Subsequent Transesophageal Echocardiogram Research Articles

Abstract 16036: Concomitant Culture-Negative Left-Sided Native Valve Endocarditis With Splenic Emboli and Babesiosis: A Case Report

Description of Case: A 76-year-old man with type 2 diabetes and a previously drained hepatic abscess presented with 3 days of fevers and chills associated with dizziness, weakness, and fatigue after hiking at a New York State Park. He denied any shortness of breath, chest pain, abdominal pain, diarrhea, skin rashes, insect bites, IV drug use, recent travel or sick contacts but reported having dental work one month prior to admission. Initial vital signs were notable for a fever of 38.4°C with a blood pressure of 145/76, heart rate of 90, and physical examination was unremarkable. Extensive laboratory studies were drawn, which initially were notable for normocytic anemia, thrombocytopenia, low haptoglobin and elevated lactate dehydrogenase. Empiric antibiotics were initiated as the patient met criteria for systemic inflammatory response syndrome (SIRS). CT abdomen and pelvis was remarkable for right-sided spleen with polysplenia and multiple peripheral wedge-shaped splenic infarcts. A transthoracic echocardiogram (TTE) was inconclusive for infective endocarditis (IE). A subsequent transesophageal echocardiogram (TEE) showed vegetations on the aortic and mitral valves with mild regurgitation respectively. After cardiothoracic surgery evaluation, he was deemed not a surgical candidate. Blood and urine cultures remained negative, but the Babesia antibodies IgM and IgG antibodies, and Babesia microti PCR was detected. He was started on atovaquone 750 mg twice daily and azithromycin 250 mg once daily for 10 days for babesiosis. He was discharged on vancomycin 1g every 12 hours and ceftriaxone 2g every 24 hours for a total of 6 weeks for empiric IE treatment given splenic emboli. Discussion : We describe a rare case of fever caused by culture-negative mitral and aortic valvular endocarditis with splenic emboli and babesiosis. Recent dental work and hiking outdoors in the Northeast United States of America were the key predisposing factors. Given splenic infarcts, pursuing a TEE was pivotal in ascertaining the diagnosis. The patient received empiric IE treatment for gram-positive cocci, HACEK organisms and babesiosis with improvement of symptoms. Identifying and treating unusual causes of fever and SIRS are crucial in reducing mortality and morbidity.

Abstract 18886: Rare but Fatal: Thrombus Formation and Cerebral Infarction Following Atrial Fibrillation Ablation

Introduction: Atrial fibrillation (AF) ablation has become increasingly common as a first line treatment for young, healthy patients and recurrent AF. While the procedures are effective and safe with a mortality rate of <0.1%, it can be associated with fatal complications. Case Presentation: A 74-year-old male with a history of AF status post epicardial ablation, ascending and thoracic aortic aneurysm, hypertension, dilated cardiomyopathy, sick sinus syndrome and alcohol use presented with left hemiparesis and left sided facial droop. He had undergone radiofrequency ablation about 3 weeks prior. Initial evaluation for stroke with computed tomography (CT) of head and CT angiography (CTA) of head/neck was negative. He was intubated for airway protection. Upon insertion of the nasogastric tube, it had dark blood concerning for an upper gastrointestinal bleed. The hospital course was complicated by sinus bradycardia and severe hypotension requiring dopamine and norepinephrine infusions. Repeat CTA head/neck demonstrated new evolving infarcts in the left middle cerebral artery (MCA), left posterior cerebral artery and right MCA territories. During an esophagogastroduodenoscopy to rule out atrioesophageal fistula, patient had a vasovagal episode which resolved with epinephrine. Subsequent transesophageal echocardiogram (TEE) demonstrated an echogenic long protruding thrombus extending across the iatrogenic atrial septal defect from the right atrium to the posterior wall of the left atrium, attached near the ostium of the right lower pulmonary vein. Repeat CT head multiple new areas concerning for developing infarctions and pneumocephalus. Given his overall grim prognosis, the patient was transitioned to comfort care. Conclusions: As ablative procedures for management of AF become more prevalent, it is imperative to maintain a high clinical suspicion for rare but fatal complications which require prompt diagnosis and early aggressive management.

Abstract 17670: Double Trouble: Exploring the Rare Coexistence of Right and Left Atrial Thrombus After Left Atrial Appendage Ligation and Maze Procedure

Introduction: Left atrial appendage (LAA) harbors around 90% of thrombus in patients with Atrial Fibrillation(AF) related strokes. Incomplete surgical ligation and LAA stump are independent risk factors for stroke and thromboembolism in AF patients. To our knowledge, we report the first case of biatrial thrombus occurring within 1 week of surgery. Case Presentation: A 76-year-old man with Paroxysmal AF and three-vessel coronary artery disease presented with 3-week exertional and resting shortness of breath and chest pain. Troponins were negative, and EKG revealed AF. Cardiothoracic surgery planned coronary bypass, MAZE procedure, and LAA clipping. Intra-operative transoesophageal echocardiogram(TEE) showed ejection fraction of 35% without LAA clot. Post-operatively, despite anticoagulation(AC) and beta blocker therapy, AF recurred within a week. Subsequent TEE prior to anticipated cardioversion(CV) revealed thrombus on the superior vena cava border of right atrium, anterolateral wall of left atrium and near the mitral valve annulus. CV was deferred, and he was sent to rehab with AC. We hypothesize that the thrombus may be attributed to a stunned atrium caused by ischemic myocardial injury. Our case underscores the need for heightened suspicion of thrombus in individual cases. Discussion: Left atrial appendage occlusion (LAAO) was implemented as stroke prophylaxis strategy in AF during surgical interventions like maze and coronary bypass. while the European Society of Cardiology advises continuing AC after LAAO, studies suggest discontinuing AC in high-risk bleeding patients after successful surgical AF ablation and LAAO if sinus rhythm is maintained for ≥3 months. LAAOS III study shows economic benefit of concomitant surgical LAAO during cardiac surgery in AF patients with CHA2DS2-VASc score ≥2 for stroke prevention. When used alongside AC, it offers incremental benefits. Safety of discontinuing AC after LAAO requires further investigation.

Abstract 520: Stethoscope Still Saving Lives: Catching A Ruptured Sinus Of Valsalva Aneurysm

Introduction: Sinus of Valsalva aneurysm (SVA) is a rare cardiac abnormality that can occur congenitally or as a result of acquired conditions. It is characterized by a weakness in the elastic lamina at the junction of the aortic media and annulus fibrosis, leading to the formation of an SVA. We present an interesting case of a 54-year-old man, initially diagnosed with infective endocarditis and later on found to have a severe acute rupture of an SVA. Case Presentation: A 54-year-old man with a past medical history of raynaud's disease and rheumatoid arthritis presented with shortness of breath and low-grade fever for two weeks. On further evaluations, a diligent finding of a continuous cardiac murmur and a palpable thrill across the precordium led to a transthoracic echocardiogram (TTE). The TTE revealed a 1.3 x 1.3 cm, nonmobile, ball of material near the base of the septal leaflet of the tricuspid valve, raising concerns about infective endocarditis and thus initiation of broad-spectrum intravenous antibiotics. Subsequent transesophageal echocardiogram, however, revealed an outpouching from the right coronary sinus suggestive of the right sinus of Valsalva which was ruptured with jet hitting the tricuspid valve continuously during diastole and systole, mimicking falsely as vegetation on TTE. Emergency interventions including CT angiogram, catheterization, and surgical repair resulted in a favorable outcome for the patient. Discussion: SVA has a higher prevalence among males and individuals of Asian ethnicity. Its presentation is variable and can include chest discomfort, shortness of breath, pulmonary edema, or even rupture. It can also be an incidental finding on an echocardiogram. The preferred initial diagnostic approach is echocardiography, and surgical repair is often required for patients, especially if the aneurysm has ruptured. Upon diagnosis, prompt evaluation by a cardiothoracic surgeon is crucial as delay in treatment may lead to fatal consequences. Conclusion: The prognosis for ruptured SVAs is poor, which further emphasizes the significance of early diagnosis and prompt treatment. A diligent physical examination is very crucial and can be lifesaving, especially in such circumstances.

Miraculous life-saving role of patent foramen ovale: a case report

Patent foramen ovale (PFO) is a relatively uncommon anatomical variant that predisposes patients to several complications, such as atrial septal aneurysm, thromboembolism, stroke, platypnea-orthodeoxia, and paradoxical embolism. Despite this, in rare cases, PFO can be a life-saving factor. We present a 72-year-old man with a PFO and fulfilled Virchov’s triad after being stationary, dehydrated, and suffering from chronic venous insufficiency. A subsequent transesophageal echocardiogram revealed a large thrombus (approx. 20 cm in length) dwelling in the PFO in between both atria. In this case, PFO effectively saved the patient from such complications as pulmonary embolism and paradoxical embolism.

Abstract 11863: Lutembacher Syndrome - Learning From the Left Atrium

Lutembacher syndrome (LS) is a rare cardiac anomaly that was first reported in 1916 by Rene Lutembacher. LS is characterized by an atrial septal defect (ASD) combined with mitral stenosis (MS), both of which can be either congenital or acquired. Without treatment, pulmonary vascular resistance (PVR) steadily increases and can cause right-to-left ASD shunting. This greatly increases the risk of infective endocarditis (IE) and cerebrovascular accidents (CVA). - We present a 69-year-old female with past medical history of laryngeal cancer that presented with dyspnea and hemoptysis. The patient had NYHA class II symptoms and had not undergone prior cardiac work-up. - Transthoracic echocardiogram demonstrated a reduced ejection fraction 35%, calcifies mitral valve leaflets, and abnormal flow across the interatrial septum. Subsequent transesophageal echocardiogram confirmed the diagnosis of Lutembacher Syndrome with a mean mitral valve gradient of 15 mmHg and evidence of a secundum ASD. There was predominant left-to-right shunting during bubble study with transient right-to-left shunt while coughing. Moderate to severe mitral regurgitation and severe pulmonary hypertension was also observed. Wilkins score was calculated at 7. The patient was ultimately transferred to a Comprehensive Valve Center for surgical mitral valve replacement (MVR). - This case highlights the importance of understanding the pathophysiology of LS for efficient diagnosis and appropriate management. Early evaluation at a Comprehensive Valve Center is recommended. Moderate to severe mitral regurgitation is a contraindication to less invasive options such as a percutaneous mitral balloon commissurotomy (PMBC). It is crucial to recognize that after surgical MVR, the secundum ASD is expected to become smaller with predominant left-to-right shunting due to reduced PVR, which decreases the risk of IE and CVA.

Abstract 15255: Clinical Risk Factors for Infective Endocarditis in Patients With Staphylococcus Aureus Bacteremia and the Diagnostic Utility of Transesophageal Echocardiogram

Background: Approximately 25% of patients with staphylococcus aureus bacteremia (SAB) develop infective endocarditis (IE), which has a consequent mortality of 46%. Current guidelines recommend routine transthoracic echocardiography (TTE) for patients with SAB; transesophageal echocardiogram (TEE) is reserved for those patients in whom initial TTE is negative and clinical suspicion for IE remains high. We sought to elucidate high risk features of SAB associated with the development of IE that warrant a TEE after a negative TTE. Methods: This retrospective study included 213 patients who were diagnosed with SAB at the University of New Mexico Hospital between 2010-2020. A pre-determined list of clinical risk factors along with TTE and TEE status was extracted from the electronic medical record (Table 1). Our primary outcome was the development of IE in patients with SAB. Multivariate logistic regression analysis was used to identify clinical risk factors for IE. Sensitivity and specificity of TTE and TEE was also calculated (Table 1). Results: Out of 213 patients with SAB, 68 patients met diagnostic criteria for infectious endocarditis. Most patients (n=209) underwent TTE and 117 patients underwent subsequent TEE. Initial TTE was diagnostic in 42 patients with a sensitivity of 63% and specificity of 94%; 45 patients had a diagnostic TEE with a sensitivity of 83% and specificity of 98%. Multivariate analysis showed significantly increased risk of IE in patients who had a permanent pacemaker (aOR 32.3, CI 5.23 - 281, p<0.001) or a persistent fever (aOR 6.97, CI 2.42 - 21.0, P<0.001). Conclusions: The routine use of TEE in patients with SAB for the diagnosis of IE may not be necessary and introduces unnecessary procedural risk. Based on our analysis, we recommend that SAB patients with a permanent pacemaker (or other intracardiac prosthetic) or a persistent fever despite appropriate antibiotic therapy be screened with TEE when initial TTE is negative.

A Case of Isolated Pulmonary Valve Endocarditis: The Importance of Repeat Echography and Microbiology in Diagnosis

A 64-year-old man presented to our centre with a one month history of fatigue, exertional dyspnoea, and worsening lower limb oedema on a background of known HFrEF. Following successful diuresis persistently raised inflammatory markers and intermittent fevers prompted investigation for infective endocarditis (IE). Serial blood cultures grew staphylococcus epidermis which were all, unusually, CO2 dependant and likely from a common source. An initial transthoracic echocardiogram (TTE) showed no evidence of endocarditis and normal Tricuspid (TV) and Pulmonary valves (PV). A subsequent transoesophageal echocardiogram (TOE) showed no significant new valvular abnormality.

Abstract 12885: A Challenging Case of Endocarditis— Multi-Disciplinary Approach is an Achievable Chimera

A 60-year-old man with history of coronary artery bypass grafting and mitral valve repair presented with confusion, gait instability and lethargy. Cardiology was consulted after a transthoracic echocardiogram demonstrated a mobile mass on the mitral valve (MV). A subsequent transesophageal echocardiogram showed a large vegetation encompassing and adherent to the anterior annulus and leaflet. Serial blood cultures were negative. The initial differential considered causes of blood culture negative endocarditis (BCNE) with embolic phenomena to the central nervous system. This diagnosis was challenged after the patient developed progressive neurologic symptoms out of proportion to findings on brain imaging. A multidisciplinary team was established to revisit the available data and facilitate a coordinated care approach. The patient was found to fulfill 5 out of 8 criteria for hemophagocytic lymphohistiocytosis (HLH). Furthermore, an H-Score of 268 supported this diagnosis with a >99% probability. Therapy was started with Dexamethasone 5mg/m 2 BID and Anakinra 100mg Q6h, resulting in a rapid improvement in mental status. Secondary HLH in adults is most commonly due to malignancy and infection. Although initial workup was negative, several days into the hospital stay Mycobacterium chimaera was detected on next-generation sequencing of microbial cell-free DNA (Karius test). M. chimaera is a non-tuberculous mycobacterium belonging to the Mycobacterium avium complex and has been associated with a global outbreak following cardiothoracic surgery related to exposure to 3T heater-cooler units (HCU). Endocarditis due to M. chimaera acquired during prior cardiac surgery, complicated by HLH, was considered the most likely unifying diagnosis. This case illustrates: (1) the differential diagnosis of BCNE and the benefit of microbial cell-free DNA testing in its diagnosis, (2) HLH as an unrecognized entity in adults and infectious endocarditis as a possible trigger, (3) the need for improved awareness of M. chimaera infection in patients who have been exposed to HCU presenting with compatible symptoms, and (4) the critical role of communication and a multidisciplinary approach to provide high-quality care in challenging cases such as this one.

Comparing Echocardiographic Modalities in Native-Valve Infective Endocarditis Due to Methicillin-Resistant Staphylococcus Aureus in People Who Inject Drugs.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Current IE guidelines recommend transesophageal echocardiogram (TEE) over transthoracic echocardiogram (TTE) to diagnose infective endocarditis. Management of IE in people who inject drugs (PWID) in many medical centers is mainly conservative with prolonged intravenous antibiotics. Cardiac valve replacement in these patients remains controversial, given the high risk of reinfection. This study’s purpose is to evaluate whether obtaining sequential TEE after TTE in PWID with MRSA native-valve IE changes the management plan in these patients.Methods: A retrospective cohort of patients who are 18 years of age or older and inject drugs with definite MRSA IE between 2013 and 2019 were studied. Their echocardiographic reports and overall management plans were reviewed.Results: One hundred and twenty-six patients met the inclusion criteria. TTE was performed in 121 patients and, of these patients, 69 (57%) had detectable valvular vegetations while 52 (43%) did not. Of the 52 patients with a negative TTE, 44 underwent TEE, 28 (53%) of which showed vegetation. A total of 18 (14%) patients underwent surgery. Of these, six (33%) patients had a positive TTE only, with no subsequent TEE. Ten (56%) patients had both a positive TTE and TEE, and two (11%) patients had a negative TTE but positive TEE.Conclusion: In this retrospective cohort, obtaining a sequential TEE after a TTE in PWID with proven MRSA native IE by modified Duke’s criteria changed the management plan in two patients. The decision to perform a TEE in these patients needs to be individualized. Larger studies are needed to better evaluate the role of TEE in this patient population.

Minimally Invasive Surgical Resection of Accessory Mitral Valve Tissue Causing Severe Symptomatic Left Ventricular Outflow Tract Obstruction in an Adult

Objective: We report a rare case of adult onset, symptomatic, severe left ventricular outflow tract obstruction secondary to accessory mitral valve tissue that was treated surgically through a minimally invasive partial sternotomy approach. Methods: A 29-year-old female with a previous diagnosis of a sub-aortic membrane with 6 months of progressive chest pain, fatigue, palpitations, and presyncope presented to the emergency department with acute onset of severe chest pain, left arm numbness, palpitations, and light-headedness. Transthoracic and subsequent transesophageal echocardiogram demonstrated a mobile, parachute-like mass in the left ventricular outflow track with severe outflow obstruction (resting velocity 3.9m/s and peak gradient 60mmHg). The patient was transferred to our institution for surgical evaluation. Results: Review of the echocardiographic imaging demonstrated obstructing accessory mitral valve tissue (Figure A). The patient underwent surgical resection of the obstructing mass through a partial upper-sternotomy. Accessory mitral valve tissue attached to the aorto-mitral curtain was removed en bloc with chordal attachments to the posteromedial papillary muscle and muscular interventricular septum (Figure C and D). A small, hemodynamically insignificant sub-aortic membrane was also excised. There was no residual gradient, and valvular and ventricular functions were preserved (Figure B). The patient was discharged home on postoperative day 3. Conclusions: While accessory mitral valve tissue rarely presents in adulthood it should remain part of the differential diagnosis of symptomatic left ventricular outflow tract obstruction. Early surgical intervention is recommended and may be performed safely via less invasive surgical approaches. Figure. Accessory mitral valve tissue causing symptomatic, severe left ventricular outflow tract obstruction before (A) and after (B) surgical resection though a minimally invasive partial sternotomy. (C) Surgeon’s view of the left ventricular outflow tract through the aortic valve of the accessory mitral valve tissue, with severed chordae tendinae, attached to the aorto-mitral curtain beneath the left/non-coronary commissure of the aortic valve. (D) Resected accessory mitral valve tissue

325 Does Quality of Transthoracic Echocardiogram (TTE) Impact Predictive Value in Detecting Infective Endocarditis (IE)? A Single Centre Experience

In patients with intermediate or high pretest probability of IE, initial evaluation with TTE and subsequent transesophageal echocardiogram (TEE) is recommended. Studies showing low sensitivity of TTE for native valve endocarditis are based on less advanced echo techniques, and do not consider quality of TTE. Recently, evidence have suggested that good quality study impacts on the negative predictive value (NPV) of TTE. This study sought to assess whether good quality TTE will have sufficient NPV value to rule out IE in the absence of high-risk clinical features. Echocardiograms from patients with both TTE and TEE ordered to assess for IE was reviewed. Quality of the TTE (good, adequate or technically-difficult) by echocardiographer was noted and whether vegetation was seen. 212 patients had TTE followed by TEE to assess for IE (Males 71.7%; 57.7±16years). 151 (71.2%) patients had a negative TTE, 32 (15.1%) were positive and 29 (13.7%) were indeterminate for vegetation. Vegetation was found on TEE in 17.2% of negative TTE and 17.2% of indeterminate TTE. 75% of patients who had a positive TTE went on to have a positive TEE. The overall NPV of TTE without factoring test quality was 81.1%. This increased to 83.6% in adequate and 90.9% in good quality study. Good quality TTE has a high NPV in ruling out native IE. False negative TTEs decrease substantially when study quality is taken into account. Further studies and quality standardization of TTE is required before this approach can be utilized in practice.

P844 A stroke of bad fortune

Abstract Case description We report the case of a 78 year old man who was referred to our hospital following identification of an intracardiac mass on transthoracic echocardiogram (TTE). The study was for work-up of a recent left middle cerebral artery thromboembolic stroke, with successful endovascular clot retrieval. His only other active medical issue was metastatic prostate cancer with bony involvement, on palliative hormone therapy with a well controlled prostate specific antigen level. He was an ex-smoker and and had an ECOG performance status of zero. On physical examination, the patient was clinically well, with unremarkable cardiopulmonary auscultation. The TTE demonstrated an echodense mass in the left atrium (LA), with Doppler colour giving a suggestion of its size (image A). The subsequent transoesophageal echocardiogram illustrated a large, well defined, heterogenous, echodense mass dominating the LA (image B). It was not adherent to the interatrial septum. There was no significant spontaneous echocontrast or thrombus formation in the left atrial appendage (LAA). Considering the location of the mass, the presumptive diagnosis of atrial myxoma was less likely. Differential diagnoses we considered included pure thrombus, infection and benign or malignant cardiac tumours. It was unlikely that this patient had a pure thrombus only considering the LAA was clear. He also did not have any non-specific or focal clinical features suggestive of infection. The patient went on to have a gated CT thoracic aortogram, which showed a contrast-enhancing soft tissue mass within the LA measuring approximately 50x40 millimetre, which invaded into the left inferior pulmonary vein, and was contiguous with a soft tissue mass in the left lower lobe of the lung (image C). He also had a positon emission tomography scan, which showed the highly metabolically active mass in the lung invading into the left inferior pulmonary vein, and as well as left atrium (image D). The patient underwent a biopsy of this left lower lung lesion, which confirmed squamous cell carcinoma of lung origin. Due to the large tumour burden in the LA, the joint decision with medical and radiation oncology teams, was not to administer systemic chemo- or localised radiotherapy, as this would lead to high risk of tumour embolisation. The patient also had a short period of therapeutic anticoagulation with intravenous unfractionated heparin to treat the likely thrombotic coating to the left atrial tumour extension, but developed a retroperitoneal haematoma, and hence anticoagulation was ceased. The patient was referred to palliative care services, and returned back to the community. Conclusion Cardiac tumours, whether primary or secondary, are rare. They are most frequently identified on post-mortem examination. This case is unusual, in that the patient had a second primary tumour and has remained completely asymptomatic prior to embolic presentation, despite the large size of the mass. Abstract P844 Figure 1.

154. Do I Really Need a Transesophageal Echo? Comparing Echocardiographic Modalities in Native Valve Infective Endocarditis due to Methicillin-Resistant Staphylococcus aureus

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE) is associated with high morbidity and mortality. Management commonly includes six-weeks of antibiotics and surgical intervention, if the patient has complications. Current guidelines recommend obtaining an echocardiogram. Transesophageal echocardiogram (TEE) is preferred over transthoracic echocardiogram (TTE). We wanted to evaluate the role of a TEE in changing management of MRSA IE.MethodsA retrospective cohort of patients with MRSA IE was analyzed between January 2013 and July 2017 at a tertiary care facility in East Tennessee. Patients with prosthetic valves or cardiac devices were excluded. Demographic, echocardiographic, antibiotic, blood culture, mortality, and intravenous drug use data were collected (Figure 1).ResultsSeventy-eight patients met the inclusion criteria. TTE was performed on 73 patients while five patients proceeded directly to TEE. Of the 73 patients that had a TTE, 33 (45.2%) detected the presence of vegetation and 40 (54.8%) did not. Of the 33 patients with a positive TTE, 15 subsequently underwent TEE, confirming IE. Out of the 40 patients with a negative TTE, 34 underwent TEE, of which 22 (64.7%) showed a vegetation. (Figure 2). A total of ten patients (12.8%) from the study underwent surgery. Of these ten, three (30%) had a positive TTE only, with no subsequent TEE. Five (50%) had both a positive TTE and TEE, and two (20%) had a negative TTE but positive TEE.ConclusionTransthoracic echocardiogram was adequate to visualize vegetations in 45.2% of patients. Completing a TEE increased the sensitivity of visualizing a vegetation, but management was most often not altered. Only two patients (5%) with a negative TTE, but positive TEE proceeded to surgery because of the findings. This causes us to question whether a subsequent TEE needs to be pursued when a TTE is negative in the setting of definite or possible IE by the modified Duke criteria. Even if a vegetation is seen on TEE the patient would most likely receive the same treatment, 6 weeks of intravenous antibiotics, as if no vegetation was seen. Forgoing a TEE reduces risk to the patient of undergoing a procedure, and reduces costs to the healthcare system. Disclosures All authors: No reported disclosures.

Septic myocardial calcification: A case report

The histological findings in the heart in cases of fatal sepsis can show myocytolysis, interstitial fibrosis, necrotic contraction band, mononuclear infiltrates, and interstitial edema, which can be used in post mortem diagnosis of sepsis. Septic myocardial calcification is a very rare condition, and only a few cases have been reported in the literature. In general, the pathogenesis of the myocardial calcification has not been well clarified, but two pathogenic mechanisms have been universally recognized: metastatic or dystrophic. We present a rare case of sepsis-related myocardial calcification.Here we report a case involving a 72-year-old white male who was admitted to a hospital for a polytrauma caused by a motorbike accident. On the 110th day of hospitalization, the patient was diagnosed with a septic process and a subsequent transesophageal echocardiogram revealed the presence of a calcification on the right atrial wall. According to the medical history of the patient there were no systemic factors predisposing to calcium crystals deposition in tissues. Patient died due to multi-organ failure in the course of multimicrobial septic shock during the 149th day. The autopsy revealed both the presence of a greenish-brown formation and a greater consistency of the right atrial wall. The histological investigation of the right atrium wall showed a wide calcification area localized at subendocardial level, which contained fibrin deposition and was surrounded by fibrotic tissue.

Ankylosing Spondylitis and Anti–Phospholipid Syndrome Resulting in Non–Bacterial Thrombotic Endocarditis: Challenges in Valvular Management

We present a difficult management case of a 39-year-old men with controlled ankylosing spondylitis who developed non–bacterial thrombotic endocarditis. He was initially admitted with pneumonia, when thoracic auscultation unveiled a pan–systolic murmur. Transthoracic echocardiogram showed moderate aortic stenosis (AS) and aortic regurgitation (AR). Subsequent transoesophageal echocardiogram (TOE) showed thickened right and left coronary cusps with moderate eccentric AR. This was thought to be secondary to valvulitis from ankylosing spondylitis and was planned for observant management. Repeat TOE at 6 months showed that his aortic valve pathology progressed to severe AS and AR, with a large mass on the anterior aspect of the valve measuring 1.3 × 1.2 cm (Figure 1). Soon after, he was admitted with an ischaemic right arm, from a thromboembolism, and underwent an uncomplicated thrombectomy. During this admission, TOE showed persistence of the mass structure and severe AS and AR. Serology was positive for primary antiphospholipid syndrome. A literature review showed that patients with antiphospholipid syndrome undergoing cardiac surgery had a perioperative morbidity and mortality of up to 50%. Owing to his extreme surgical risk, a consensus decision, from multiple specialities, was obtained to postpone surgery until he was anticoagulated for 3 months. With meticulous coordination with anaesthetics and haematology, he underwent an uncomplicated surgical mechanical aortic valve replacement. Histology showed myxoid degenerative changes of the valve without thrombus. At the 3-month review, he remained well and has planned life-long anticoagulation with international normalised ratio between 2.5 and 3.5. This case exemplifies the importance of multidisciplinary management of complex, systemic disorders where evidenced-based treatment and guidelines are deficit.

Pylephlebitis presenting as spontaneous coronary sinus thrombosis: a case report

BackgroundCoronary sinus thrombosis is a rare phenomenon. When identified, it most often is a complication of infective endocarditis or procedural intervention. We present an unusual and unreported case of spontaneous coronary sinus thrombosis as embolic sequela of an intra-abdominal infectious process.Case presentationWe report a case of a 61-year-old white woman with a history of end-stage renal disease on hemodialysis, paroxysmal atrial fibrillation not on long-term systemic anticoagulation, and history of recurrent diverticulitis that presented with acute onset abdominal pain and nausea. Computed tomography of her abdomen and pelvis with intravenous contrast was negative for acute intra-abdominal pathology, but incidentally identified an oval-shaped filling defect at the ostium of the coronary sinus suspicious for thrombus or mass which was confirmed on subsequent transesophageal echocardiogram. In light of her concomitant transaminitis but otherwise negative workup, the mass was believed to be thromboembolic in nature, originating within the hepatic venous system as a manifestation of recurrent diverticulitis with associated pylephlebitis and ultimately lodging into the coronary sinus. With the newly detected thrombus and history of paroxysmal atrial fibrillation, she was started on warfarin for therapeutic systemic anticoagulation that resolved her clot by 3-month follow up.ConclusionsAlthough coronary sinus thrombosis is rare, a high index of suspicion and close scrutiny of the venous system in patients with intra-abdominal infectious processes would prevent delay in management of this potentially serious complication. The discussion of this case highlights the anatomy of the cardiac venous system, the pathophysiology of thrombus formation, and the utility of transesophageal echocardiography in confirming a diagnosis and assessing treatment efficacy.

First use of Amplatzer device for bronchopleural fistula after lung transplantation

Lung transplant recipients have a higher morbidity and mortality when compared with other solid organ transplants. Particularly vascular complications can compromise the function of the transplanted lung and increase mortality....

Acute onset heart failure due to Marfan syndrome

A 28-year-old visiting from Central America presented with twenty-four hours of lower extremity swelling, dyspnea and orthopnea. Clinically, she was diagnosed with acute heart failure requiring inotropes with a transthoracic echocardiogram revealing severe mitral regurgitation with a normal ejection fraction. Subsequent transesophageal echocardiogram confirmed severe mitral regurgitation with aortic root dilatation (Z-score: 3.9). She was also found to have arachnodactyly, scoliosis on X-ray and severe mitral valve prolapse. Given her clinical features she was assessed for Marfan syndrome with the modified Ghent nosology systemic score and met diagnostic criteria. A FBN1 genetic test confirmed the diagnosis of Marfan syndrome discovering a frameshift mutation resulting in an inappropriate stop codon and peptide truncation. For patients presenting with heart failure at an atypical age without typical risk factors, rare conditions such as Marfan syndrome should be considered. Marfan syndrome can accurately and quickly be screened for and diagnosed using the systemic score from the modified Ghent nosology.

QUALITY OF TRANSTHORACIC ECHOCARDIOGRAM IMPACTS VALUE IN RULING OUT NATIVE VALVE ENDOCARDITIS: A SINGLE CANADIAN CENTER EXPERIENCE

Detection of infective endocarditis (IE) remains a diagnostic challenge. Current guidelines recommend initial evaluation with transthoracic echocardiogram (TTE) with subsequent transesophageal echocardiogram (TEE) if the pre-test probability of IE is intermediate or high. The low reported sensitivity of TTE for detection of IE is based on studies using less advanced echo techniques than are available today, and do not take into account TTE quality. More recent evidence suggests that image quality of TTE may greatly impact the negative predictive value (NPV) of TTE for ruling out native valve vegetations. A good quality TTE may be sufficient to rule out IE in the absence of high risk clinical features.