Tricuspid Valve Infective Endocarditis Research Articles

Infective Endocarditis—Characteristics and Prognosis According to the Affected Valves

Background: Infective endocarditis (IE) continues to be a disease with high mortality despite medical advances. Objective: The objective of this study was to investigate the characteristics and prognosis of IE according to the affected valves. Materials and methods: This study was retrospective and single-centered, and it included 270 patients with a diagnosis of IE, for the period 2005–2021, who received treatment at the University Hospital “St. Georgi” in Plovdiv, Bulgaria. Results: Single-valve IE (SIE) was found in 82.6% (n-223), multivalvular IE (MIE) in 16.66% (n = 45) and device IE (CDRIE) in 0.74% (n = 2) of patients. The most commonly affected valve was the aortic valve, in 44.8% (n = 121). The predominant multivalvular involvement was aortic–mitral valves (AV-MV) (13.7%, n = 37). The patients with tricuspid valve (TV) IE were significantly younger, at 39 (30) years, and were more frequently male (80.8%). Mortality was higher in MIE than in SIE (31.1% vs. 23.8%) and was the highest in multivalve aortic–tricuspid (AV-TV) IE (75%). Early surgery was performed most in AV-MV IE, in 29.7% (n = 11). The Charlson comorbidity index (CCI) was significantly higher in MV 4 (4) and AV 3 (3) vs. TV IE 1 (5) (p = 0.048 and p = 0.011, respectively). Septic shock occurred most frequently in AV-TV involvement (75%; p = 0.0001). The most common causative agents were of the Staphylococcus group. Staphylococcus aureus more often affected TV alone (46.2%, n = 124) vs. AV (9.9%, n = 14; p = 0.0001) and vs. MV (22.6%, n = 17; p = 0.022); Staphylococcus coagulase-negative (CNG) was the prevalent cause of MV IE (22.7%, n = 17) vs. AV-MV (2.7%, n = 1; p = 0.007). Streptococci were represented in a low percentage and only in left-sided IE, more frequently in AV-MV (18.9%, n = 7) vs. AV (6.6%, n = 8; p = 0.025). Conclusions: The aortic valve is the most frequently affected valve, as single-valve IE or as multivalve AV-MV, with the predominant causative agents being of the Staphylococcus group. AV-TV IE has the worst prognosis, with the most common complication of septic shock and the highest in-hospital mortality.

Comparison of Medical Therapy, Valve Surgery and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis

BackgroundThe opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided IE are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients high-risk for re-infection of a prosthetic valve but lacks robust outcomes data.This retrospective analysis compares the primary outcome of death within one-year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy versus percutaneous mechanical aspiration and valve surgery. MethodsThe authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic and outcomes related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting. ResultsBetween January 1st, 2009 and December 31st, 2018 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One-hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the three treatment groups (p = 0.15). Vegetation size >2.0 cm was associated with increased 1-year mortality (HR 3.01; p = 0.03). Addiction medicine consultation was associated with decreased 1-year mortality (HR 0.117; p = 0.0008). ConclusionThe study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated TVIE. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

Haemophilus influenzae endocarditis: a case report and literature review.

Haemophilus influenzae (HI) is an exceedingly rare cause of infective endocarditis (IE). We present a case of a 90-year-old female diagnosed with HI-IE involving the native tricuspid valve in the absence of traditional risk factors for right-sided endocarditis. She was treated with a 5-week course of IV Ampicillin from negative cultures and suffered no complications. We also conducted a thorough literature review through PubMed and Google Scholar, which yielded a mere 15 reported cases of HI-IE. Fourteen of the reported HI-IE cases included epidemiological data, showing no gender predominance. The mean age of the subjects was 39.5, with the mitral valve being the most implicated (64%) and tricuspid valve involvement being rare (21%). Native tricuspid valve IE is an uncommon entity, especially in the absence of IV drug use. Haemophilus influenzae is an extremely rare cause of IE, with a literature review showing merely 15 reported cases. This article cites the 16th case of HI-IE published in the literature.

Tricuspid valve repair and replacement for infective endocarditis

AbstractInfective endocarditis represents a challenging and life-threatening clinical condition affecting native and prosthetic heart valves, endocardium, and implanted cardiac devices. Right-sided infective endocarditis account for approximately 5–10% of all infective endocarditis and are often associated with intravenous drug use, intracardiac devices, central venous catheters, and congenital heart disease. The tricuspid valve is involved in 90% of right-side infective endocarditis. The primary treatment of tricuspid valve infective endocarditis is based on long-term intravenous antibiotics. When surgery is required, different interventions have been proposed, ranging from valvectomy to various types of valve repair to complete replacement of the valve. Percutaneous removal of vegetations using the AngioVac system has also been proposed in these patients. The aim of this narrative review is to provide an overview of the current surgical options and to discuss the results of the different surgical strategies in patients with tricuspid valve infective endocarditis.

Infective endocarditis of tricuspid valve following septic abortion: a case report

Introduction: Right-sided infective endocarditis (IE) in non-intravenous drug users is a rare finding. IE of the tricuspid valve is considered an important but uncommon complication in patients with a recent history of obstetric and gynecological procedures. Case presentation: We report a case of a 28-year-old female with IE of the tricuspid valve with a prior history of dilatation and curettage. The echocardiography revealed two mobile vegetation in the septal leaflet of the tricuspid valve with severe eccentric tricuspid regurgitation. Blood culture was positive for Staphylococcus aureus. The patient was started on intravenous (i.v.) antibiotics with supportive treatments and improved over the days. Clinical discussion: Infection can get access to the venous system via pelvic veins after the septic obstetric and gynecological procedure and subsequently to the right side of the heart. Different studies have highlighted the role of prophylactic antibiotics in significantly reducing post-abortal infections. In our patient, the disease was diagnosed on the basis of clinical, echocardiographic, and blood culture findings, and the patient responded well to i.v. antibiotics and supportive care under close monitoring in the coronary care unit. Conclusion: It is important for healthcare providers to be aware of the risk factors and symptoms associated with right-sided IE for early diagnosis and treatment. Appropriate antibiotic prophylaxis and adherence to sterile techniques can help to prevent IE.

Surgical Treatment Methods for Tricuspid Valve Infective Endocarditis

Introduction: In recent years, there has been a significant increase in the incidence of tricuspid valve infective endocarditis (IE), which is associated with both the increased number of invasive examinations and procedures and the high rates of intravenous drug use. The initial treatment for tricuspid valve IE was surgical removal of the focus of infection and restoration of intracardiac hemodynamics.Reconstructive surgery aimed at preserving the valve is the preferred method of surgical treatment. If a valve-­preserving operation is not possible due to significant valvular apparatus destruction, implantation of artificial heart valves (both mechanical and biological) is the method of choice.Objective: To analyze the results of reconstructive valve-­preserving surgery and tricuspid valve replacement for tricuspid valve IE treatment.Materials and methods: In the Scientific Research Institute – Specialized Cardiac Surgery Clinical Hospital named after Academician B.A. Korolev (Nizhny Novgorod, Russian Federation) 110 patients underwent surgery for tricuspid valve IE. Primary surgery was performed in 97 patients, and 13 patients underwent repeated surgery. The patients were divided into 2 groups based on the chosen surgical method for correcting tricuspid valve disease. Group 1 included 62 patients who successfully underwent tricuspid valve replacement: mechanical prostheses in 10 patients and biological prostheses in 52 patients. Group 2 included 38 patients who underwent reconstructive valve­preserving surgery. All patients underwent De Vega annuloplasty. In 10 patients it was directly associated with bicuspidalization of the tricuspid valve and plastic surgery of intact leaflets. Two patients had suture annuloplasty of the tricuspid valve based on the modified technique. In 2 of 3 patients, an infected right atrial thrombus was removed. Three patients underwent removal of the left ventricular wall abscess and aortic valve replacement for critical stenosis. After translocation of the chords, triangular resection of the anterior leaflet was performed to separate the chord of the left side of the chest and the myxoma of the right and left chest.Results: In the early postoperative period, no valve­related complications were observed in group 1. The most common nonlethal complication was a third­-degree atrioventricular block. Multiple organ dysfunction syndrome occurred in 3 patients; cardiac tamponade was reported in 2 patients, and 1 patient had postoperative bleeding that required resternotomy for serous mediastinitis in the mid­term period and reosteosynthesis. At the hospital stage, 1 patient from group 1 died, whereas there were no deaths in group 2. In­-hospital mortality in the groups of operated patients was 0.9%.Functional ultrasound imaging findings in the postoperative period show that patients from group 1 had the peak gradient across the prosthetic tricuspid valve of 9.4 ± 1.8 mm Hg, while the mean gradient was 5.8 ± 1.75 mm Hg. There was a significant decrease in the estimated right ventricle pressure from 54.0 ± 16.2 to 35.0 ± 5.5 mm Hg. In group 2 tricuspid valve regurgitation was not observed in 27 patients, while mild and moderate regurgitation was reported in 8 and 3 patients, respectively. The peak gradient during the tricuspid valve reconstruction was 6.2 ± 1.7 mm Hg, while the mean gradient was 2.8 ± 0.75 mm Hg. The annulus fibrosus size during tricuspid valve annuloplasty averaged 30.8 ± 2.5 (28­33) mm. There was a decrease in the right ventricle pressure from 44.0 ± 18.4 to 32.0 ± 7.3 mm Hg. In the mid-­term follow­up, surviving patients were classified as NYHA classes I­-II. Of 110 patients discharged from the clinic, we were able to trace the fate of 69 patients, which accounted for 62.7%. In the long-­term period, 3 patients from group 1 died. Thus, long­term mortality in the general group was 2.72%.Conclusions: Reconstructive surgery has significant advantages over tricuspid valve replacement using various artificial heart valve models: lower rates of in-­hospital and long­-term mortality and specific complications, higher quality of life. Compliance with principles and methods of pathogenetic treatment of electrode­induced IE guarantees a success in the cohort of severe patients. The technique of reconstruction and restoration of tricuspid valve structures and functions in case of active tricuspid valve IE with detachment of the chords and destruction of the leaflets demonstrated high surgical efficiency.

Abstract 17584: Tricuspid Valve Infective Endocarditis: A Catastrophic Complication of Preterm Rupture of Membranes

Background: Few cases of post-partum complication of Group B Streptococcus (GBS) tricuspid valve (TV) infective endocarditis (IE) after live vaginal birth have been reported. We present the same, further complicated by septic emboli tospleen through patent foramen ovale (PFO). Case: 33-year-old 4 weeks post-partum female (G7P6) in septic shock was diagnosed with GBS TV IE with 41mm X 21mm vegetation(F1) with septic emboli to lungs and spleen. Echocardiogram showed PFO with right to left shunt. Ceftriaxone and Gentamycin were started. Her pregnancy was complicated with preterm premature rupture of membrane (PPROM); she had received no antenatal care. Vegetation was debulked with AngioVac procedure (AVP) while PFO was occluded with trans-septal compliant balloon(F2). After recovery from acute illness TV was replaced with bioprosthetic valve. Decision-Making: IE was most likely a post-partum complication in absence of IV drug use, intravascular device, right sided cardiac anomaly. Large size of vegetation with embolization warranted use of AVP to debulk the vegetation as a bridge to valve surgery. PFO occlusion with balloon during AVP prevented potential catastrophic embolization to the brain. Conclusion: Mothers colonized with GBS routinely get antibiotics to prevent transmission to the newborn; this case highlights the need for GBS screening and treatment to reduce maternal morbidity as well. Minimally invasive AVP can debulk vegetations thus decreasing infectious burden and risk of septic embolization before surgery.

A Rare Case of Postpartum Native Tricuspid Valve Infective Endocarditis with Septic Pulmonary Embolization

Infective endocarditis (IE) is a rare life-threatening infection in pregnancy and postpartum period. In 90% of cases, right-sided IE involves the tricuspid valve. This case report illustrates acute IE with native tricuspid valve vegetation with septic pulmonary embolization in immediate postpartum period.

Intractable complicated course of tricuspid valve infective endocarditis due to non-compliance of treatment with clinical guidelines with a decisive role of molecular biological study in etiological diagnosis: a case report

A clinical observation of the treatment non-compliance consequences with clinical guidelines and principles of empirical therapy selection in a female patient with intravenous drug abuse, viral hepatitis C and HIV infection, with a history of a COVID-19 and the development of uncontrolled staphylococcal infective endocarditis (IE) of the tricuspid valve, complicated recurrence of early prosthetic IE is presented. Successful treatment was achieved only by a combination of tricuspid valve replacement and the appointment of etiotropic therapy for S. aureus (MSSA). The typical clinical scenario was not accompanied by the choice of adequate empirical antibiotic therapy, despite the high suspicion of association with MSSA, which determined the complicated course of IE. Only the polymerase chain reaction of the heart valve tissue played a key role in the etiological diagnosis. The use of valve tissue polymerase chain reaction in addition to traditional microbiological methods is a valuable diagnostic study.

Outcomes With Percutaneous Debulking of Tricuspid Valve Endocarditis.

In patients with tricuspid valve infective endocarditis, percutaneous debulking is a treatment option. However, the outcomes of this approach are less well known. We performed a retrospective analysis of all patients who underwent percutaneous vegetation debulking for tricuspid valve infective endocarditis from August 2020 to November 2022 at a large academic tertiary care public hospital. The primary efficacy outcome was procedural success defined by clearance of blood cultures. The primary safety outcome was any procedural complication. For the composite outcome of in-hospital mortality or heart block, outcomes were compared (sequential noninferiority and superiority) with published surgical outcomes data. Of the 29 patients with tricuspid valve infective endocarditis who underwent percutaneous debulking, the average age was 41.3±10.1 years, all patients had septic pulmonary emboli with 27 (93.1%) patients having cavitary lung lesions before the procedure. For the efficacy outcomes, 28 patients (96.6%) had clearance of cultures after their procedure, mean white blood cell count significantly decreased from 16.8±1.4×103 to 12.6±1.0×103 per µL (P<0.01), and mean body temperature significantly decreased from 99.8F ±0.30 to 98.3F ±0.20 (P<0.001) post-procedure. For safety outcomes, there were no procedural complications (0%). Two patients (6.9%) died during the follow-up period, both during the index hospitalization due to severe necrotizing pneumonia. When compared with published data on surgical outcomes, percutaneous debulking was noninferior and superior for the composite of in-hospital death or heart block (noninferiority, P<0.001; superiority, P=0.016). Percutaneous debulking is feasible, effective, and safe in treating patients with tricuspid valve infective endocarditis refractory to medical therapy.

Strokes in Patients With Injection Drug Use and Tricuspid Valve Endocarditis - A Case Series.

Research Design: In this study, we describe patients from a tertiary care safety-net hospital endocarditis registry with tricuspid valve infective endocarditis (TVIE), and concomitant acute or subacute ischemic stroke predominantly associated with injection drug use (IDU). We retrospectively obtained data pertinent to neurologic examinations, history of injection drug use (IDU), blood cultures, transthoracic/transesophageal echocardiography (TTE/TEE), neuroimaging, and Modified Rankin Scale (mRS) scores at discharge. Only those patients with bacteremia, tricuspid valve vegetations, and neuroimaging consistent with acute to subacute ischemic infarction and microhemorrhages in two cases were included in this series. Results: Of 188 patients in the registry, 66 patients had TVIE and 10 of these were complicated by ischemic stroke. Neurologic symptoms were largely non-specific, eight patients had altered mental status and only 3 had focal deficits. Nine cases were associated with IDU. Two patients had evidence of a patent foramen ovale on echocardiography. Blood cultures grew S. aureus species in 9 of the patients, all associated with IDU. Three patients died during hospitalization. The mRS score at discharge for survivors ranged 0-4. Conclusions: Patients with strokes from TVIE had heterogeneous presentations and putative mechanisms. We noted that robust neuroimaging is lacking for patients with TVIE from IDU and that such patients may benefit from neuroimaging as a screen for strokes to assist peri-operative management. Further inquiry is needed to elucidate stroke mechanisms in these patients.

Isolated tricuspid valve infective endocarditis: A report of three cases

Abstract This is a case report of three patients who were managed for right sided infective endocarditis, each posing diagnostic challenges due to atypical clinical presentations and negative blood culture results. Case 1 is a 20-year-old female intravenous (IV) drug user who presented with septic emboli to the lung. Case 2 is a 43-year-old woman with a tunnel catheter for dialysis who had huge vegetations on the tricuspid valve which turned out to be fungal in origin. Case 3 is a 45-year-old female with background Ehlers-Danlos syndrome who developed tricuspid endocarditis following IV injections/line in a peripheral hospital. In this report, we discussed the factors causing late diagnosis of isolated tricuspid valve infective endocarditis in our environment, challenges of diagnosing this condition in patients with underlying health issues and the difficulties of obtaining blood culture results.

Abstract 13195: A Case of Ebstein Anomaly Diagnosed Following Tricuspid and Pulmonic Valve Infective Endocarditis in an Adult Patient

Background: We present a rare case of infective endocarditis (IE) involving both tricuspid (TV) and pulmonic valves (PV) in the setting of newly diagnosed Ebstein anomaly (EA) with isolated, small membranous VSD. Case: A 48 yo woman with no known medical history presented with two weeks of fever, flu-like symptoms, and dyspnea. Vitals showed fever, tachycardia, and tachypnea. Poor dentition, grade III systolic murmur, and S3 gallop were noted on physical exam. EKG showed sinus tachycardia and right bundle branch block. Laboratory studies showed leukocytosis and elevated CRP. A chest CT revealed bilateral lung infiltrates in a rounded configuration concerning for septic emboli. Blood cultures grew Streptococcus mitis , and IV antibiotics were initiated. TTE revealed 3.2cm apical displacement of the TV resulting in right ventricular atrialization, diagnostic for EA. TTE also found a 26x17mm vegetation on the septal and anterior leaflets of the TV with moderate tricuspid regurgitation and an 11x6mm vegetation on the PV, confirmed by TEE. Cardiac MRI also noted a focal aneurysm of the membranous interventricular septum with a hemodynamically insignificant shunt. Discussion: While interatrial communications are seen in a majority of EA patients (80-94% of cases), this patient presented solely with a small membranous VSD and absence of ASD and PFO. Moreover, this patient had no PDA to depend on for pulmonary flow. Remarkably, she had an asymptomatic course with EA until the development of endocarditis. It is believed the presence of an isolated VSD in this patient’s severe EA likely promoted forward pulmonic flow in an already inadequate right ventricle. Right-sided IE is itself rare (5-10% of cases) with isolated PV involvement being even rarer (2% of cases). This patient’s uncorrected EA with redundant TV and PV leaflet tissue likely contributed as a nidus for simultaneous infection of both valves.

TRICUSPID VALVE INFECTIVE ENDOCARDITIS REQUIRING VALVE REPLACEMENT THREE TIMES IN AN IV DRUG USER

TRICUSPID VALVE INFECTIVE ENDOCARDITIS REQUIRING VALVE REPLACEMENT THREE TIMES IN AN IV DRUG USER

MYCOTIC PULMONARY ARTERY ANEURYSM SECONDARY TO SEPTIC EMBOLI: A POTENTIALLY LIFE-THREATENING COMPLICATION OF INFECTIVE ENDOCARDITIS

MYCOTIC PULMONARY ARTERY ANEURYSM SECONDARY TO SEPTIC EMBOLI: A POTENTIALLY LIFE-THREATENING COMPLICATION OF INFECTIVE ENDOCARDITIS

Infective endocarditis and COVID-19: the impact of SARS-CoV-2 infection on diagnostics, course, and prognosis

Aim. To study the impact of coronavirus disease 2019 (COVID-19) pandemic on hospitalization rates, diagnosis, and outcomes of infective endocarditis (IE) with a subanalysis of IE course in combination with COVID-19.Material and methods. This prospective cohort study included 168 patients with definite or probable IE (DUKE 2015) hospitalized in the V.V. Vinogradov City Clinical Hospital from July 2017 to July 2022. All patients underwent a conventional examination in accordance with current clinical guidelines. We studied clinical, paraclinical and etiological parameters, as well as outcomes.Two clinical observations of the combination of IE and COVID-19 are presented.Results. When assessing the local registry of patients with IE, a trend towards an increase in hospitalizations rate of IE in 2021-2022 was shown, with a decrease during the period of long-term lockdowns in Moscow and a subsequent surge after their cancellation. Patients with IE during the COVID-19 pandemic had a more favorable clinical profile, a 2-fold increase in IE diagnosis (due to late hospitalization), frequent detection of Staphylococcus aureus MSSA (32,6%), and frequent surgical treatment (up to 87,6% with a combination of IE and COVID-19), as well as high in-hospital mortality, but without a tendency to increase (30,4%). Clinical observations of IE and COVID-19 combination are presented, which demonstrates the contribution of COVID-19 as the only risk factor for native tricuspid valve IE in a patient without predisposing causes, as well as a factor in the unfavorable prognosis for native aortic valve IE after the addition of COVID-19, which led to lethal outcome.Conclusion. The present study demonstrates the profile of patients with IE and COVID-19 depending on the epidemiological situation of COVID-19 and the association with SARS-CoV-2 infection. The data obtained make it possible to discuss the potential relationship between COVID-19 and IE. The "endocarditis team" determines the timely implementation of surgery and the absence of an increase in inhospital mortality, regardless of the epidemiological situation.

Similar outcome of tricuspid valve repair and replacement for isolated tricuspid infective endocarditis.

To compare early and late mortality of acute isolated tricuspid valve infective endocarditis (TVIE) treated with valve repair or replacement. Patients who were surgically treated for TVIE from 1983 to 2018 were retrieved from the Italian Registry for Surgical Treatment of Valve and Prosthesis Infective Endocarditis. All the patients were followed up by means of phone interview or calling patient referral physicians or cardiologists. Kaplan-Meier method was used to assess late survival and survival free from TVIE recurrence with log-rank test for univariate comparison. The primary end points were early mortality (30 days after surgery) and long-term survival free from TVIE recurrence. A total of 4084 patients were included in the registry. Among them, 149 patients were included in the study. Overall, 77 (51.7%) underwent TV repair and 72 (48.3%) TV replacement. Early mortality was 9% (13 patients). Expected early mortality according to EndoSCORE was 12%. The TV repair showed lower mortality and major complication rate (7% and 16%), compared with TV replacement (11% and 25%), but statistical significance was not reached. Median follow-up was 19.1 years (14.3-23.8). Late deaths were 30 and IE recurrences were 5. No difference in cardiac survival free from IE was found between the two groups after 20 years (80 ± 6% Repair Group vs 59 ± 13% Replacement Group, P = 0.3). Overall results indicate that once surgically addressed, TVIE has a low recurrence rate and excellent survival, apparently regardless of the type of surgery used to treat it.

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

Heart failure presentation thirty years after tricuspid valvectomy for infective endocarditis

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus

Introduction Cerebral air embolism is a rare, yet serious neurological occurrence with unclear incidence and prevalence. Here, we present a case of fatal cerebral arterial and venous cerebral gas embolism in a patient with infective endocarditis and known large right-to-left shunt and severe tricuspid regurgitation following pressurized fluid bolus administration. Case Presentation. A 32-year-old female was admitted to the medical intensive care unit from a long-term acute care facility with acute on chronic respiratory failure. Her medical history was significant for intravenous heroin and cocaine abuse, methicillin-sensitive Staphylococcus aureus tricuspid valve infective endocarditis on vancomycin, patent foramen ovale, septic pulmonary embolism with cavitation, tracheostomy with chronic ventilator dependence, multifocal cerebral infarction, hepatitis C, nephrolithiasis, anxiety, and depression. After intravenous fluid administration, she became unresponsive with roving gaze, sluggish pupils, and hypotensive requiring vasopressors. CT of the brain showed diffuse arterial and venous cerebral air embolism secondary to accidental air administration from fluid bolus. Magnetic resonance imaging of the brain showed diffuse global anoxic injury and flattening of the globe at the optic nerve insertion. Given poor prognosis, her family chose comfort measures and she died. Conclusions Fatal cerebral air embolism can occur through peripheral intravenous routes when the lines are inadequately primed and fluids administered with pressure. Caution must be exercised in patients with right-to-left shunting as air may gain access to systemic circulation.

INFECTIVE ENDOCARDITIS WITH SPINAL CORD INFARCTION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Infective endocarditis can present with disseminated septic emboli phenomenon. Neurological complications of disseminated infective endocarditis include spinal epidural abscess. Spinal cord infarction is a very rare complication of infective endocarditis with only two cases previously reported. We present a case with fulminant infective endocarditis with widespread septic emboli and spinal cord infarction. CASE PRESENTATION: 34-year-old male, intravenous drug abuser with recent incarceration presented with five-day history of progressive lower extremity weakness and pain associated with inability to walk, lower back pain, loss of bowel and bladder control, and pleuritic chest pain. Past medical history was significant for recurrent infective endocarditis of tricuspid valve and prosthetic tricuspid valve with recent tricuspid valve repair 6 months ago. Laboratory analysis was remarkable for leukocytosis, microcytic anemia, severe thrombocytopenia, lactic acidosis, and oliguric acute kidney injury requiring emergent hemodialysis. The patient was subsequently intubated for acute respiratory failure with worsening septic shock requiring pressor support. Transthoracic echocardiogram revealed a normal left ventricular ejection fraction. A large 4.1 x 1.6 cm mobile vegetation was noted involving the bioprosthetic tricuspid valve extending into the right ventricle associated with moderate stenosis. Blood cultures were positive for Serratia marcescens. CT chest was significant for bilateral ground-glass opacities, multiple nodular infiltrates, and cystic cavitary lesions representing septic emboli. CT abdomen was significant for splenomegaly with multiple splenic infarcts and bilateral multiple renal cortical infarcts. CT scan of spine ruled out epidural abscess. MRI could not be performed due to presence of epicardial leads. Based on above findings, patient was diagnosed with infective endocarditis with systemic shower of septic emboli to lungs, spleen, and kidneys with high suspicion of spinal cord infarction. Patient was started on empiric antibiotics on admission later adjusted to culture sensitivities. He continued to deteriorate clinically and underwent cardiac arrest within 72 hours of admission and expired. DISCUSSION: Infective endocarditis with septic emboli phenomenon can present with a myriad of clinical features. In the presence of neurological deficits, spinal cord infarction should be high in the differential and managed emergently due to its time-sensitive salvage. However, the probability of complete recovery after spinal infarction is very low; overall mortality in the first month is 25%, with long-term disability in 40-50% requiring wheelchair or chronic bladder catheterization. CONCLUSIONS: Spinal cord infarction is a rare complication of infective endocarditis with disseminated septic emboli phenomenon that requires emergent time-sensitive management with overall high mortality. REFERENCE #1: Kfoury B, Sharma D, Mansour W, Suen P, Abou Yassine A, Chalhoub M. Endocarditis to the Spine: A Rare Cause of Spinal Cord Infarction. Chest. 2017 Oct 1;152(4):A366. REFERENCE #2: Robertson, C.E., et al., Recovery after spinal cord infarcts: long-term outcome in 115 patients. Neurology, 2012. 78(2): p. 114-21 DISCLOSURES: No relevant relationships by Huda Asif, source=Web Response No relevant relationships by Adam Friedlander, source=Web Response No relevant relationships by Katherine Hodgin, source=Web Response No relevant relationships by Stanislav Ivanov, source=Web Response No relevant relationships by Arsalan Wappi, source=Web Response No relevant relationships by Christopher Wood, source=Web Response