Tricuspid Valve Vegetation Research Articles

Clinical outcomes of severe tricuspid valve infective endocarditis related to intravenous drug abuse – a case series

Background Right-sided infective endocarditis (IE) related to intravenous drug use (IVDU) can follow an acute fulminant course. However, there is limited information on its longer-term clinical outcomes. Aim and Methods We assessed a cohort of consecutive patients who presented with IVDU complicated by severe tricuspid valve regurgitation to determine their presentation, treatment, and long-term outcomes. In this study, severe tricuspid regurgitation (TR) was defined by the European Association of Cardiovascular Imaging criteria at initial presentation to the hospital. Results Thirty-three patients with a mean age of 35 ± 18 years (72% males) presented with IVDU associated with severe TR. At the initial presentation, 15 patients were in septic shock and required inotropes. 26 patients had septic pulmonary emboli; 10 patients had associated metastatic systemic sites of infection of which 5 patients had central nervous system (CNS) involvement. Three patients were in disseminated intravascular coagulation (DIC) and 1 patient had multi-organ failure (MOF), but not requiring dialysis or mechanical ventilation. Most patients had large tricuspid valve vegetations of >20mm. Eleven patients underwent surgery with 18% perioperative mortality. The Median follow-up was 6.4 years (0.5–11.4). Recurrent IE occurred in one-third of patients, the overall incidence of heart failure and Atrial fibrillation (AF) on follow-up was low in all 3 groups. Five-year survival was 94%. Conclusion Acute severe TR following associated endocarditis IVDU results in a fulminant initial presentation, but a longer-term prognosis is good with surgical and medical treatment.

Recent Trends in Infective Endocarditis Among Patients with and Without Injection Drug Use: An Eight-Year Single Center Study

BackgroundInfective endocarditis (IE) is associated with considerable morbidity and mortality. Given the opioid crisis and emergence of drug-resistant organisms, we sought to examine annual trends in hospitalization rates for IE and potential epidemiologic shift in the causative microorganisms among patients with and without injection drug use (IDU). MethodsThis was a single-center retrospective cohort study of hospitalized adults with IE. Annual trends in hospitalization rates were calculated (2011-2018), and patient characteristics and clinical outcomes were compared according to IDU status. ResultsOur cohort of 244 hospitalized patients with IE had a subset of 112 with IDU. The annual hospitalization rate for IE increased almost four-fold and was most notable among patients with IDU. The highest increase occurred in patients with Staphylococcus aureus-associated IE. Patients with IDU were younger, and more likely to be women with tricuspid valve vegetations and have IE due to methicillin-sensitive and methicillin-resistant Staphylococcus aureus. Patients without IDU were more likely to have central venous catheters with mitral and aortic valve vegetations and have IE due to Streptococcus and coagulase-negative Staphylococcus species. Patients without IDU had a higher requirement for cardiac surgery and higher 90-day mortality. Age was the only independent variable associated with 90-day mortality. ConclusionsThe rising incidence of IE in younger and older persons is driven in part by the opioid public health crisis and higher prevalence of indwelling central venous catheters, respectively. Timely treatment of opioid use disorders and stewardship surrounding use of central venous catheters is urgently needed.

The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle.

In patients undergoing transvenous lead extraction (TLE) transesophageal echocardiography (TEE) provide valuable information after procedure. We analyzed data from 936 TEE performed in patients undergoing TLE between 2015 and 2019 (mean follow-up 566.23±224.47 days) and assessed the role of echocardiographic phenomena after procedure. Increment in tricuspid regurgitation (TR) was observed in 9% of patients after TLE. Factors increasing the risk of TR were: binding sites between lead and right ventricle (RV) (OR: 5.429), tricuspid valve (TV) (OR: 3.42), superior vena cava (SVC) (OR: 3.30) and lead-to-lead adhesions (OR: 2.88). Predisposing factors of residual structures after TLE were: asymptomatic masses on the leads (AMEL) (OR: 1.68), binding sites between SVC and cardiac structures (OR: 1.72), and multiple leads (OR: 1.30). Probability of vegetation remnants increased in the presence of abandoned leads (OR: 7.91). The risk factors of tamponade were: dwell time of the oldest lead (OR: 1.17), lead-to-lead adhesion (OR: 22.47), binding sites between lead and TV (OR: 6.08), RA (OR: 11.50), SVC (OR: 4.47), higher LVEF (OR: 2.35; P=0.006), female gender (OR: 5.43), multiple leads (OR: 2.11), looped leads (OR: 4.90) and AMEL (OR: 6.42). The risk of lead fracture was increased by: lead-to-lead adhesion (OR: 5.69), fibrosis binding the lead to RV (OR: 5.16), RA (OR: 2.39) and dwell time of the oldest lead (OR: 1.068). The mortality rate was 11.97% during follow-up. The risk of death was increased by: severe TR and vegetation remnants. The most important phenomena evaluated after TLE are: tricuspid valve function, residual fibrosis and vegetation remnants, progression of pericardial effusion and retained lead fragments. Postoperative TEE provides information about the results of TLE and helps establish further management.

Patients with infective endocarditis and history of injection drug use in a Swedish referral hospital during 10\u2009years

BackgroundPatients with injection drug use (IDU) have increased risk of developing infective endocarditis (IE). Previous studies have reported recurrent IE, increased duration of hospital stay, poor adherence and compliance as well as higher mortality and worse outcomes after surgery in the IDU-IE patient group. Further studies are needed to provide a basis for optimized care and prevention of readmissions in this population. This study aims to describe the clinical characteristics and outcomes among patients with IDU-IE.MethodsData of adults with IDU-IE and non-IDU-IE, treated between 2008 and 2017 at the Karolinska University Hospital in Stockholm were obtained from the Swedish National Registry of Infective Endocarditis. Clinical characteristics, microbiological results, treatment durations, results from echocardiography and in-hospital mortality were compared between the groups.ResultsOf the total 522 patients, 165 (32%) had IDU-IE. Patients with IDU-IE were younger than the patients with non-IDU-IE (mean age IDU-IE: 41.6 years, SD 11.9 years; non-IDU-IE: 64.3 years, SD 16.4 years; P < 0.01). No difference in distribution of gender was observed, 33% were females in both the IDU-IE and the non-IDU-IE group. History of previous IE (IDU-IE: n = 49, 30%; non-IDU-IE: n = 34, 10%; P < 0.01) and vascular phenomena (IDU-IE: n = 101, 61%; non-IDU-IE: n = 120, 34%; P < 0.01) were more common among patients with IDU-IE while prosthetic heart valves (IDU-IE: n = 12, 7%; non-IDU-IE: n = 83, 23%; P < 0.01) and known valvular disease (IDU-IE: n = 3, 2%; non-IDU-IE: n = 78, 22%; P < 0.01) were more common among patients with non-IDU-IE. Aetiology of Staphylococcus aureus (IDU-IE: n = 123, 75%; non-IDU-IE: n = 118, 33%; P < 0.01) as well as tricuspid (IDU-IE: n = 91, 55%; non-IDU-IE: n = 23, 6%; P < 0.01) or pulmonary valve vegetations (IDU-IE: n = 7, 4%; non-IDU-IE: n = 2, 1%; P < 0.01) were more common in the IDU-IE group. The overall incidence of IDU-IE decreased during the study period, while the incidence of definite IE increased (P < 0.01).ConclusionsThis study presents that patients with IDU-IE were younger, less frequently treated with surgery and had higher prevalence of vascular phenomena and history of previous IE, aspects that are important for improved management of this population.

697. 8 Years of Characteristics and Outcomes of Patients with MRSA Endocarditis Based on Vancomycin Minimum Inhibitory Concentration: Experience at a Tertiary Care Hospital

BackgroundVancomycin has been the mainstay of treatment for methicillin-resistant Staphylococcus aureus (MRSA) infective endocarditis (IE). MRSA reduced susceptibility to vancomycin is a growing threat. Data assessing the effect of vancomycin reduced susceptibility on outcomes is limited. Our study aimed to evaluate characteristics and outcomes of MRSA-related IE based on the minimum inhibitory concentration (MIC) to vancomycinCharacteristics and outcomes of 51 patients with MRSA-related endocarditis according to the minimal inhibitory concentration (MIC) to vancomycin MethodsIRB approval was obtained for a retrospective cohort study at a tertiary care center. Records of hospitalized adults diagnose with IE by ICD-9/ICD-10 CM codes were identified from 2011 to 2018. 51 patients had MRSA-related IE and were selected for the analysis. Demographic, microbiologic, Imaging and outcome variables were obtained. Characteristics and outcomes of patients with MRSA-related IE according to the MIC to vancomycin (≤ vs. > 1 mcg/mL) were comparedResults35.3% of patients had a MIC > 1 mcg/mL. 59% were men, mean age was 46±3 years old. 65% acquired the infection through injection drug use. Only 3.9% of patients had prosthetic valve IE. 35.3% had tricuspid valve vegetation, 25.5% mitral valve and 21.6% aortic valve vegetation. Two patients had IE possibly related to a PICC-line infection; both of these patients had a MIC to vancomycin >1 mcg/mL, suggestive of prolonged antibiotic therapy. All patients with MRSA-related IE were started empirically on vancomycin. Patients with a MIC > 1 mcg/mL were more likely to be switched to a combination of daptomycin and ceftaroline, compared to those with a MIC ≤ 1 mcg/mL (44.4% vs. 6.1%; P=0.001). 25.4% underwent valvular replacement within 6 months. 12% died within 90 days. MRSA-related IE with MIC > 1mcg/mL did not confer and an increase risk in in-hospital mortality (11.1% vs. 15.2%; P=0.67) or mortality at 90 days (11.1% vs. 12.5%; P=0.89).ConclusionIn this single-center experience, we found that in 8 years 35% of patients with MRSA-related IE had MIC >1 mcg/mL. This is an alarming finding. Although our study did not reach statistic significance we didn’t found difference in valvular surgery requirement or mortality among those with MIC > 1mcg/d as compared to those with a more sensitive MRSA strain. A study with more power or a metha-analysis will be require to better answer this question.Disclosures All Authors: No reported disclosures

698. 8 Years of Infective Endocarditis in Intravenous and Non-Intravenous Drug Users a Single Center Experience

BackgroundDespite advances in diagnosis and management, infective endocarditis (IE) is associated with considerable morbidity and mortality. Given the emergence of drug- resistant organisms, it is unclear whether this has impacted the characteristics and outcomes of IE among intravenous drug users (IDUs) and non-IDUs.MethodsWe conducted a single center retrospective cohort study. 306 records of hospitalized adults diagnose with IE by ICD-9/ICD-10 codes were identified from 2011 to 2018. 244 patients met criteria. IRB approval was obtained. The baseline demographic, microbiologic, echocardiographic variables and outcomes were extracted from the chart, and compared between IDUs and non-IDUs.Results112 (45.9%) patients were IDUs and significantly younger (mean age 36 vs. 64, p< 0.001). Both methicillin-sensitive (44.6% vs. 23.5%, p< 0.001) and methicillin-resistant (29.5% vs. 13.6%, p= 0.002) Staphylococcus aureus associated IE were more prevalent in IDUs compared to non-IDUs. Streptococcus species (22.7% vs 11.6%, p=0.02), excluding Enterococcus species, and coagulase-negative Staphylococcus (12.1% vs 1.8%, p=0.002) were significantly more prevalent in non-IDUs. IE in IDUs were more likely to have tricuspid valve vegetations (56.3% vs. 13.6%, p< 0.001), whereas non-IDUs were more likely to have mitral valve (39.4% vs. 25%, p=0.02) and aortic valve vegetations (46.2% vs. 15.2%, p< 0.001). 19% of patients with IE underwent valve replacement within 6 months, and 17% died within 90 days. A multivariable model that included age, gender, and IDU status, age was the only variable that remained independently associated with 90-day mortality (adjusted OR 1.031; 95% CI 1.006, 1.057; p< 0.01).ConclusionIn this single-center experience, we found that methicillin-sensitive Staphylococcus aureus was the dominant organism among IDUs and non-IDUs. We also found that methicillin-resistant Staphylococcus aureus was significantly more prevalent among IDUs with IE. Provably related to an increase prevalence of colonization with resistant organisms in the community. Despite the shift in prevalence of methicillin-resistant Staphylococcus aureus among IDUs, there was no increased 90-day mortality risk after adjustment for age and gender.Disclosures All Authors: No reported disclosures

A RARE PRESENTATION OF GROUP C STREPTOCOCCUS ENDOCARDITIS WITH DIFFUSE SEPTIC EMBOLI

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Group C beta-hemolytic Streptococcus (GCS) typically causes skin and soft tissue infections, pharyngitis, and wound infections. However, the incidence of bacteremia from GCS has increased significantly over the past decade1. Most cases of GCS bacteremia and complications including endocarditis, meningitis, and septic arthritis occur in older adults with underlying chronic illnesses2. We present the unusual case of GCS endocarditis with diffuse septic emboli causing multi-organ failure in a young female. CASE PRESENTATION: A 24-year-old female with a history of intravenous drug use was admitted with altered mental status after IV drug use. On presentation, patient was afebrile with no leukocytosis, and examination was significant for tachycardia, extreme agitation, hyperalgesia, and hallucinations. Preliminary workup revealed thrombocytopenia, acute kidney injury, acute liver injury, and troponinemia. Chest radiographs showed cardiomegaly with concern for mild pulmonary edema. Toxicology screen was positive for amphetamines and cannabinoids but negative for opioids. Echocardiogram revealed a 1.9cm x 1.8cm echodensity attached to the basal free wall of the right ventricle near the level of the tricuspid valve. Blood cultures were positive for GCS, meeting 2 major Duke criteria for infective endocarditis. Her clinical course was complicated by septic shock and acute hypoxic respiratory failure requiring intubation. Repeat chest imaging revealed diffuse patchy airspace opacities with superimposed interstitial predominance. Computed tomography of the chest showed a bronchovascular distribution of wedge-shaped consolidative opacities scattered diffusely throughout bilateral lungs. Imaging findings also included hepatosplenomegally and evidence of embolization to the kidneys. She showed clinical improvement with intravenous antibiotics and mechanical ventilation and is under evaluation by cardiothoracic surgery for valve repair and vegetation excision. DISCUSSION: Though GCS bacteremia and endocarditis are typically seen in older adults with comorbidities, this case highlights the rapid progression and clinical sequelae of GCS bacteremia in a young female with IV drug use. Tricuspid valve vegetations are commonly seen in IV drug use-associated endocarditis, however a vegetation in the right ventricle arising from the basal free wall is exceedingly rare. The location of the vegetation likely contributed greatly to the rapid showering of emboli and severity of symptoms in this case. CONCLUSIONS: Though GCS is not an organism frequently associated with IV drug use, it should now be considered given the rising incidence of GCS bacteremia and the severity of disease it may cause1. Reference #1: Lother S, Jassal D, Lagacé-Wiens P, Keynan Y. Emerging Group C and Group G Streptococcal Endocarditis: A Canadian Perspective. Int J Infect Dis 2017; 65: 128-132 Reference #2: Berenguer J, Sampedro I, Cercenado E, et. al. Group-C Beta-Hemolytic Streptococcal Bacteremia. Diagn Microbiol Infect Dis 1992; 15(2): 151-155 DISCLOSURES: No relevant relationships by Gold Adkins, source=Web Response No relevant relationships by Aria Bryan, source=Web Response No relevant relationships by Shine Raju, source=Web Response No relevant relationships by Pallavi Sharma, source=Web Response No relevant relationships by Catalina Teba, source=Web Response

AN UNUSUAL CASE OF TRICUSPID VALVE INFECTIVE ENDOCARDITIS CAUSED BY ERYSIPELOTHRIX RHUSIOPATHIAE

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Erysipelothrix rhusiopathiae is an uncommon cause of endocarditis. We present a case of Erysipelothrix rhusiopathiae in a patient with tricuspid valve involvement. CASE PRESENTATION: This is a 47-year-old male with a history of hypertension who presented with a four-week history of bilateral lower extremity edema. The patient is a lumberjack by occupation and was having difficulty working. His swelling extended to his knees, prompting a visit to his primary physician. The patient was started on oral furosemide but reported no improvement. On admission, the patient was afebrile. The patient was fluid overloaded with bibasilar lung crackles and 3+ pitting edema in bilateral lower extremities. Labs revealed leucocytosis, creatinine of 3.8, and an NT-pro-BNP level of 29,959. CT of the chest revealed pulmonary edema. The patient was started on intravenous diuretic therapy and oral beta-blockers in view of his acute decompensated heart failure. The patient's blood cultures were positive for gram-positive rods and started on empiric treatment with intravenous vancomycin. Echocardiogram revealed severe tricuspid regurgitation and multiple tricuspid valve vegetations. The most significant vegetation was noted to be 2.6 cm x 1.6 cm in size. A trans-esophageal echocardiogram revealed severe tricuspid regurgitation with significant vegetations visible on all three leaflets of the tricuspid valve. After 6 days, repeat blood cultures showed gram-positive rods with sensitivities revealing Erysipelothrix rhusiopathiae as the causative agent. The patient's antibiotic regimen was converted to intravenous Penicillin G. DISCUSSION: Erysipelothrix rhusiopathiae is a gram-positive, rod-shaped, non-sporing bacillus. It is a zoonotic disease known for its association with occupations involving close exposure to animals [1]. Patients who are diagnosed with this infection manifest with skin infections or systemic organ involvement. Our patient presented with systemic bacteremia, with common involvement of the aortic valve [1]. The clinical presentation of our patient was unique, given that in the absence of heart disease, he presented with overt volume overload and acute renal failure. He lacked the more classic symptoms of infective endocarditis, including fever, chills, and skin lesions. Our patient did not have any significant past medical conditions increasing his risk for infective endocarditis. In past literature, reported cases of Erysipelothrix rhusiopathiae and endocarditis had shown a proclivity towards the aortic valve [1,2]. In our case, we felt the most astonishing feature was the isolated involvement of the tricuspid valve. Its mortality rate is higher when compared to the more common etiological pathogens of infective endocarditis [1]. CONCLUSIONS: Physicians should not only observe clinical symptoms but aim to holistically assess the patient to reach a timely diagnosis and initiate appropriate therapy. Reference #1: Reboli, A.C. and W. Farrar, Erysipelothrix rhusiopathiae. Principles and practice of infectious diseases, 2010. 5: p. 2226-7. Reference #2: Veraldi, S., et al., Erysipeloid: a review. Clinical and Experimental Dermatology: Clinical dermatology, 2009. 34(8): p. 859-862. DISCLOSURES: No relevant relationships by Karthik Gonuguntla, source=Web Response No relevant relationships by Pranav Karambelkar, source=Web Response No relevant relationships by Shivaraj Patil, source=Web Response No relevant relationships by Chaitanya Rojulpote, source=Web Response

Serratia marcescens Tricuspid Valve Vegetation and Successful Use of the AngioVac® System

Serratia marcescens bacteremia is common in patient populations with a history of intravenous drug use (IVDU), but it rarely causes infective endocarditis. We are reporting a 27-year-old female with a medical history significant for IVDU and hepatitis C virus infection who presented to the emergency department complaining of fever and shortness of breath. Computed tomography of the chest with intravenous (IV) contrast revealed extensive bilateral pulmonary infiltrates with multiple cavitary lesions. The patient was treated with IV vancomycin and piperacillin/tazobactam. Blood culture grows methicillin-sensitive Staphylococcus aureus (MSSA) and S. marcescens, both sensitive to cefepime/meropenem. Transesophageal echocardiogram revealed 3.4 x 2 cm tricuspid valve vegetation. Cardiothoracic surgery was consulted, who recommended transcatheter aspiration with the AngioVac® system (AngioDynamics Inc., Latham, NY). Post-procedure transesophageal echocardiogram revealed a significant reduction of vegetation size. Vegetation tissue culture grew MSSA and S. marcescens. The repeated blood culture revealed no growth, and the patient significantly improved clinically. She completed a six-week course of IV meropenem as an inpatient until she was discharged home.

Transesophageal echocardiography (TEE) indicated tricuspid valve vegetation in the midesophageal four-chamber view, which resulted in a change in treatment and led to a new antibiotic regimen

Transesophageal echocardiography (TEE) indicated tricuspid valve vegetation in the midesophageal four-chamber view, which resulted in a change in treatment and led to a new antibiotic regimen

Associations between echocardiographic manifestations and bacterial species in patients with infective endocarditis: a cohort study

BackgroundThe diagnosis of infective endocarditis (IE) is based on microbiological analyses and diagnostic imaging of cardiac manifestations. Echocardiography (ECHO) is preferred for visualization of IE-induced cardiac manifestations. We investigated associations between bacterial infections and IE manifestations diagnosed by ECHO.MethodsIn this cohort study, data from patients aged 18 years or above, with definite IE admitted at the Karolinska University Hospital between 2008 and 2017 were obtained from Swedish National Registry of Endocarditis. Bacteria registered as pathogen were primarily selected from positive blood culture and for patients with negative blood culture, bacteria found in culture or PCR from postoperative material was registered as pathogen. Patients with negative results from culture or PCR, and patients who did not undergo ECHO during hospital stay, were excluded. IE manifestations diagnosed by ECHO were obtained from the registry. Chi-squared test and two-sided Fisher’s exact test was used for comparisons between categorical variables, and student’s t test was used for continuous numerical variables. Multivariable analyses were performed using logistic regression. Secular trend analyses were performed using linear regression. Associations and the strength between the variables were estimated using odds ratios (ORs) with 95% confidence intervals (CIs). P < 0.05 was considered significant.ResultsThe most common bacteria were Staphylococcus aureus (n = 239, 49%) and viridans group streptococci (n = 102, 21%). The most common manifestations were vegetation in the mitral (n = 195, 40%), aortic (n = 190, 39%), and tricuspid valves (n = 108, 22%). Associations were seen between aortic valve vegetations and Enterococcus faecalis among patients with native aortic valves, between mitral valve vegetations and streptococci of group B or viridans group, between tricuspid valve vegetations and S. aureus among patients with intravenous drug abuse, and between perivalvular abscesses as well as cardiovascular implantable electronic device (CIED)-associated IE and coagulase negative staphylococci (all P < 0.05).ConclusionsAssociations were found between certain bacterial species and specific ECHO manifestations. Our study contributes to a better understanding of IE manifestations and their underlying bacterial etiology, which pathogens can cause severe infections and might require close follow-up and surgical treatment.

Percutaneous extraction of tricuspid valve vegetation in a patient of infective endocarditis

Percutaneous extraction of tricuspid valve vegetation in a patient of infective endocarditis

1357. Mycobacterium abscessus Native Tricuspid Valve Endocarditis. Is a 6-Week Course of Combination Antibiotic Therapy Enough?

BackgroundInfective endocarditis of the native heart valves due to M. abscessus has been reported in individuals who inject drugs. Only one case thus far has been reported with survival beyond 4 months after completion of antibiotic therapy. 24-year-old Caucasian woman with a history of intravenous drug use presented with intermittent fevers for 3–4 months. She was having chills, night sweats, and productive cough. She acknowledged using intravenous cocaine and heroin every few days after being discharged from our hospital 6 months previously when she was treated for tricuspid valve endocarditis. Chest radiograph demonstrated right lower lobe airspace disease suggestive of pneumonia. Three days later her blood cultures grew acid-fast bacilli, later identified as M. abscessus.MethodsShe was empirically treated with azithromycin, amikacin, and imipenem. Transthoracic and transesophageal echocardiograms were suggestive of tricuspid valve endocarditis. CT angiogram of the chest showed filling defects within several large right lower lobe pulmonary arteries and dense right lower lobe consolidation with pleural effusion. The patient underwent bronchoscopy with bronchoalveolar lavage (BAL) and therapeutic thoracoscopy with drainage and thoracostomy tube placement. BAL cultures also grew AFB. Multiple sets of blood cultures drawn after commencement of antibiotic therapy during the hospital course were negative. Drug susceptibilities were available 3 weeks later. The isolate was susceptible to amikacin. Linezolid, imipenem, and cefoxitin exhibited intermediate activity, and TMP/SMX, ciprofloxacin, moxifloxacin, doxycycline, minocycline, and clarithromycin were reported resistant. Inducible erm gene was present. Azithromycin and linezolid were discontinued and tigecycline was added.ResultsPatient completed 6 weeks of antibiotics from the day of the first negative blood culture. Repeat TTE 1 month after completion of therapy revealed a decrease in tricuspid valve vegetation. Blood culture done 3 months later was sterile. AFB blood cultures done a year later did not report any growth.ConclusionThis case opens a debate, if in a selected group of patients, a short course of combination antibiotic therapy is enough to obtain cure. This will require further analysis. Disclosures All authors: No reported disclosures.

Large Tricuspid Valve Vegetation Secondary to Austrian Syndrome in a Healthy Young Adult

Large Tricuspid Valve Vegetation Secondary to Austrian Syndrome in a Healthy Young Adult

Neonatal meningitis, endocarditis, and pneumonitis due to Streptococcus gallolyticus subsp. pasteurianus: a case report

BackgroundStreptococcus pasteurianus is a rare cause of neonatal infection, with only 3 cases reported in the USA and 18 cases reported in other countries within the past decade. Neonatal S. pasteurianus infection typically presents as meningitis. This case report describes the first neonatal case of S. pasteurianus endocarditis in the literature, in addition to a neonatal case of S. pasteurianus infection presenting as pneumonitis without meningitis. The S. pasteurianus infections in these two cases are unusual not only because of how rare this particular pathogen is, but also because of the atypical clinical manifestations.Case presentationThe first patient is a full-term male infant admitted to NICU at 20 h of life due to respiratory distress. He was empirically started on ampicillin and gentamicin for presumed sepsis. Laboratory analysis of cerebral spinal fluid obtained after initiation of antibiotics was suggestive of partially treated meningitis. Blood cultures came back positive for S. pasteurianus. The neonate was transitioned from ampicillin to cefepime, while gentamicin was continued. Echocardiograph showed a possible tricuspid valve vegetation concerning for endocarditis. Due to the unusual complication of endocarditis, the patient remained on IV cefepime for 28 days rather than the more conventional duration of 14–21 days reported in the literature. The baby clinically improved with no evidence of thrombi or vegetations on repeat cardiac echo.The second patient is a full-term male infant who required intubation at birth for respiratory distress. Chest X-ray findings were concerning for meconium aspiration with pneumonitis. The baby went into septic shock and was empirically started on ampicillin and gentamicin. Blood cultures came back positive for S. pasteurianus, while cerebral spinal fluid and urine cultures were negative. Ampicillin and gentamicin were discontinued after 3 days and the baby was started on cefepime and clindamycin for a total 14-day course. The baby clinically recovered and was discharged from NICU without any sequelae.ConclusionsThese two cases highlight the importance of recognizing S. pasteurianus as a potential cause of neonatal sepsis and the importance of recognizing endocarditis and pneumonitis as possible clinical manifestations of this infection.

The effect of conscientious intelligence on the ability to manage patient expectations: Example from a university hospital

Infective endocarditis (IE) is still associated with severe complications and poor prognosis. The surgery of IE has various technical difficulties due to severe infection, inflammation of heart tissue, and systemic effects, so controversies continue about the optimal timing of operation. This study presents the treatment approaches, early and late-term outcomes of IE patients, who underwent surgery.This retrospective descriptive study is conducted with 46 patients (31males) operated between 2002-2018. The demographics and preoperative, intraoperative and postoperative data of patients were analyzed from the clinical database and patient records. Emergency surgery was performed to 15 (32.26%) patients.Numbers of patients with mitral valve, aortic valve, and prosthetic valve endocarditis were 14, 25, 7 respectively. Aortic valve replacement (AVR), mitral valve replacement (MVR), MVR + AVR and mitral valve repair were performed in 24, 12, 8 and 2 patients, respectively. Additionally, pericardial patch repair (periannular abscess or damage (n=12), aorta-right atrial fistulae (n=3)), debulking of associated tricuspid valve vegetation (n=2), tricuspid De Vega annuloplasty (n=3), Bentall operation (n=1) and aortic root enlargement (n=5) were performed. The mean follow-up period and mortality rates were 24.86 ± 38.98 months, 13.04% respectively. The mean survival and reoperation-free time were 179.02 ± 13.78 and 203 ± 10.09 months, respectively. Patients can be managed appropriately with early diagnosis, aggressive medical and surgical treatment via a multidisciplinary approach with customized management according to guidelines in terms of individual characteristics. In cases of worsening hemodynamic status, uncontrolled infection, large and mobile vegetations surgery should be performed as soon as possible.

SPONTANEOUS PNEUMOTHORAX AND RIGHT SIDED HEART FAILURE: AN UNUSUAL PRESENTATION OF INFECTIVE ENDOCARDITIS

SESSION TITLE: Critical Care 4 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Over the years, despite advancements in the treatment and diagnosis of Infective Endocarditis (IE), the incidence continues to rise. This is thought to be as a result of the progressive evolution in the various risk factors leading to IE. One example is the increasing rates of intravenous drug abuse leading to IE[1]. Right-sided IE has been shown to have significant mortality and morbidity amongst those diagnosed[1]. Spontaneous pneumothorax represents one of the less common presentations of right-sided IE secondary to Intravenous drug abuse (IVU); to date, there have only been 7 documented cases[2]. CASE PRESENTATION: A 29-year-old male presented to the ED with chief complaints of fever, shortness of breath (SOB) and bilateral pedal edema. He was a known IVU. His vitals in the ED were as follows: BP 117/66, HR 113, RR 20, T 97.1, SPO2 was 93% on RA. General physical examination was significant for severe respiratory distress. Respiratory exam revealed decreased air entry on the right lung with rhonchi and rales throughout the left lung. Tricuspid regurgitation murmur was auscultated. Laboratory investigations showed WBC 22600 cells/ul, Hb 6.6 g/dL, LA 5.3 mm/L, BNP 236 Pg/ml. Initial CXR showed a 30-40% right-sided pneumothorax with a left lower lung consolidation, a chest tube was immediately inserted. 2D-echocardiogram showed findings consistent with tricuspid valve vegetation. He was started on empiric antimicrobial therapy for treatment of methicillin-sensitive staph aureus. CT scan showed moderate right pneumothorax, a right chest tube in situ and numerous septic emboli. Patient had tricuspid valve replacement on his 3rd day of hospitalization, with a prolonged and eventful hospitalization. DISCUSSION: IE is a well-documented complication of IVU. The pulmonary complications of septic pulmonary embolism commonly described include: pulmonary infarction, pulmonary abscess, pleural effusion, and empyema[2]. The pathophysiology behind spontaneous pneumothorax in the setting of IE is thought to be rupture of sub-pleural lesions from multiple septic pulmonary emboli seeded from the right-sided vegetations with underlying pathogen as S. Aureus[2]. Right heart failure (RHF) can be secondary to pulmonary hypertension, right ventricular or tricuspid valve pathology, as well from primary diseases of the pericardium[3]. In this particular case our patient had both pulmonary hypertension from extensive pulmonary cavitation and tricuspid valve pathology as contributing factors to RHF. CONCLUSIONS: It is important to highlight as IDV continues to evolve as one of the most common causes of IE, we as clinicians must become aware of the unusual ways in which the complications may present. Patients who have a high index of suspicion for IDU presenting with worsening SOB and persistent fever, IE should be considered as apart of our differential list to allow timely implementation of appropriate management. Reference #1: Hussain, S. T., Witten, J., Shrestha, N. K., Blackstone, E. H., & Pettersson, G. B. (may 2017). Tricuspid valve endocarditis. Annals of cardiothoracic surgery, 6(3), 255-261. Retrieved December 27, 2017. https://doi.org/10.21037/acs.2017.03.09 Reference #2: Sheu, Chau-Chyun, et al. “Spontaneous Pneumothorax as a Complication of Septic Pulmonary Embolism in an Intravenous Drug User: A Case Report.” The Kaohsiung Journal of Medical Sciences, vol. 22, no. 2, 2006, pp. 89–93., https://doi.org/10.1016/s1607-551x(0970226-8). Reference #3: (n.d.). Retrieved December 27, 2017, from https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-14/Right-ventricular-failure# DISCLOSURES: No relevant relationships by kimberley cousins, source=Web Response No relevant relationships by Wayne Davis, source=Web Response No relevant relationships by Nitheesha Ganta, source=Web Response No relevant relationships by Funmilola Ogundipe, source=Web Response

A case of Cardiobacterium valvarum endocarditis with cerebral hemorrhage after MVR, TVP and vegetation removal operation

BackgroundCardiobacterium is a fastidious Gram-negative bacillus, and is a rare human pathogen in clinical settings. Herein, we describe a case of Cardiobacterium valvarum (C. valvarum) endocarditis with a rare complication of cerebral hemorrhage after mitral valve replacement (MVR), tricuspid valve prosthesis (TVP) and vegetation removal operation.Case presentationA 41-year-old woman who had a history of gingivitis developed into infective endocarditis due to the infection of C. valvarum. Then, she was hospitalized to receive MVR, TVP and vegetation removal operation. The indicators of patient tended to be normal until the abrupt cerebral hemorrhage occurred on day 15 after operation. This is the first well-described case of C. valvarum infection in China, and the first report of C. valvarum endocarditis with cerebral hemorrhage after MVR, TVP and vegetation removal operation worldwide.ConclusionsWe reported the first case of C. valvarum infection in China clinically, with a rare complication of cerebral hemorrhage after MVR, TVP and vegetation removal operation.

A novel approach to percutaneous removal of large tricuspid valve vegetations using suction filtration and veno-venous bypass: A single center experience.

Tricuspid valve surgery has been the de facto standard treatment for tricuspid valve endocarditis (TVE) refractory to medical therapy. It is now possible to remove right-sided vegetations percutaneously using a venous drainage cannula with an extracorporeal bypass circuit. The purpose of our study is to describe our single-center experience of percutaneous tricuspid valve vegetation removal. We reviewed the perioperative course of 33 consecutive patients with large tricuspid valve vegetations who carried high surgical risk. The cohort included 12 males and 21 females over a 40-month period with an average age of 37 years. A preponderance of patients carried an admitted or confirmed diagnosis of injection drug use (72.7%). Average vegetation size was 2.1 +/- 0.7 cm prior to the procedure with a 61% reduction in size after the procedure. All patients survived the procedure and 90.9% survived the index hospitalization. Three patients proceeded to elective tricuspid valve replacement due to worsening severity of tricuspid regurgitation. Percutaneous removal of large tricuspid valve vegetations is a safe and effective alternative for patients with TVE who carry high-surgical risk. © 2017 Wiley Periodicals, Inc.

Eustachian Valve Endocarditis in an Intravenous Drug User

Case Description: We present the case of an intravenous drug user(IVDU) who presented with back pain. Initial Investigations and Management: His blood cultures demonstrated Staphylococcus aureus bacteraemia. He was diagnosed with a psoas abscess on CT scan, which was drained. He developed septic shock post operatively. CT chest demonstrated bilateral multifocal cavitating pneumonia with an inferior vena cava(IVC) thrombus for which patient had an IVC filter inserted. Transthoracic echocardiogram(TTE) demonstrated normal left and right ventricular function. The aortic and mitral valve were unremarkable, however there were vegetations visualised on the anterior(1.2 cm) and septal(1.0 cm) leaflets of the tricuspid valve with moderate regurgitation. Cardiothoracic surgical opinion was of conservative management at the time as there was no urgent indication for surgery. Despite a combination of broad spectrum antibiotics guided by the infectious disease specialists, our patient remained febrile with persistently positive blood cultures, elevated inflammatory markers and fluctuating levels of consciousness. Key Investigation: Transoesophageal echocardiogram(TOE) demonstrated anterior tricuspid valve vegetation, with aneurysm formation, localised perforation and eccentric severe regurgitation. The anteriorly directed tricuspid regurgitant jet had resulted in an infective seeding of the Eustachian valve, where a vegetation was visualised. The patient was transferred to ICU for further management of septic shock. He subsequently underwent tricuspid valve replacement, resection of the Eustachian valve, and completed the course of antibiotics, achieving a full recovery. The Eustachian valve vegetation was verified at surgery. Conclusion: This case demonstrates a rare form of endocarditis, with seeding of the Eustachian valve from a tricuspid valve jet lesion.