Medical therapy of a left-sided native valve endocarditis with neurologic sequela

Infective endocarditis could present with a plethora of signs and symptoms. Among the rarity of its presentation is acute confusion associated with neurological deficits, mimicking stroke especially in the young population. We report a case of a 33-year-old young man with acute right-sided hemiparesis and confusion 2 weeks after tooth extraction. The brain CT and MRI was consistent with new infarction on the left middle and anterior cerebral arteries’ territory. Echocardiography unveiled the existence of posterior mitral valve leaflet vegetation. Blood culture grew Group B beta-haemolytic Streptococcus, sensitive to penicillin. Two weeks of intravenous gentamicin with 6 weeks of intravenous benzylpenicillin were administered. In this case report, we highlight the importance of recognition of infective endocarditis in a young patient presenting with cerebrovascular accident following tooth extraction.A wide variety of organisms have been attributed to infections of native heart valves. Among them are staphylococci, streptococci, and the group of Haemophilus, Aggregatibacter (previously Actinobacillus), Cardiobacterium, Eikenella corrodens, Kingella (HACEK) organisms. Aortic or mitral valves (left-sided) accounts for the vast majority of endocarditis cases in non-intravenous drug users. Right sided infective endocarditis contributes 5-10% of all cases of endocarditis, usually among intravenous drug users.1 Emboli from left-sided valvular vegetation can become dislodged or fragmented into the brain via systemic circulation, resulting in neurological complications. In contrast with the right sided embolus, the right sided infective endocarditis may cause embolic phenomenon due to preexisting congenital heart diseases such as patent foramen ovale, atrial septal defect, or ventricular septal defect. In this case report, we highlight the importance of recognition of infective endocarditis with an embolic stroke in a young confused patient with normal cardiac valve following a simple dental extraction procedure.     

Tricuspid valve papillary fibroelastoma: a rare tumor with a diagnostic dilemma

Papillary fibroelastoma is a rare primary tumor of the heart valves. This lesion can occur on any of the valves or endothelial surface of the heart and has been detected by echocardiography, by cardiac catheterization, during open heart operations for other conditions, and at autopsy. Because of the potential for comorbidities, this tumor should be removed. We present the case of an elderly man with a diagnosis of severe mitral valve regurgitation and moderate tricuspid valve regurgitation who was suspected to have a tricuspid valve vegetation. Mitral valve replacement, tricuspid valve repair, and excision of the lesion were performed successfully. A histologic examination of the vegetation confirmed it to be a papillary fibroelastoma. We present this case to emphasize the rarity of this tumor and the importance of a correct diagnosis to avoid delaying its prompt and definitive management.     

A cross-sectional study of diastolic dysfunction in rheumatoid arthritis and its association with disease activity

Aims: The aim of this study was to evaluate the left ventricular (LV) diastolic dysfunction in rheumatoid arthritis (RA) patients without clinically evident cardiovascular manifestations and to estimate whether there is any correlation between RA disease severity and disability and LV diastolic dysfunction. Methods: The study was a cross‐sectional study involving 53 patients (47 female and 6 male) with RA without clinically evident heart disease and 53 healthy subjects (47 female and 6 male) who served as a control group. Both groups were matched for age and sex. Echocardiographic and Doppler studies were conducted in all patients with RA and control subjects. Results: Of 17 cardiac parameters assessed, only two were abnormal. None of the specific cardiac diastolic dysfunction parameters were significantly different in RA patients compared to the control group. There was no significant correlation between diastolic function values in RA patients and value of Disease Activity Score 28 (DAS‐28) and value of Health Assessment Questionnaires Disability Index (HAQDI). Atrial (A) wave velocity was greater in RA patients compared to the control group (0.71 [0.58–0.83] vs. 0.61 [0.51–0.71]; P < 0.04). However, interventricular relaxation time (IVRT) ([73.08 ± 9.92 vs. 70.74 ± 9.02], P = 0.207), lower E/A ratio (1.27 [1.02–1.56] vs. 1.42 [1.20–1.68], P = 0.102), diastolic dysfunction parameters according to Redfield Classification (25 [47.2%] vs. 27 [50.9%] P = 0.56), diastolic dysfunction using E/A (P = 0.321) and tissue doppler imaging (E/E′) (P = 0.148) were not different. Conclusion: Prevalence of diastolic dysfunction in the rheumatoid arthritis group (47.2%) was not different from controls (50.9%). LV diastolic function had no significant correlation with RA disease severity and duration of disease.     

Primitive neuroectodermal tumor of the lung with pericardial extension: a case report

A 16-year-old student presented with a 4-week history of progressive shortness of breath, loss of appetite, and occasional blood-tinged sputum. The chest X-ray revealed massive right-sided pleural effusion with cardiomegaly. An echocardiogram revealed a large pericardial mass with massive pericardial effusion. Subsequent computed tomography of the thorax revealed a large heterogeneous mass in the right lung with extension into the pericardium. Lung biopsy revealed primitive neuroectodermal tumor (PNET) with small round blue cells, Homer–Wright rosettes, and CD99 positivity. We discuss pericardial metastases of PNET and its implication in this patient.     

Left atrial volume index is an independent predictor of major adverse cardiovascular events in acute coronary syndrome

Background

Left atrial volume index (LAVI) is well proven to be a reliable method of determining left atrial size, which has prognostic implications in cardiovascular diseases. Studies demonstrate that increased LAVI is a predictor of mortality in myocardial infarction, but its association with other major adverse cardiovascular events (MACEs) among patients post acute coronary syndrome (ACS) has not been adequately evaluated.

Methods

We calculated the baseline LAVI for all patients who were admitted with ACS between December 2010 and August 2011. The patients were stratified into 2 arms: normal LAVI and increased LAVI, with a cutoff value of 28 mL/m². All patients were prospectively followed up during 6 months for development of MACEs.

Results

Of the 75 patients who completed the study, 32 had increased LAVI, and 43 had normal LAVI. More than half (55%) of the patients were diagnosed with unstable angina. During the follow-up period of 6 months, 30 patients (93.8%) in the increased-LAVI arm and 23 patients (53.5%) in the normal-LAVI arm developed at least a single MACE. Patients with increased LAVI had significantly more MACEs (P = 0.021). The occurrence of MACE remained significantly higher in the increased-LAVI group even when atrial fibrillation was excluded (P = 0.016). After adjusting for confounding variables by multivariate analysis, LAVI was found to have a significant association with MACEs (P = 0.030, odds ratio = 1.229 (95% confidence interval, 1.020-1.481).

Conclusion

LAVI is a useful tool for prognostication and an independent predictor of MACEs post ACS.     

Finger photoplethysmogram pulse amplitude changes induced by flow-mediated dilation

This study was conducted to investigate the utility and efficacy of finger photoplethysmogram pulse amplitude (PPG-AC) in comparison with the standard Doppler ultrasound in assessing an endothelial function via flow-mediated dilation (FMD). High-resolution B-mode scanning of the right brachial artery (BA) of 31 healthy subjects aged 39.7 +/- 11.3 (range 22-64) years and 52 risk subjects aged 47.7 +/- 10.8 (range 30-65) years were performed before and after 4 min of upper arm occlusion. Concurrent with the ultrasound measurement (where color Doppler imaging was used to enhance arterial boundary detection), PPG signals were recorded from both index fingers for cross evaluation and comparison. Our results show that the finger PPG-AC exhibits a similar response to that of the well-known BA dilation: following the release of pressure (cuff around the BA), the PPG-AC increases abruptly before slowly decreasing toward the baseline. The peak PPG-AC is reached significantly faster than the peak FMD measured by ultrasound among healthy and risk groups (P < 0.001). The proposed technique using a finger photoplethysmogram can be applied in a rapid and non-invasive assessment of peripheral vascular functions as an alternative low-cost and less operator-dependent tool compared to ultrasound.