocytosis. Computed tomography of the chest, abdomen, and pelvis revealed multiple pulmonary septic emboli and a right femoral artery pseudoaneurysm with an arteriovenous fistula confirmed on duplex ultrasound. Transthoracic echocardiogram (TTE) showed preserved ejection fraction (60-65%), normal aortic and mitral valves, but poor visualization of the prosthetic tricuspid valve. Blood cultures grew MRSA, and the patient was started on IV vancomycin. Transesophageal echocardiogram (TEE) revealed a large, mobile echogenic mass attached to the Chiari network (CN), positioned in line with the tricuspid regurgitant jet. These new findings, absent on prior imaging, strongly suggested isolated Chiari network endocarditis (CNE) Right-sided infective endocarditis (IE) is a rare clinical entity, accounting for less than 10% of all IE cases. Among these, involvement of the CN- the embryonic remnant of the right valve of the sinus venosus and present in under 2% of the population- is even rarer, with only a few reported cases to date. IVDU remains the leading risk factor for right-sided IE, as seen in our patient. The true incidence of CNE is likely underreported due to the limited sensitivity of TTE, which can make visualizing it challenging. TEE remains the imaging modality of choice for identifying such atypical presentations. Our case reinforced the critical role of TEE in identifying uncommon, non-valvular sources of infection. In the absence of clear treatment guidelines and high surgical risk, the patient was treated conservatively with a 6-week course of antibiotics followed by repeat TEE for monitoring.

Paradoxical coronary embolism (CE) causes an estimated 4-13% of ST-segment-elevation myocardial infarction (STEMI) presentations. A thromboembolism can originate in the venous system and cross into systemic circulation via an intracardiac or intrapulmonary shunt, resulting in a variety of clinical presentations. Patent foramen ovale (PFO) is the most common intracardiac shunt, found in nearly 30% of the general population. A 72-year-old male with a history of prior pulmonary embolism and severe degenerative disc disease was admitted to the hospital for elective cervical laminectomy and decompression of C3-T1. His hospital course was complicated by aspiration pneumonia with resultant Streptococcus salivarius bacteremia and new onset atrial fibrillation and spontaneous conversion to sinus rhythm. Transthoracic echocardiogram and subsequent transesophageal echocardiogram after conversion to sinus rhythm demonstrated normal left ventricular systolic function, no evidence of endocarditis nor left atrial appendage thrombus, and a large PFO demonstrating bidirectional shunting. Later, he was noted to have new ST-segment elevations on telemetry, prompting an electrocardiogram which confirmed anterior and lateral ST-segment elevations. Emergent coronary angiography revealed mild coronary artery disease with no evidence of plaque rupture; however, thrombotic occlusions of the distal left anterior descending artery and distal second obtuse marginal artery were most consistent with a thromboembolic event. Bilateral upper and lower extremity duplexes revealed a superficial vein thrombosis in the right cephalic vein. Clinical suspicion was high for paradoxical CE related to his PFO; closure was pursued with transcatheter placement of an occluder device. Paradoxical CE is underdiagnosed, and subsequent evaluation for common culprits should include thrombus of aortic or mitral prosthetic valves, atrial fibrillation, endocarditis, PFO, neoplasm, and hypercoagulable disorders. The incidence of PFO related CE is unknown but suggested to be <4% of STEMI. Current guidelines give conditional recommendations for closure in paradoxical CE, owing to limited literature. As in our case, we would recommend closure of PFO once a paradoxical embolus occurs given risk for recurrent events and data suggesting a higher mortality rate despite lower cardiovascular risk.

Description of case: A 39-year-old man with history of unicuspid aortic valve status-post bicuspidization (2017), subsequent severe aortic insufficiency prompting mechanical aortic valve replacement (2023), recent prosthetic valve thrombosis on therapeutic warfarin complicated by stenosis and shock prompting redo mechanical aortic valve replacement (2/2025, 23mm On-X), presented with acute dyspnea, chest pain, and loss of mechanical click. He was found to have SCAI-C cardiogenic shock, with exam notable for III/VI systolic crescendo-decrescendo and IV/IV decrescendo early diastolic murmurs, and absent mechanical click. Labs were notable for absolute eosinophils of 11.5 K/cu mm. On TTE, valve disks were poorly visualized. The mean gradient was 59mmHg and there was severe aortic insufficiency with preserved ventricular function. Due to concern for valvular obstruction, TEE was performed, revealing a well-seated valve with severe valvular regurgitation originating posteriorly and a reduction in systolic excursion of the disks. Valve fluoroscopy showed minimal movement of both discs suggesting thrombosis. The patient was deemed high risk for surgical intervention and therefore received systemic thrombolysis with alteplase 25mg over 6h x2. Repeat TTE showed mean gradient 29mmHg, and mild-moderate aortic insufficiency. Eosinophilia peaked at 16.7 K/cu mm and normalized with high-dose prednisone. Eosinophilia workup is ongoing. Discussion: Prosthetic valve thrombosis is a rare and feared complication without randomized controlled trials to support optimal treatment. The 2017 American Heart Association guidelines suggest surgery or fibrinolytics determined by individualized patient factors. Previously, surgery was preferred in patients with advanced NYHA symptoms or large thrombi. However, a novel strategy with echocardiogram-guided, low-dose infused fibrinolytics has demonstrated high success rates in this patient population. In our case, multimodal imaging was essential in the rapid diagnosis of prosthetic valve thrombosis. Our preference for fibrinolytics was based on surgical risk and to enable pre-operative workup and management of his hypercoagulable state. Few cases have been reported of eosinophilia-driven prosthetic valve thrombosis, with differential including eosinophilic granulomatosis polyangiitis and IgG4-related disease. Further data are needed to enable tailored treatment strategies in different patient populations.

Clinical Course: A 62-year-old male with a history of coronary artery disease presented with one month of intermittent chest pain which progressed to severe persistent chest pain. Initial vitals: blood pressure 78/50 mmHg, pulse rate 100 bpm, and oxygen saturation 94%. Examination revealed bilateral pulmonary crackles and grade 4/6 holosystolic murmur at the cardiac apex. The electrocardiogram suggested inferolateral STEMI, and the patient was taken for coronary catheterization, and intubated due to hypoxic respiratory failure from pulmonary edema. Impella CP was placed for hemodynamic support. Catheterization revealed 100% occlusion of the mid-left circumflex (LCx), 75% occlusion of the distal left anterior descending artery, and chronic total occlusion of the right coronary artery. Two drug eluting stents were deployed to the mid-LCx lesion, achieving TIMI 3 flow. Emergent transesophageal echocardiogram (TEE) revealed hyperdynamic LV systolic function, severe mitral regurgitation (MR) with severe MV flail involving the posterior leaflet (Figure 1a-c). The posterolateral papillary muscle head was ruptured (Figure 1d). Despite Impella CP and pressor support with norepinephrine at 4 mcg/min, cardiogenic shock persisted; mixed venous oxygen saturation (MVO2) was 47%, pulmonary artery pulsatility index (PAPi) was 1.4, cardiac power output (CPO) was 0.61 W. Upgrading to Impella 5.5 improved MVO2 to 68%, PAPi to 2.5, and CPO to 1.16 W. He underwent coronary artery bypass grafting (CABG) and surgical mitral valve replacement (MVR) with a bioprosthetic valve. Following surgical MVR, TTE revealed an appropriately functioning bioprosthetic valve, and LV ejection fraction of 35-40% with multiple areas of hypokinesis. Despite appropriate prosthetic valve function, the patient suffered pulmonary hemorrhage, septic shock, and expired on hospital day 10. Discussion: Papillary muscle rupture is an uncommon complication of acute myocardial infarction but is often fatal. In our patient, TTE was imperative in timely recognition and management of acute MR and preparation for MVR. Impella mechanical circulatory support was used as a bridge to surgical intervention with MVR and temporized the patient’s cardiogenic shock. Despite its importance, literature on Impella use in this condition is scarce. While the patient ultimately expired, prompt use of echocardiography and Impella were important to bridge the gap to MVR.

Background: Mitral valve (MV) partial heart transplantation (PHT) is an exceptionally rare and technically demanding procedure, with only one prior case reported using a living donor valve. This case represents the first known MV PHT to replace a mechanical prosthesis. In patients with prior valve replacement, distorted cardiac geometry and absent subvalvular structures pose significant challenges to donor valve implantation. Precise placement and tensioning of donor chordae necessitate accurate spatial measurements that conventional imaging cannot reliably provide. 3D virtual modeling offers a patient-specific solution to quantify anatomic relationships and support high-precision surgical planning for these complex and unprecedented interventions. Methods: A 12-year-old male with a history of VSD closure and supra-annular 21 mm mechanical MV replacement at age 2 presented with severe prosthetic valve stenosis and was evaluated for MV PHT. ECG-gated contrast-enhanced cardiac CT scans were acquired in both systole and diastole (Fig 1A ). 3D digital hearts (DHs) were reconstructed for each phase to include the ventricular myocardium, mechanical valve, and remnant anterolateral papillary muscle (PM) ( Fig 1B ). The resulting DHs enabled direct measurement from the native annular plane to the PM, providing a critical spatial reference to guide intraoperative donor chordae placement. Results: The DHs revealed annular-to-PM distances ranging from 25 to 35 mm ( Fig 1C ). These measurements informed the placement of pledgeted sutures for donor chordae attachment on the LV free wall, ensuring physiologic leaflet tensioning. The DHs also clarified spatial constraints posed by the prior valve and altered LV geometry, assisting surgical decision-making beyond what static imaging allowed. The patient underwent successful MV PHT with serial follow-up echocardiography showing stable MV function with mild regurgitation and preserved biventricular function. Conclusion: This case highlights the critical role of 3D virtual modeling in the planning of MV PHT, enabling precise intraoperative chordal placement in the absence of native subvalvular anatomy. Patient-specific DHs allowed accurate quantification of complex spatial relationships that were otherwise inaccessible, enhancing surgical confidence and procedural precision. Integration of DHs into preoperative workflows may broaden the feasibility of complex reconstructive valve strategies in pediatric and reoperative populations.

PurposeFungal endocarditis (FE), a rare but severe subset of infective endocarditis (IE), accounts for 2–4% of cases, with significant morbidity and mortality despite combined clinical and surgical interventions. The incidence of FE has been rising due to an increase in patients with predisposing risk factors, such as prosthetic heart valves, indwelling central venous catheters, prolonged fungemia, and intravenous drug use, alongside advancements in diagnostic techniques. Diagnosing FE is challenging due to nonspecific symptoms and often negative or delayed blood culture results, necessitating repeated cultures and sometimes surgical specimen collection for confirmation. FE is associated with a higher incidence of extracardiac complications, such as systemic and central nervous system embolization, compared to bacterial endocarditis.MethodsThis study retrospectively analyzed 687 patients with non-device-related IE admitted to a high-volume surgical center from January 2013 to December 2023, identifying 8 cases of FE (1.2%). The diagnostic work-up followed European Society of Cardiology guidelines, including blood cultures and echocardiography. Management involved a multidisciplinary team approach, combining antifungal therapy and early surgical intervention.ResultsDespite advancements, the prognosis of FE remains poor, with a mortality rate exceeding 50%. Early diagnosis and timely intervention, including early surgery, are crucial for improving outcomes.ConclusionThis study and the review of the literature aim to enhance understanding of FE by reviewing clinical presentations, diagnostic challenges, and management strategies, emphasizing the importance of a high index of suspicion and comprehensive diagnostic evaluation in high-risk patients.

Incidence and Predictors of Candida Endocarditis in Hospitalized Patients With Candidemia: Insights From the National Inpatient Sample (2016 to 2022).

IntroductionIn patients with prior valve replacement requiring venoarterial extracorporeal membrane oxygenation (VA ECMO), there is a risk of prosthetic valve thrombosis (PVT) due to intracardiac stasis. We describe our experience with PVT in patients on VA ECMO.MethodsThis was a retrospective cohort study of patients with prior valve replacement undergoing VA ECMO. Patients who developed PVT on VA ECMO were compared to those who did not.ResultsForty-six patients who had prior valve replacement (total of 63 valves) were placed on VA ECMO. Six patients (13%) suffered PVT on VA ECMO. There was no difference in the rate of PVT in mitral versus aortic valve prostheses (22% [5/23] vs 3% [1/32]; p = .07) or between tissue and mechanical valves (16% [8/50] vs 0% [0/13]; p = .19). There were no differences in ECMO parameters, including site of cannulation (central vs peripheral), initial ECMO flow, time to initiation of anticoagulation, or use of a concomitant IABP between patients who did and did not develop PVT. Patients who developed PVT demonstrated significantly lower pulse pressures compared to those who did not (12.7mmHg vs 32.7mmHg; p = .03). Surgical thrombectomy was performed in three of the six patients with PVT and one survived to discharge.ConclusionPVT occurred in 13% of patients on VA ECMO after prior valve replacement. The only predictor of PVT on VA ECMO was a lower pulse pressure. Strategies to maintain intracardiac flow and pulsatility may reduce this risk. Treatment options are limited and pose significant risk, and therefore prevention is key.

Silent non-obstructive prosthetic mitral valve thrombosis revealed by acute coronary embolism.

The current study aims to describe outcomes after transcatheter valve replacement in adults with congenital heart disease. Retrospective study of adults with congenital heart disease who underwent transcatheter valve replacement and had a 1-year follow-up postintervention at Mayo Clinic (2010-2024). The study period was divided into early (2010-2014), mid (2015-2019), and late (2020-2024) eras. The primary outcome was valve reintervention. The secondary outcomes were all-cause mortality and temporal change in prosthetic valve gradient and clinical indices of disease severity. Overall, 341 patients (age 38±17 years; 175 [51%] males) received 346 prostheses (pulmonary [N=236, 68%], tricuspid [N=75, 22%], aortic [N=22, 8%], and mitral [N=7, 2%]). The prostheses were Sapien (N=181, 52%), Melody (N=142, 41%), and Harmony prostheses (N=23, 7%). The number of transcatheter valve implantations increased from the early era (N=75), mid era (N=109), to the late era (N=162). The 10-year incidence of valve reintervention was 35%, and was similar between Sapien versus Melody prosthesis (41% versus 33%; P=0.11). The 10-year incidence of all-cause mortality was 13%. There was a temporal increase in prosthetic valve Doppler mean gradient (baseline versus 10 years) for pulmonary (12±5 versus 28±11 mmHg; P<0.001), tricuspid (3±1 versus 8±3 mmHg; P<0.001), and aortic prosthesis (13±5 versus 26±12 mmHg; P<0.001). There was a temporal increase in predicted peak oxygen consumption (absolute ∆, 9% [95% CI, 4-13]; P=0.006) and a decrease in NT-proBNP (N-terminal pro-B-type natriuretic peptide) level (absolute ∆, -138 pg/mL [95% CI, -209 to -64]; P<0.001) at 1-year postintervention. There has been a temporal increase in the number of transcatheter valve implantations over time. Transcatheter valve replacement was associated with clinical improvement across multiple domains. However, there was a significant increase in prosthetic valve gradient within 10 years of follow-up, suggesting limited prosthesis longevity. There is a need for strategies to improve prosthetic valve longevity, which in turn may improve outcomes in this population.