Vegetative Endocarditis Research Articles

A Case of Re-Do Aortic Valve Replacement for Early Bioprosthetic Valve Dysfunction due to a Large Vegetation of Nonbacterial Thrombotic Endocarditis

A Case of Re-Do Aortic Valve Replacement for Early Bioprosthetic Valve Dysfunction due to a Large Vegetation of Nonbacterial Thrombotic Endocarditis

Echocardiographic predictors and associated outcomes of multiple vegetations in infective endocarditis: A pilot study.

Infective endocarditis (IE) is a life-threatening infection with an annual mortality of 40%. Embolic events reported in up to 80% of patients. Vegetations of > 10 mm size are associated with increased embolic events and poor prognosis. There is a paucity of literature on the association of multiple vegetations with outcome. To study the echocardiographic (ECHO) features and outcomes associated with the presence of multiple vegetations. In this retrospective, single-center, cohort study patients diagnosed with IE were recruited from June 2017 to June 2019. A total of 84 patients were diagnosed to have IE, of whom 67 with vegetation were identified. Baseline demographic, clinical, laboratory, and ECHO parameters were reviewed. Outcomes that were studied included recurrent admission, embolic phenomenon, and mortality. Twenty-three (34%) patients were noted to have multiple vegetations, 13 (56.5%) were male and 10 (43.5%) were female. The mean age of these patients was 50. Eight (35%) had a prior episode of IE. ECHO features of moderate to severe valvular regurgitation [odds ratio (OR) = 4], presence of pacemaker lead (OR = 4.8), impaired left ventricle (LV) relaxation (OR = 4), and elevated pulmonary artery systolic pressure (PASP) (OR = 2.2) are associated with higher odds of multiple vegetations. Of these moderate to severe valvular regurgitation (P = 0.028), pacemaker lead (P = 0.039) and impaired relaxation (P = 0.028) were statistically significant. These patients were noted to have an increased association of recurrent admissions (OR = 3.6), recurrent bacteremia (OR = 2.4), embolic phenomenon (OR = 2.5), intensive care unit stay (OR = 2.8), hypotension (OR = 2.1), surgical intervention (OR = 2.8) and device removal (OR = 4.8). Of this device removal (P = 0.039) and recurrent admissions (P = 0.017) were statistically significant. This study highlights the associations of ECHO predictors and outcomes in patients with IE having multiple vegetations. ECHO features of moderate to severe regurgitation, presence of pacemaker lead, impaired LV relaxation, and elevated PASP and outcomes including recurrent admissions and device removal were found to be associated with multiple vegetations.

PROSTHETIC GRAFT INFECTION: WHEN ECHOCARDIOGRAPHY IS NOT ENOUGH!

Abstract A 68–year–old Caucasian male, post–Bentall procedure with a bioprosthetic valve following extensive aortic dissection involving the ascending aorta and aortic arch, presented to the Emergency Department with persistent fever for over a month. During his hospitalization, he experienced ventricular fibrillation in the setting of hypokalemia, successfully managed with Advanced Cardiovascular Life Support (ACLS) and DC shock, leading to the restoration of sinus rhythm. Subsequently, he was admitted to the Cardiovascular Intensive Care Unite. Blood tests revealed neutrophilic leukocytosis with elevated inflammatory markers, anemia, and a troponin curve consistent with myocardial injury in the context of sepsis and anemia. Echocardiography demonstrated a left ventricle of normal dimensions with globally depressed function (EF 45%), attributed to apical akinesia. The prosthetic valve was functioning normally, and there were no signs of endocarditic vegetations or pericardial involvement. A transesophageal echocardiogram confirmed the absence of vegetations. Given echocardiographic signs of myocardial ischemia, coronary angiography was performed, revealing a coronary circulation free from significant stenosis. Cultural exams showed positivity for Enterococcus faecalis. A PET–CT revealed the presence of radioisotope uptake around the vascular prosthesis situated in the aortic arch. An Infectious Disease specialist recommended antibiotic therapy with Piperacillin/Tazobactam and Teicoplanin. At the one–month follow–up, the patient remained asymptomatic, free from new febrile episodes. The follow–up echocardiogram indicated improved global systolic function, and inflammatory markers remained consistently negative. Repeat blood cultures were negative. This case illustrates a suspected endocarditis on a prosthetic valve where both transthoraci and transesophageal echocardiography yielded negative results. The use of PET–CT, on the other hand, revealed the presence of vascular graft infection, proving to be a valuable method in this clinical setting.

NOT JUST A SIMPLE FEVER: DIAGNOSIS OF COMPLICATED INFECTIVE ENDOCARDITIS ON BICUSPID AORTIC VALVE IN A YOUNG MAN

Abstract Bicuspid aortic valve is the most common form of congenital heart disease (prevalence of 0.5 to 2.0%). These patients develop infective endocarditis at significantly higher rates than the general population; furthermore, they are at increased risk of developing infective endocarditis at a younger age owing to intrinsic factors of the aortic valve, but demonstrate better long–term survival after surgical treatment. This case report concerns a 33–year–old caucasian man who presented to the emergency department for persistent fever. He had no significant past medical history, except for a known bicuspid aortic (type 0) valve. The laboratory test demonstrated an active infection and blood cultures were positive, so we performed a transthoracic echocardiogram showing a mobile mass on the aortic valve, associated to a severe aortic regurgitation. Hence, we decided to perform a transesophageal echocardiogram that documented a bicuspid aortic valve with an extensive endocarditic vegetation on anterior leaflet, cusp prolapse and a non–homogenous peri–valvular area, involving the mitral–aortic junction, compatible with abscess. Perivalvular extension of infective endocarditis is the most frequent cause of uncontrolled infection and is associated with a poor prognosis so, as suggested by ESC Guidelines, this clinical case represented an indication for early surgery. The patient was transferred to cardiac surgery department where he underwent surgery. Extensive debridement of the endocarditic lesion was performed; the mitral–aortic junction was reconstructed by suturing a double patch of heterologous pericardium. The defect resulting from the debridement beneath the left coronary ostium was also reconstructed using an additional sutured pericardial patch; then, an Inspiris Resilia size 23 prosthesis was implanted. Transesophageal echocardiography revealed good functioning of the aortic valve prosthesis with mild mitral insufficiency. Meanwhile, blood cultures resulted positive for Staphylococcus Aureus coagulase–negative, so specific antibiotic therapy was started.

Current Knowledge of Enterococcal Endocarditis: A Disease Lurking in Plain Sight of Health Providers.

Enterococcus faecalis is a bacterial pathogen that can cause opportunistic infections. Studies indicate that initial biofilm formation plays a crucial regulatory role in these infections, as well as in colonising and maintaining the gastrointestinal tract as a commensal member of the microbiome of most land animals. It has long been thought that vegetation of endocarditis resulting from bacterial attachment to the endocardial endothelium requires some pre-existing tissue damage, and in animal models of experimental endocarditis, mechanical valve damage is typically induced by cardiac catheterisation preceding infection. This section reviews historical and contemporary animal model studies that demonstrate the ability of E. faecalis to colonise the undamaged endovascular endothelial surface directly and produce robust microcolony biofilms encapsulated within a bacterially derived extracellular matrix. This report reviews both previous and current animal model studies demonstrating the resilient capacity of E. faecalis to colonise the undamaged endovascular endothelial surface directly and produce robust microcolony biofilms encapsulated in a bacterially derived extracellular matrix. The article also considers the morphological similarities when these biofilms develop on different host sites, such as when E. faecalis colonises the gastrointestinal epithelium as a commensal member of the common vertebrate microbiome, lurking in plain sight and transmitting systemic infection. These phenotypes may enable the organism to survive as an unrecognised infection in asymptomatic subjects, providing an infectious resource for subsequent clinical process of endocarditis.

Sensitizing methicillin-resistant Staphylococcus aureus (MRSA) to cefuroxime: the synergic effect of bicarbonate and the wall teichoic acid inhibitor ticlopidine.

Methicillin-resistant Staphylococcus aureus (MRSA) strains are a major challenge for clinicians due, in part, to their resistance to most β-lactams, the first-line treatment for methicillin-susceptible S. aureus. A phenotype termed "NaHCO3-responsiveness" has been identified, wherein many clinical MRSA isolates are rendered susceptible to standard-of-care β-lactams in the presence of physiologically relevant concentrations of NaHCO3, in vitro and ex vivo; moreover, such "NaHCO3-responsive" isolates can be effectively cleared by β-lactams from target tissues in experimental infective endocarditis (IE). One mechanistic impact of NaHCO3 exposure on NaHCO3-responsive MRSA is to repress WTA synthesis. This NaHCO3 effect mimics the phenotype of tarO-deficient MRSA, including sensitization to the PBP2-targeting β-lactam, cefuroxime (CFX). Herein, we further investigated the impacts of NaHCO3 exposure on CFX susceptibility in the presence and absence of a WTA synthesis inhibitor, ticlopidine (TCP), in a collection of clinical MRSA isolates from skin and soft tissue infections (SSTI) and bloodstream infections (BSI). NaHCO3 and/or TCP enhanced susceptibility to CFX in vitro, by both minimum inhibitor concentration (MIC) and time-kill assays, as well as in an ex vivo simulated endocarditis vegetations (SEV) model, in NaHCO3-responsive MRSA. Furthermore, in experimental IE (presumably in the presence of endogenous NaHCO3), pre-exposure to TCP prior to infection sensitized the NaHCO3-responsive MRSA strain (but not the non-responsive strain) to enhanced clearances by CFX in target tissues. These data support the notion that NaHCO3 is acting similarly to WTA synthesis inhibitors, and that such inhibitors have potential translational applications in the treatment of certain MRSA strains in conjunction with specific β-lactam agents.

Transcatheter vacuum aspiration of valvular and lead related infective endocarditis

BackgroundTranscatheter aspiration is utilized for removal of thrombi and vegetations in inoperable patients and high-risk surgical candidates where medical therapy alone is unlikely to achieve desired outcome. A number of case reports and series have been published since the introduction of AngioVac system (AngioDynamics Inc., Latham, NY) in 2012 where this technology was used in the treatment of endocarditis. However, there is a lack of consolidated data reporting on patient selection, safety and outcomes. MethodsPubMed and Google Scholar databases were queried for publications reporting cases where transcatheter aspiration was used for endocarditis vegetation debulking or removal. Data on patient characteristics, outcomes and complications from select reports were extracted and systematically reviewed. ResultsData from 11 publications with 232 patients were included in the final analyses. Of these, 124 had lead vegetation aspiration, 105 had valvular vegetation aspiration, and 3 had both lead as well as valvular vegetation aspiration. Among the 105 valvular endocarditis cases, 102 (97 %) patients had right sided vegetation removal. Patients with valvular endocarditis were younger (mean age 35 years) vs. patients with lead vegetations (mean age 66 years). Among the valvular endocarditis cases, there was a 50–85 % reduction in vegetation size, 14 % had worsening valvular regurgitation, 8 % had persistent bacteremia and 37 % required blood transfusion. Surgical valve repair or replacement was subsequently performed in 3 % and in-hospital mortality was 11 %. Among patients with lead infection, procedural success rate was reported at 86 %, 2 % had vascular complications and in-hospital mortality was 6 %. Persistent bacteremia, renal failure requiring hemodialysis, and clinically significant pulmonary embolism occurred in about 1 % each. ConclusionsTranscatheter aspiration of vegetations in infective endocarditis has acceptable success rates in vegetation debulking as well as rates of morbidity or mortality. Large prospective multi-center studies are warranted to determine predictors of complications, thus helping identify suitable patients.

P20 LOOK BEYOND APPEARANCES:NOT ONLY A SIMPLE AORTIC ENDOCARDITIS

Abstract Infective endocarditis (IE) refers to the colonization of cardiac valve endocardium by virulent microorganisms. It is the fourth leading cause of life–threatening infectious disease syndrome, if not efficiently diagnosed and treated. The three most common causes of IE on native valves (from the most to the least frequent) are Staphylococci, Streptococci and Enterococci. Enterococcus related IE are often associated to endoscopic procedures involving the digestive tract. The most remarkable structural complications associated with IE are: cusp or leaflet rupture, perforation, aneurysm/pseudoaneurysm, fistula, abscess, embolization. The usual final consequences of these lesions are severe valve regurgitation and heart failure.A 74 years old male patient with no history of heart disease, presented to the hospital with orthopnoea and periferal edema, consistent with acute heart failure.Few months before he underwent a routine colonscopy. Transthoracic echocardiography revealed a mildly reduced ejection fraction and the presence of a little, mobile mass on the aortic valve, suggestive of vegetation, associated with a severe aortic regurgitation. The diagnosis was confirmed thanks to a transesophageal echocardiogram that represents the technique of choice for the diagnosis of endocarditis and for detecting eventual perivalvular extention; it documented the presence of an endocarditic vegetation protruting in the LVOT, complicated by a pseudoaneurysm, identified as a pulsatile perivalvular echo free–space with colour doppler flow inside. Successively, a specific antibiotic therapy was started because of the positivity of blood cultures for Enterococcus Faecalis. After performing a thoracic computed tomography that showed the presence of “plus image" at the level of aortic valvular plane, particularly between the right coronary and non–coronary cusp, consistent firstly with a pseudoaneurysm, the patient underwent urgent cardiac surgery with the removal of the vegetations and the implantion of an aortic valve bioprosthesis after the apposition of bovine pericardial patches for repairing aortic wall’s lacerations. A post–operative transesophageal echocardiogram revealed a good result with a mild paravalvular leak. Pseudoaneurysm and severe valvular regurgitation are among the major causes of acute heart failure in the setting of infective endocarditis. In such cases, surgery should be considered to decrease mortality.

Impact of cardiac surgery on left-sided infective endocarditis with intermediate-length vegetations

ObjectiveThe best strategy to manage patients with left-sided infective endocarditis (IE) and intermediate-length vegetations (10–15 mm) remains uncertain. We aimed to evaluate the role of surgery in patients with intermediate-length...

Echocardiography in cardioembolic stroke prevention.

Stroke is a leading cause of mortality and disability, and cardiac embolism accounts for one-third of all ischaemic strokes. Thirty per cent of strokes are cryptogenic. In this setting, echocardiography is essential in the diagnosis, treatment, and prevention of embolic stroke of undetermined source since it is a widely available, safe, and inexpensive tool. Transthoracic echocardiography and transoesophageal echocardiography, furthermore, are proven to change therapeutic management leading to initiation of anti-coagulation, anti-microbial therapy, patent foramen ovale (PFO) closure, or cardiac tumour resection. The most common cardioembolic sources include left atrial appendage thrombus, left ventricular thrombus, vegetations in endocarditis, paradoxical embolization in PFO, prosthesis thrombosis, and intracardiac tumours. Although the presence of a cardioembolic source only represents a risk factor for an ischaemic stroke, it could not assure the certain or the unique cause of the event. The purpose of this review is to underline the importance of echocardiography and overview the main sources of cardiac embolism and the echocardiographic features.

Acute occlusion of the left main coronary ostium by an endocarditis vegetation.

Acute occlusion of the left main coronary ostium by an endocarditis vegetation.

Measurement of vegetations in infective endocarditis: An inaccurate method to decide the therapeutical approach.

The European Society of Cardiology and American Heart Association guidelines give a central role to the maximal vegetation diameter in the indication for surgery to prevent embolism in left sided infective endocarditis. Vegetation measuring is likely to be inaccurate. The hypothesis herein, is that the vegetation diameter is not an appropriate surgical criterion given the variability of its measurement. Two trained echocardiographers independently measured the maximal vegetation diameter by transesophageal echocardiogram of 76 vegetations in 67 consecutive patients with definite infective endocarditis in an off-line workstation. The interobserver variability was calculated by the interclass correlation coefficient. The relationship between the strength of agreement for the cut-off points of 10 and 15 mm was also calculated. Finally, the number of patients whose surgical indication would have changed depending on which operator measured the vegetation was evaluated. Interobserver interclass correlation coefficient in the measurement of the maximal longitudinal diameter of the vegetations was 0.757 (0.642-0.839). The strength of agreement of the interobserver analysis for the cut-off point of 10 mm was 0.533 (0.327-0.759). For the cut-off point of 15 mm it was 0.475 (0.270-0.679). If heart failure or uncontrolled infections had been absent, the surgical indication would have changed in a total of 33 patients (33/76; 43%) depending on which operator measured the vegetation. The variability in the measurements of the maximal longitudinal diameter by transesophageal echocardiogram is high. Surgical indications based on the cut-off points recommended by the international guidelines should be revised.

Enterococcus casseliflavus infection in a captive Southern Cassowary (Casuarius casuarius): clinical and post-mortem findings.

An adult 22-year-old, male southern cassowary (Casuarius casuarius) presented for lethargy, dysorexia and soft feces. Clinical findings under chemical immobilization were unremarkable except for heterophilic toxic changes on blood smear, reduced albumin/globulin ratio and potentially elevated liver parameters. The animal was treated for suspected hepatobiliary insufficiency and received supportive treatment with daily subcutaneous fluids and medication and was monitored with a quality-of-life assessment. It was eventually euthanized after further deterioration. Post-mortem examination revealed vegetative valvular endocarditis, bile duct obstruction, cholangiohepatitis and splenitis with intralesional Enterococcus casseliflavus isolated. This is a first documented case of E. casseliflavus infection in a bird with multiorgan involvement.

Pathology of vegetative valvular endocarditis associated with ß-haemolytic Streptococci in pigs

Pathology of vegetative valvular endocarditis associated with ß-haemolytic Streptococci in pigs

Abstract 11724: Echocardiographic Predictors and Outcomes of Multiple Vegetations in Infective Endocarditis

Introduction: Infective endocarditis (IE) is a life-threatening infection with an annual mortality of 40%. Embolic events reported in up to 80% of patients. Vegetations of > 10 mm size are associated with increased embolic events and poor prognosis. There is a paucity of literature on the association of multiple vegetations with outcomeHypothesis: We aimed to study the echocardiographic (ECHO) features and outcomes associated with the presence of multiple vegetationsMethods: In this retrospective, single-center, case-control study patients diagnosed with IE were recruited from June 2017 to June 2019. A total of 84 patients were diagnosed to have IE, of whom 67 with vegetation were identified. Baseline demographic, clinical, laboratory, and ECHO parameters were reviewed. Outcomes that were studied included recurrent admission, embolic phenomenon, and mortality. Results: Twenty-three (34%) patients were noted to have multiple vegetations, 13 (56.5 %) were male and 10 (43.5%) were female. The mean age of these patients was 50. Eight (35%) had a prior episode of IE. ECHO features of moderate to severe valvular regurgitation (OR:4), presence of pacemaker lead (OR:4.8), impaired LV relaxation, (OR:4), and elevated PASP (OR:2.2) are associated with higher odds of multiple vegetations. Of these moderate to severe valvular regurgitation (p: 0.028), pacemaker lead (p-0.039) and impaired relaxation (p-0.028) were statistically significant. These patients were noted to have an increased association of recurrent admissions (OR:3.6), recurrent bacteremia (OR:2.4), embolic phenomenon (OR:2.5), ICU stay (OR:2.8), hypotension (OR:2.1), surgical intervention (OR:2.8) and device removal (OR:4.8). Of this device removal (p-0.039) and recurrent admissions (0.017) were statistically significantConclusions: This study highlights the associations of echocardiographic predictors and outcomes in patients with IE having multiple vegetations. ECHO features of moderate to severe regurgitation, presence of pacemaker lead, impaired LV relaxation, and elevated PASP and outcomes including recurrent admissions and device removal were found to be associated with multiple vegetations

Abstract 13714: Clinical Characteristics and Comparative Outcomes of Patients Undergoing Angiovac Endovascular Debulking of Tricuspid Valve Endocarditis versus Medical Therapy in Patients Considered Non-Surgical Candidates

Introduction: There remains a paucity of research regarding clinical characteristics and comparative outcomes of patients with tricuspid valve (TV) endocarditis, considered non-surgical candidates, undergoing debulking of TV vegetations using the AV(AngiVac) device compared to medical therapy. Methods: We conducted a retrospective cohort study at a single tertiary referral center comparing patients with TV endocarditis who were not considered surgical candidates. We compared clinical characteristics and outcomes in patients who underwent debulking of TV vegetations with AV vs those who were treated with medical therapy. Results: A total of 75 patients with TV endocarditis were included in the study. At baseline, patients in the medical therapy group were younger (34.4 years ± 10.5 vs 48.6 years ± 21, p < 0.0003), more frequently male in gender (55.9% vs 44%, p < 0.39) and had higher incidence of intravenous drug use (93.2% vs 56%, p < 0.0002). Patients were more likely to have history of malignancy (6% vs 1.7%, p < 0.32), cardiac implantable electronic device (31% vs 8.5%, p = 0.02) and central venous access (19% vs 1.7%, p = 0.01) if they underwent AV. Medical therapy was more commonly used for relatively smaller TV vegetations (1.68 cm vs 2.9 cm, p < 0.0001). Medical therapy was also associated with higher complication rates including distal embolization (81.4% vs 0%, p < 0.0001) and cerebrovascular accidents (5.1% vs 0% p = 0.36). In hospital mortality was similar for both groups and length of stay remained unchanged. Conclusions: Debulking of TV endocarditis with AV is feasible in patients not deemed to be surgical candidates and is not associated with higher inpatient mortality or length of stay. There was a lower rate of distal embolization and cerebrovascular accident in patients undergoing AV. Larger, multi center studies are needed to evaluate whether AV might improve outcomes in patients with TV endocarditis and large vegetations not deemed surgical candidates.

Abstract 15513: Angiovac as an Alternative to Surgical Excision of a Large Infective Endocarditis Vegetation

Background: Angiovac device is a suction cannula inserted percutaneously or surgically connected to extracorporeal circuit approved for removal of fresh soft thrombi/emboli. Cardiac surgery is indicated in Infective Endocarditis (IE) when the vegetation is >10 mm. Angiovac is used for IE in nonsurgical candidates. Here, we present 2 cases of successful use of Angiovac in treating large IE vegetation. Presentation: (1) A 70-year-old male with HFrEF and inducible VF on electrophysiological study requiring ICD implantation admitted for sepsis with Corynebacterium stratum bacteremia. TTE revealed mobile echo-density, 24 X 14 mm attached to the RV ICD lead. (2) 67-year-old female with sinus node dysfunction requiring permanent pacemaker who presented with constitutional symptoms. Blood culture grew coagulase-negative Staphylococcus. TEE revealed echodense coating around the RV lead, 15 mm in thickness. Management: Patient 1 was deemed nonsurgical candidate by cardiothoracic surgery. Instead, Angiovac was performed. Intraoperative TEE revealed a 30x20mm right atrial ICD lead vegetation. Angiovac catheter was advanced under TEE guidance to the right atrium. Once the catheter was abutting the infected thrombus multiple aspiration harvesting embolic material as in the picture. A postprocedural TTE demonstrated the absence of the RA echodensity. A subsequent laser lead extraction was performed. Patient 2 was given IV vancomycin. Angiovac procedure was successfully performed with subsequent laser lead extraction planning. Conclusion: AngioVac is a minimally invasive and effective procedure in the management of large vegetations in nonsurgical candidate patients.

Comparative Genomics of Streptococcus oralis Identifies Large Scale Homologous Recombination and a Genetic Variant Associated with Infection.

The viridans group streptococci (VGS) are a large consortium of commensal streptococci that colonize the human body. Many species within this group are opportunistic pathogens causing bacteremia and infective endocarditis (IE), yet little is known about why some strains cause invasive disease. Identification of virulence determinants is complicated by the difficulty of distinguishing between the closely related species of this group. Here, we analyzed genomic data from VGS that were isolated from blood cultures in patients with invasive infections and oral swabs of healthy volunteers and then determined the best-performing methods for species identification. Using whole-genome sequence data, we characterized the population structure of a diverse sample of Streptococcus oralis isolates and found evidence of frequent recombination. We used multiple genome-wide association study tools to identify candidate determinants of invasiveness. These tools gave consistent results, leading to the discovery of a single synonymous single nucleotide polymorphism (SNP) that was significantly associated with invasiveness. This SNP was within a previously undescribed gene that was conserved across the majority of VGS species. Using the growth in the presence of human serum and a simulated infective endocarditis vegetation model, we were unable to identify a phenotype for the enriched allele in laboratory assays, suggesting a phenotype may be specific to natural infection. These data highlighted the power of analyzing natural populations for gaining insight into pathogenicity, particularly for organisms with complex population structures like the VGS. IMPORTANCE The viridians group streptococci (VGS) are a large collection of closely related commensal streptococci, with many being opportunistic pathogens causing invasive diseases, such as bacteremia and infective endocarditis. Little is known about virulence determinants in these species, and there is a distinct lack of genomic information available for the VGS. In this study, we collected VGS isolates from invasive infections and healthy volunteers and performed whole-genome sequencing for a suite of downstream analyses. We focused on a diverse sample of Streptococcus oralis genomes and identified high rates of recombination in the population as well as a single genome variant highly enriched in invasive isolates. The variant lies within a previously uncharacterized gene, nrdM, which shared homology with the anaerobic ribonucleoside triphosphate reductase, nrdD, and was highly conserved among VGS. This work increased our knowledge of VGS genomics and indicated that differences in virulence potential among S. oralis isolates were, at least in part, genetically determined.

Paravalvular vegetations in prosthetic valve endocarditis with a malignant course: a case report

Prosthetic valve endocarditis (PVE) accounts for 20.1% of all infective endocarditis cases. We report a case of PVE complicated by arrhythmias, embolic phenomenon, and sepsis. A 64-year-old female with history of mitral valve replacement presented to the hospital with febrile episode and malaise. Echocardiography showed vegetation at paravalvular area, and Staphylococcus aureus was found on blood culture. Aggressive intravenous antibiotic cover and hemodynamic support were initiated. The management of PVE remains a challenge due to its malignant course and heterogenous complications.
 Citation: Suwanto D, Lefi A, Chandra E, Putra TS, Mulia EPB. Paravalvular vegetations in prosthetic valve endocarditis with a malignant course: a case report. Anaesth. pain intensive care 2022;26(5):723-726.
 DOI: 10.35975/apic.v26i5.2012

LAMBL EXCRESCENCE IN A PATIENT WITH SEPSIS: COULD IT BE JUST ENDOCARDITIS?

LAMBL EXCRESCENCE IN A PATIENT WITH SEPSIS: COULD IT BE JUST ENDOCARDITIS?