Subacute Endocarditis Research Articles

Functional Analysis of a Fibronectin Binding Protein of Streptococcus parasanguinis FW213.

Streptococcus parasanguinis is a primary colonizer of dental plaque and an opportunistic pathogen for subacute endocarditis. A putative fibronectin binding protein (Spaf_1409) that lacks both an N-terminal signal peptide and a C-terminal cell wall-anchoring motif was identified from the S. parasanguinis FW213 genome. Spaf_1409 was abundantly present in the cytoplasm and also was found in the cell wall preparation and culture supernatant. By using an isogenic mutant strain, MPH4, Spaf_1409 was found to mediate the binding of S. parasanguinis FW213 to fibronectin. Inactivation of Spaf_1409 did not significantly alter the mass of static biofilm, but reduced the resistance of S. parasanguinis against the shearing force in a flow cell biofilm system, resulting in scattered biofilm. The mortality in Galleria mellonella larvae infected with MPH4 was higher than in those infected with wild-type S. parasanguinis. However, fewer viable bacterial cells were recovered from larvae infected with MPH4, compared to those infected with wild-type S. parasanguinis, up to 42h post infection, suggesting that the infection by MPH4, but not the growth, was responsible for the elevated mortality. The phagocytic analysis using flow cytometry indicated that Spaf_1409 participates in the recognition of S. parasanguinis FW213 by RAW264.7 macrophages, suggesting that inactivation of Spaf_1409 intensified the immune responses in larvae, leading to larval death. Taken together, the data indicate that Spaf_1409 plays different roles in the development of dental biofilm and in systemic infections.

Congenital Heart Diseases Associated With Cleft Lip and Palate and Its Impact on Surgical Treatment Planning of Patients With Cleft Lip and Palate-A Cross-Sectional Study.

The aim of this study is to know the prevalence, type of congenital heart diseases (CHDs), and its association with cleft lip and/or palate and to know the impact of CHDs on surgical treatment planning of cleft lip and palate from a craniofacial hospital specializing in orofacial clefts, head and neck cancer, and trauma management. A total of 1381 patients with nonsyndromic cleft lip and palate were included in the study. This is a hospital-based retro-prospective case record analysis. The data were collected from clinical records of the patients which included clinical, chest radiographic and 2D echocardiographic findings. Total incidence of CHDs and its impact on treatment planning was evaluated using κ statistics and χ2 test. There were 32 (2.32%) cleft lip and palate patients with CHDs. In 2 patients, cleft surgery was delayed by 6 to 9 months to allow the defect to decrease in size. Subacute bacterial endocarditis prophylaxis was administered in 7 patients before cleft surgery. Cardiac surgery was advised prior to cleft surgery in 3 patients. Sixteen patients with CHDs were not taken for cleft surgery considering the potential risk to the patient's life as they had multiple cardiac anomalies. There were no intraoperative and postoperative complications in these patients. The results emphasize the association between clefting and CHD. The collected data suggest that there should be careful examination of children with cleft lip and palate for signs of heart disease. This could significantly reduce the morbidity/mortality of cleft lip and palate surgery making it more predictable and safer.

A Study on Dental Caries and Dental Plaques Caused by Streptococcus Mutans, of Patients at Border Guard Hospital Dhaka, Peelkhana

Background: Dental caries is one of the most common chronic infectious diseases in the world. The acids generated through the fermentation of sugar by the microorganisms in dental plaque can decalcify the superficial layers of tooth enamel and can initiate dental caries. Streptococcus mutans have been proposed as the main etiological agents of dental caries .The aim of this study is to identify the main etiological agents of dental caries and plaque which are supposed to be Streptococcus mutans as correlating microorganism.
 Materials and Methods: This cross sectional study was carried out in the Pathology department of Border Guard Hospital, Peelkhana, Dhaka during the period of 1st October, 2018 to 3IST December,2018. Study population was newly enrolled soldiers and their families as male ,female and children in BGB. A total of 50 clinical samples were included in this study. The samples were collected from the Dental outdoor patient department and all laboratory tests were performed at Pathology department of aforementioned hospital. After performing all possible microbiological tests for bacterial isolation, results were recorded.
 Results: Among 50 samples, 46(92%) samples are considered to be positive for Streptococcus viridans and 27(54%) isolates are identified as Streptococci mutans according to ability of producing special kind of exopolysaccharide, lactic acid formation and high salt tolerance tests. Associated organisms (32%) like candida were present in 15(30%) samples and other bacterial colonies were present in 31(62%) samples, along with Streptococcus viridans.
 Conclusion: The finding of this study will help the dentists to treat the patients with chronic caries, dental plaques as they pose the gravest threat when they settle down on damaged heart valves, cause subacute bacterial endocarditis and other infections in various sites including mouth, joints, skin, muscle, and central nervous system after tooth extraction or any other invasive procedure
 J Bangladesh Coll Phys Surg 2020; 38(3): 121-125

Policies for Mandatory Ethics Consultations at U.S. Academic Teaching Hospitals: A Multisite Survey Study.

To determine the number of top-ranked U.S. academic institutions that require ethics consultation for specific adult clinical circumstances (e.g., family requests for potentially inappropriate treatment) and to detail those circumstances and the specific clinical scenarios for which consultations are mandated. Cross-sectional survey study, conducted online or over the phone between July 2016 and October 2017. We identified the top 50 research medical schools through the 2016 U.S. News and World Report rankings. The primary teaching hospital for each medical school was included. The chair/director of each hospital's adult clinical ethics committee, or a suitable alternate representative familiar with ethics consultation services, was identified for study recruitment. None. A representative from the adult ethics consultation service at each of the 50 target hospitals was identified. Thirty-six of 50 sites (72%) consented to participate in the study, and 18 (50%) reported having at least one current mandatory consultation policy. Of the 17 sites that completed the survey and listed their triggers for mandatory ethics consultations, 20 trigger scenarios were provided, with three sites listing two distinct clinical situations. The majority of these triggers addressed family requests for potentially inappropriate treatment (9/20, 45%) or medical decision-making for unrepresented patients lacking decision-making capacity (7/20, 35%). Other triggers included organ donation after circulatory death, initiation of extracorporeal membrane oxygenation, denial of valve replacement in patients with subacute bacterial endocarditis, and posthumous donation of sperm. Twelve (67%) of the 18 sites with mandatory policies reported that their protocol(s) was formally documented in writing. Among top-ranked academic medical centers, the existence and content of official policies regarding situations that mandate ethics consultations are variable. This finding suggests that, despite recent critical care consensus guidelines recommending institutional review as standard practice in particular scenarios, formal adoption of such policies has yet to become widespread and uniform.

Personality Disorder as the Initial Presentation of a Complicated Endocarditis: Diagnostic Challenges in the CARDIO-PSYCHIATRY

Background: Bacterial endocarditis is a rare infectious entity with a very heterogeneous clinical spectrum; neurological manifestations are the most frequent and serious extracardiac complications of infective endocarditis. However, little is known about the psychiatric manifestations and / or sequels due to septic embolism of the infective endocarditis. Case Report: 50-year-old male, history of arterial hypertension and nephrolithiasis with recurrent urinary tract infections. He began his condition with behavioral changes characterized by marked impulsivity and instability in his interpersonal relationships, adding repetitive events of fever and nephrolithiasis requiring urological interventions and antibiotic therapy. Upon admission assessed by psychiatry because of his impulsive behavior and emotional changes with the presumptive diagnosis of borderline personality disorder. Conclusion: In the following work we describe the first case found in the literature of a psychiatric manifestation in a male patient as the initial complication of a subacute bacterial endocarditis, his diagnostic approach, clinical picture and therapeutic outcome. The early recognition of the clinical picture and the diagnostic approach allowed to establish effective antibiotic treatment; to recognize that bacterial endocarditis might present in a multifaceted way allows to suspect this disease and give treatment opportunely to reduce its burden and mortality.

Diagnostic and treatment challenge of unrecognized subacute bacterial endocarditis associated with ANCA-PR3 positive immunocomplex glomerulonephritis: a case report and literature review

BackgroundDiagnosis and treatment of either ANCA disease or silent infection-related glomerulonephritis is complicated and is a huge treatment challenge when overlapping clinical manifestations occur. We report a case of ANCA-PR3 glomerulonephritis, nervous system involvement, hepatosplenomegaly and clinically silent subacute infectious endocarditis.Case presentationA 57-year-old man with known mitral valve prolaps was admitted for unexplained renal failure with signs of nephritic syndrome, hepatosplenomegaly, sudden unilateral hearing loss, vertigo, malaise, new onset hemolytic anemia and thrombocytopenia. Immunoserology revealed positive c-anti-neutrophil cytoplasm antibody (ANCA)/anti-proteinase 3 (anti-PR3), mixed type crioglobulinemia and lowered complement fraction C3. Head MRI showed many microscopic hemorrhages. Common site of infection, as well as solid malignoma were ruled out. In accordance with clinical and laboratory findings, systemic vasculitis was assumed, although the etiology remained uncertain (ANCA-associated, cryoglobulinemic or related to unrecognized infection). After kidney biopsy, clinical signs of sepsis appeared. Blood cultures revealed Streptococcus cristatus. Echocardiography showed mitral valve endocarditis. Kidney biopsy revealed proliferative, necrotizing immunocomplex glomerulonephritis. Half a year later, following intravenous immunoglobulins, glucocorticoids, antibiotic therapy and surgical valve repair, the creatinine level decreased and c-ANCA and cryoglobulins disappeared. A second kidney biopsy revealed no residual kidney disease. Four years after treatment, the patient is stable with no symptoms or signs of vasculitis recurrence.ConclusionsHere we describe the diagnostic and treatment challenge in a patient with unrecognized subacute bacterial endocarditis associated with ANCA-PR3 immunocomplex proliferative and crescentic glomerulonephritis. In patients with ANCA-PR3 immunocomplex glomerulonephritis and other overlapping manifestations suggesting systemic disease, it is important to recognize and aggressively treat any possible coexisting bacterial endocarditis, This is the most important step for a favorable patient outcome, including complete clinical and pathohistological resolution of the glomerulonephritis.

Roth spots: A window to underlying systemic conditions

Roth spots are white-centered hemorrhages which can be the first clinical presentation of an underlying systemic disorder such as subacute bacterial endocarditis, leukemia, and anemia. We present a case of Roth spots in a patient with acute myeloid leukemia.

P1243 Nonbacterial thrombotic endocarditis (NBTE) of the aortic valve: incidental finding in hospitalized patients with advanced heart failure

Abstract Background The presence of small mobile masses on the ventricular side of the aortic valves in the absence of valvular regurgitation and signs of systemic inflammation has been previously described as marantic endocarditis and is now referred to as nonbacterial thrombotic endocarditis (NBTE). It is thought to be associated with endothelial dysfunction and procoagulative status, as is the case of acute decompensated heart failure (HF). Case description We present a series of three male patients, with similar clinical characteristics, who were admitted for acute decompensated HF. All three patients had chronic HF, due to non-ischemic dilated cardiomyopathy with severe biventricular dysfunction, with resynchronization therapy, with elevated natriuretic peptides and previous HF hospitalizations in the past year requiring prolonged intravenous treatments. Other clinical, biological criteria for the definition of advanced HF were also met. All patients were under chronic anticoagulation treatment using a direct oral anticoagulant because of persistent atrial fibrillation. Thorough echocardiographic evaluation (both transthoracic and transoesophageal ultrasound) identified small mobile masses on the ventricular side of the aortic valves, centrally, on the line of cusp coaptation, with only minor central regurgitation. The lack of progression of valve lesion and the absence of gross signs of inflammation (no fever, normal hemoleucogram, normal CRP, repeated negative blood cultures) on serial examinations during several weeks follow-up allowed for the exclusion of infective endocarditis. In one case we also identified a left atrial appendage thrombus and presumably thrombotic masses attached to right side pacing leads. No clinically systemic embolic events were identified. Conclusion We consider this to be an incidental finding in the given subclinical prothrombotic and inflammatory predisposing milieu of advanced chronic HF and the increasing high quality echocardiography imaging. Its clinical significance is still unknown, while differential diagnosis from subacute or chronic endocarditis relies largely on clinical judgment.

Pseudoaneurysm after Tetralogy of Fallot Repair Using Right Ventricular Outflow Tract Patch

Background: Pseudoaneurysm complicating right ventricular outflow tract (RVOT) with conduit placement was an infrequent complication but with potential for significant morbidity and mortality, and a more unusual pseudoaneurysm after RVOT patching was investigated here. Methods: Patients diagnosed as pseudoaneurysms at our institution from 2010 to 2019 were reviewed and their clinical characteristics were analyzed. Results: A total of seven patients developed pseudoaneurysm in RVOT were identified. One pseudoaneurysm arose after placement of a conduit between the right ventricle and the pulmonary artery, and the other six formed after RVOT patching. One patient presented with arrhythmia, one patient had the pseudoaneurysm discovered after the diagnosis of subacute infective endocarditis and mediastinal infection, another patient was diagnosed during the operation for relief of anastomotic stenosis, and the other four patients were diagnosed during follow-up. Three patients had a RVOT pressure gradient immediately postoperatively and a progressive elevation, and another two patients presented with new emergence of RVOT pressure gradient at the discovery of pseudoaneurysm. A new mass in the left superior mediastinum on chest X ray film was showed in 5 patients. The pseudoaneurysm was surgical resected successfully with an uneventful recovery course and without relapse in six patients, and the other one caused by infection was still in a strict followup. Conclusion: The increasing elevation or new emergence of RVOT pressure gradient and radiological abnormality with a new mass in superior mediastinum are probable evidences for pseudoaneurysm formation after RVOT patch repair, and the clinicians should pay special attention to patients when indicated.

Q Fever Endocarditis in Iran

Patients with the underlying valvular heart disease are at the high risk of developing sub-acute or chronic endocarditis secondary to Coxiella burnetii. Q fever endocarditis is the most common manifestation along with persistent the infection. There is some serologic and molecular evidence of C. burnetii infection in humans and livestock in Iran. As it is possible to observe chronic Q fever in Iran, it seems necessary to study the prevalence of Q fever endocarditis in this country. In the present study, Infective Endocarditis (IE) patients (possible or definite based on Duke Criteria) hospitalized in Rajaie Cardiovascular Medical and Research Center were enrolled from August 2016 to September 2018. Culture-negative endocarditis patients were evaluated by Raoult criteria for diagnosis Q fever endocarditis. The serological results for brucellosis were negative for all subjects. All blood and tissue samples including valve samples were tested for C. burnetii infection using serology and Polymerase Chain Reaction (PCR). In this study, 126 patients who were admitted to the hospital were enrolled; of which 52 subjects were culture-negative IE. Among the participants, 16 patients (30.77%) were diagnosed with Q fever IE and underwent medical treatment. The mean age of patients was 46.6 years ranging from 23 to 69 years and 75% of them were male. Considering the high prevalence of Q fever IE, evaluation of the patients with culture-negative IE for C. burnetii infections was highly recommended.

Subacute bacterial endocarditis with vasculitis-like presentation; report of a case and literature review

Infective endocarditis is a diagnostic challenge since it could manifest as a systemic disease mimicking rheumatologic disorders by immunological mechanisms. We introduced a case of infective endocarditis which was a 62-year-old man who presented with weakness, weight loss, myalgia, arthritis, petechiae, hematuria and proteinuria and was admitted by a rheumatologist for evaluation of possible vasculitis.

Epidemiology, pathogenesis, treatment and outcomes of infection-associated glomerulonephritis.

For over a century, acute 'post-streptococcal glomerulonephritis' (APSGN) was the prototypical form of bacterial infection-associated glomerulonephritis, typically occurring after resolution of infection and a distinct infection-free latent period. Other less common forms of infection-associated glomerulonephritides resulted from persistent bacteraemia in association with subacute bacterial endocarditis and shunt nephritis. However, a major paradigm shift in the epidemiology and bacteriology of infection-associated glomerulonephritides has occurred over the past few decades. The incidence of APSGN has sharply declined in the Western world, whereas the number of Staphylococcus infection-associated glomerulonephritis (SAGN) cases increased owing to a surge in drug-resistant Staphylococcus aureus infections, both in the hospital and community settings. These Staphylococcus infections range from superficial skin infections to deep-seated invasive infections such as endocarditis, which is on the rise among young adults owing to the ongoing intravenous drug use epidemic. SAGN is markedly different from APSGN in terms of its demographic profile, temporal association with active infection and disease outcomes. The diagnosis and management of SAGN is challenging because of the lack of unique histological features, the frequently occult nature of the underlying infection and the older age and co-morbidities in the affected patients. The emergence of multi-drug-resistant bacterial strains further complicates patient treatment.

Improving the Quality of Outpatient Pediatric Cardiology Management Plan Documentation

Purpose: Concise, complete physician documentation by sub-specialists is imperative. In the case of pediatric patients with congenital heart disease, it is of utmost importance that certain considerations such as the need for sub-acute bacterial endocarditis (SBE) prophylaxis, need for activity restrictions, and need for additional follow-up and testing be included in outpatient clinic documentation. The objective of our quality improvement initiative was to improve the rate of …

Trends and Predictors of 30-day Readmission Among Patients Hospitalized with Infective Endocarditis in the United States.

BackgroundThe incidence and 30-day readmission rates of patients with infective endocarditis (IE) are not fully determined. We used the United States Nationwide Readmission Database (NRD) to assess national trends and predictors of 30-day readmission.MethodsWe queried the NRD from 2010 to 2014 and identified patients with index hospitalizations primarily for IE. Univariate and multivariate logistic regression analyses were conducted to identify predictors of 30-day readmission.ResultsA total of 48,500 patients (mean age 58 ± 19 years; 38% women; 6.4% died during index hospitalization) were admitted for IE. There was an annual decrease in hospitalization rates by 1.5%. With an exception for 2014, subsequent 30-day readmission rates remained relatively unchanged. All-cause 30-day readmission occurred in 25.4% of patients, 21.8% of which were due to acute or subacute bacterial endocarditis. Leaving against medical advice (odds ratio (OR): 3.46, 95% CI: 3.12 - 3.84; P <0.001), history of drug abuse and a cardiac implantable electronic device in situ (OR: 2.17, 95% CI: 1.53 - 3.08; P <0.001), fungal IE (OR: 1.5, 95% CI: 1.28 - 1.76; P < 0.001), and uninsured patients (OR: 1.39, 95% CI: 1.12 - 1.74, P <0.001) were the strongest independent predictors of 30-day readmission. Readmission cost ($58 million annually) accounted for 14% of the total hospitalization cost.ConclusionsThe annual incidence of IE in the US decreased slightly from 2010 to 2014, but the 30-day readmission rates remained relatively unchanged. Addressing modifiable predictors of readmission may reduce the financial burden of IE on health care.

Epidemiological analyses to inform stroke clinical practice guidelines development.

Stroke is one of the leading causes of mortality and the leading cause of functional impairment and cognitive deficits worldwide. It is important that clinical practice guidelines development is based on robust statistical and epidemiological data and their analysis throughout the whole process of guidelines development and implementation. The aim of this short communication is to analyse epidemiology of prevalence and incidence of ischaemic stroke, its main causes, brain imaging using MRI, recanalization therapies, secondary prevention with antiplatelet and anticoagulants, mortality data and to inform development of stroke clinical practice guidelines in the Czech Republic. The main analysed diagnosis was I63 (cerebral infarction) and secondary diagnoses were: I48 (atrial fibrillation and flutter), I35.9 (nonspecified aortic valve disease), Q21.1 (atrial septal defect) or I33.0 (acute and subacute endocarditis). We have also analysed use of brain imaging with MRI, recanalization treatment using intravenous thrombolysis and mechanical thrombectomy, stroke secondary prevention with antiplatelet drugs and anticoagulation as well as hospital admissions and mortality. In total, 159 344 patients were diagnosed with an ischaemic stroke from 2015 to 2017. Average prevalence of ischaemic stroke in the Czech Republic is 54.9 patients per 100 000. 22.2% of patients with stroke received intravenous thrombolysis or mechanical thrombectomy in 2017.

Draft Genome Sequence of Campylobacter fetus subsp. fetus CITCf01, Isolated from a Patient with Subacute Bacterial Endocarditis.

Campylobacter fetus is a Gram-negative, zoonotic pathogen and a member of the class Epsilonproteobacteria We report the draft genome sequence of C. fetus subsp. fetus CITCf01, isolated from a patient with subacute bacterial endocarditis. CITCf01 grew under aerobic, microaerobic, and anaerobic conditions, and at 42°C, an unusual combination of growth conditions.

Edwards SAPIEN transcatheter pulmonary valve implantation: Mid-term results from a French registry

The Edwards SAPIEN XT and SAPIEN 3 valve have been reported for percutaneous pulmonary valve implantation (PPVI), but long-term data are not available. The aim of the study was to describe and analyze data from patients treated in France with the Edwards SAPIEN™ transcatheter heart valve (Edwards Lifesciences LLC, Irvine, CA, USA) in pulmonary position. From April 2011 to May 2017, 71 patients undergoing PPVI were consecutively included. Median age at PPVI was 26.8 years (range: 12.8–70.1). PPVI indication was pure stenosis in 33.8% of patients, pure regurgitation in 28.1% and mixed lesions in 38.1%. PPVI were successfully implemented in 68 patients (95.8%). No significant regurgitation was recorded after the procedure. Transpulmonary gradient was significantly reduced from 34.5 mmHg to 10.5 mmHg ( P < 0.0001). At one-year follow-up, death rate was 2.9% and 3 patient had a surgical reintervention (4.4%). The indication for reintervention were: one subacute endocarditis, one bioprosthesis dysfunction and one heart transplantation. For others patients, they did not show any significant valve's dysfunction. We highlighted the persistence of low gradient and absence of significant pulmonary regurgitation in long-term follow-up. Mid-term results with the Edwards SAPIEN valve in pulmonary position demonstrate a persistence of good hemodynamic results.

Early bioprosthetic aortic valve endocarditis from dual bacterial pathogens including a HACEK microorganism (Cardiobacterium hominis)

This article presents Bacillus thuringiensis, a new pathogen implicated in causing infective endocarditis, in combination with Cardiobacterium hominis, which has never been reported in a dual pathogen endocarditis scenario.This is the first reported case of dual pathogen HACEK endocarditis that was identified by the authors. Our patient presented with a subacute course of infective symptoms and investigations found prosthetic valve endocarditis with C. hominis and B. thuringiensis. This is the first instance where B. thuringiensis has been implicated in infective endocarditis, where it was thought to previously be non-pathogenic. This is the nineteenth case of C. hominis prosthetic valve endocarditis and eighth case of C. hominis prosthetic valve endocarditis requiring re-do surgery reported in the English language.The pathogens isolated in this instance provide insight into causative pathogens and appropriate treatment modalities for successful management of sub-acute bioprosthetic infective endocarditis.

REDO-BENTALL OPERATION – ITERATIVE AORTIC ROOT RECOSTRUCTION – THERAPEUTIC DECISION-MAKING COMPLEXITY AND PROCEDURAL COMPLEXITY

We present the case of a 59-year-old woman who undergoes surgery 12 years after the Bentall-de Bono operation (replacement of the aortic valve and ascending aorta with valvular duct and direct reimplantation of the coronaryan ostia in the duct). For the acute aortic dissection of type I De Bakey (Stanford type A), diagnosed with subacute infectious endocarditis at the level of the aortic valvular duct with abscess in the aortic root.

TWO CASES OF FATAL BACTERIAL ENDOCARDITIS IN ADULTS WITH CORRECTED CHD

SESSION TITLE: Critical Care 1 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Over the last 40 years advances in the treatment of pediatric congenital heart disease (CHD) have resulted in increasing numbers of adults with repaired CHD. Bacterial Endocarditis is a known complication of CHD; however, subacute bacterial endocarditis (SBE) has variable symptoms and can be difficult to diagnose. We present two cases of fatal SBE in adults with corrected CHD. CASE PRESENTATION: Patient A was a 34-year-old male with a bicuspid aortic valve and aortic stenosis who had a Ross procedure 20 years prior. One month prior to presentation he developed progressive renal failure and pancytopenia. He underwent a renal and bone marrow biopsy and was treated with steroids for presumed vasculitis. Three days prior to transfer he presented with abdominal pain, vomiting, and jaundice. He developed progressive renal failure and was transferred with consideration for plasmapheresis for presumed TTP. Blood cultures prior to transfer grew MRSA. Upon arrival, he was normotensive and afebrile with a saturation of 91% and heart rate 116. His exam was notable for an early systolic murmur at the RUSB. Laboratory tests showed WBC 19.1 k/ul, hemoglobin 7.9 g/dL, platelets 44 k/ul, creatinine 7.5 mg/dl, and BUN 151. A blood smear showed no schistocytes. He was started on antibiotics for MRSA bacteremia and arrangements were made for hemodialysis. However, he abruptly developed chest pain, ST elevations, and respiratory distress followed by cardiac arrest. Resuscitation efforts were unsuccessful. At autopsy, he was noted to have MRSA pulmonic valve endocarditis and evidence of DIC. Patient B was a 35-year-old female with aortic coarctation post-surgical repair who presented with two months of arthralgia, dyspnea, and chest pain. She was initially treated for pneumonia with levofloxacin but developed acute liver injury with ALT 2008 and AST 3444. She was transferred for liver transplant evaluation. Her blood pressure was 91/47, pulse 94, respiratory rate 49, and saturation of 95%. Laboratory studies were notable for a WBC 14.29 k/uL, hemoglobin 9.3 g/dL, platelets 99 k/uL, INR 2.5, lactic acid 12.5 mmol/L, AST 4921, ALT 2373, and normal renal function. She developed progressive multi-organ failure and shock, resulting in a family decision to focus on palliative measures. At autopsy, she was noted to have infective tricuspid valve endocarditis. DISCUSSION: Corrected CHD is a known risk factor for SBE but the absolute risk is low. As patients can be decades removed from their surgeries, a careful review of history is paramount. Patients with corrected CHD are more likely to have right-sided IE which is more likely to have atypical presentations. CONCLUSIONS: These two cases highlight the need for a keen understanding of adult corrected CHD, its myriad presentations, and the need for early recognition, prompt antimicrobial therapy, and appropriate surgical referral. Reference #1: Knirsch W, Nadal D. Infective endocarditis in congenital heart disease. Eur J Pediatr. 2011;170(9):1111-27. Reference #2: Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015;132(15):1435-86. Reference #3: Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736-54. DISCLOSURES: No relevant relationships by Andrew Barros, source=Web Response No relevant relationships by Michael Bergman, source=Web Response no disclosure on file for Max Weder