310 Ruptured sinus of Valsalva aneurysm as a rare cause of sisto-diastolic murmur: role of multimodality imaging in diagnosis and surgical planning

A 27-year-old man had an incidental finding of sisto-diastolic murmur during a screening medical evaluation. Transthoracic and subsequent transesophageal echocardiography revealed a saccular enlargement of non-coronary (NC) sinus of Valsalva. The aneurysm extended into the right atrium (RA) and presented a large wall discontinuity, with continuous sisto-diastolic flow from the aorta to the right atrium. Computed tomography confirmed the findings and excluded other associated abnormalities. The patient underwent urgent surgical intervention. Intraoperatively, findings reported a floppy and cribrose saccular aneurysm sprouting from the NC sinus inside the RA. The correction turned out to be very challenging due to the close connection between the aneurysmal wall and the tricuspid valve (TV) and aortic valve (AV) annuli. The aortic NC sinus was excised and replaced with a Dacron patch. Damaging of the TV septal leaflet required repair through a consolidating suture involving the septal leaflet of TV and the corresponding annular insertion. AV replacement was also needed due to damage of the AV NC cusp. No complications occurred during the postoperative stay. Histopathology revealed severe atrophy of muscular and elastic fibres of the aortic wall, elastic fiber fragmentation, replacement fibrosis and extensive deposition of mucopolysaccharides. Sinus of Valsalva aneurysm (SoVA) is a rare condition characterized by an enlargement of the aortic root between the aortic valve and the sinotubular junction. SoVA can be either congenital, as a consequence of weakness of the elastic lamina, or acquired, due to infective, degenerative, or traumatic conditions. A prevalence of 0.09% was described in autopsy series and males are more frequently affected. Acute rupture of SoVA requires emergent surgery because of acute life-threatening haemodynamic instability. Congenital and chronic ruptured SoVA could be asymptomatic. Nevertheless, such incidental finding requires urgent surgical correction due to the possibility of unexpected further rupture, generating massive left-right shunt. The close relationship with nearby anatomical structures is a major issue which should be taken into account. In this perspective multimodality imaging is of paramount importance, allowing for a fine surgical planning and avoidance of complications.

The Art of the Clinician

Background: The promotion of clinical abilities could represent a significant factor leading the clinicians to in making the correct diagnosis in a timely matter. Case: Our patient is a 42-year-old African male with a history of Hypertension, ESRD on hemodialysis via right-sided Permcath (PC), Mastoidectomy & Right ear surgery due to trauma in childhood, AV Fistula (Needed intervention 4 times) in left upper extremity, admitted due to witnessed seizures in the setting of hypertensive emergency. The patient denied family history and toxic habits. While the patient was at the emergency room, CT head revealed stable curvilinear hyper-attenuation thought to be a thrombosed developmental vein more likely than small subarachnoid hemorrhage. He was loaded with levetiracetam, received Ativan 1mg IV and HD done as per Nephrology. The patient was transferred to the floor he was not in acute distress and was asymptomatic, the cardiovascular (CV) examination showed regular pulse, normal S1, S2, S4+ appreciated with 2/4 diastolic murmur at second right intercostal space (ICS); 2/6 pansystolic murmur at third right intercostal space left parasternal border (LPSB) radiated to the right parasternal border (RPSB) and right mid-clavicular line (MCL); 3/6 systolic murmur at 5LICS MCL radiated to the posterior axillar line (PAL). Point of maximal impulse (PMI) displaced to mid axillar line (MAL). Parasternal heave present; the neurological exam was preserved. Endocarditis was suspected and echocardiogram was expedited, it showed severe aortic regurgitation, 1.60cm x 1.68cm mass in the tip of the catheter in the right atrium, possible vegetation in the tricuspid valve with mild regurgitation, moderate mitral valve regurgitation. Later, staphylococcus epidermidis was identified in blood cultures twice, as well as the culture from the PC. The transesophageal echocardiogram found 2.41 X 0.62 cm mass appears to be a fibrin sheath, possibly remnant of a prior catheter, small perforation in the non-coronary cusp likely in the setting of healed endocarditis. Infectious disease onboard for antibiotic management. Conclusion: The art of the clinician goes beyond the available technology; it could prevent the loss of critical time as well as unnecessary studies, guiding a better assessment and treatment of our patients and potentially improving their outcomes.

Not a Coincidental Concurrence of Breast Carcinoma and Cardiac Myxoma: Case Report

Background: Myxoma has been considered to undergo a simple and benign process but not always so. Case presentation: A female patient was admitted for evaluation of left breast nodule. Physical examination showed facial pigmentation, left breast nodule and 3/6 diastolic murmur at the mitral valve area. Preoperative echocardiography revealed a massive mobile left atrial mass attaching to the interatrial septum causing obstruction to mitral orifice. Histopathologic investigation confirmed the left atrial mass to be myxoma and left breast nodule to be cancer. Carney complex was considered and lifelong follow-up was advised. Conclusion: Cardiac myxoma may present as a part of a systematic disease entity. In patients with a combination of breast nodule and facial pigmentation, transthoracic echocardiography examination is advised to guide decision-making.

Pulsation of catheter during coronary angiography: Is it a sign of severe aortic regurgitation?

A 48-year-old male patient was admitted to our outpatient clinic with complaints of shortness of breath. He also had a holo-diastolic murmur at the right sternal border and an apical impulse being displaced laterally and inferiorly. Transthoracic echocardiography showed a severe aortic regurgitation without aortic valve stenosis and a mildly dilated left ventricle accompanied by an ejection fraction of 55%. The aortic regurgitation jet was eccentric and there were significant holodiastolic flow reversals in the descending thoracic aorta. Surgical management was advised for this patient because of symptomatic severe aortic regurgitation. Then, the patient underwent preoperative coronary angiography through the right femoral artery route. The left coronary ostium could be engaged with a 6 Fr Judkins left diagnostic catheter; however, the catheter jumped through the ascending aorta. Afterwards, the catheter was engaged and again jumped through the ascending aorta. Engagement and jumping cycles observed between successive systole to diastole. In our opinion, this catheter movement is explained by wide pulse pressure, like the severe characteristic physical findings of severe aortic regurgitation. Further studies are needed to understand whether this catheter movement is angiographically evidence of severe aortic regurgitation.

Successful treatment of aortic valve endocarditis caused by Enterococcus casseliflavus: a case report

Background Enterococcus casseliflavus is rarely isolated from human specimens. To the best of our knowledge, there are no reports on its detailed treatment course and prognosis. Here, we present the first known case of E. casseliflavus endocarditis with a detailed treatment course. Case presentation An 86-year-old Japanese woman was transferred to the emergency department with dyspnoea, wheezing, and lumbago. Her medical history included hypertension, chronic kidney disease, idiopathic interstitial pneumonia, and rectal carcinoma. Physical examination revealed expiratory wheezes and a diastolic murmur (Levine 2/6) at the 4th right sternal border. Chest radiography revealed bilateral interstitial opacities and slight cardiac dilatation. Transthoracic echocardiography demonstrated the presence of mobile vegetation with perforation, prolapse, and regurgitation of the aortic valve. With a suspicion of infective endocarditis, we started administering intravenous ampicillin/sulbactam. Thereafter, blood cultures identified E. casseliflavus through matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. The antimicrobial treatment was then switched to ampicillin plus gentamicin. The patient underwent aortic valve replacement on the thirteenth hospital day. She was administered intravenous ampicillin and gentamicin for 6 weeks. The patient was discharged 8 weeks after admission. Conclusions Our case demonstrated that E. casseliflavus could cause infective endocarditis, which can be successfully treated with a 6-week regimen of ampicillin and gentamicin in combination with proper surgical treatment.

P24: MANAGEMENT OF RHEUMATIC VALVE DISEASE OF THE AORTIC VALVE USING THE OZAKI PROCEDURE WITH AUTOLOGOUS PERICARDIUM

Case-Study A 15-year-old boy was referred to our tertiary centre from his local paediatric services with a background of rheumatic fever, severe aortic regurgitation (AR) and mild to moderate mitral regurgitation. He had a history of angina and dyspnoea on exertion, a 2/6 ejection systolic murmur and 2/4 end diastolic murmur. Transthoracic echocardiography showed severe aortic valve insufficiency (with flow reversal seen in the descending aorta and an LV end diastolic volume of 173 ml/m2) and trivial pulmonary valve regurgitation. Autograft failure following the favoured Ross procedure deemed the patient as a candidate for an Ozaki procedure. Autologous pericardium was used to replace the diseased aortic valve. Intraoperative transoesophageal echocardiography showed a deficient left coronary cusp leaflet and a retracted right coronary cusp leaflet. The patient was under cardiopulmonary bypass for 124 minutes and on cross-clamping for 99 minutes with no intraoperative complications. Histological examination of the aortic valve leaflets showed neovascularisation, myxoid changes and disarray of the fibrous stroma. Postoperative recovery was uneventful. The postoperative echocardiogram showed trivial AR, end diastolic volume 217ml, end systolic volume 12 ml and 40% ejection fraction. There was full resolution of the dyspnoea, angina and diastolic murmur on follow-up 4-months postoperatively as supported by healthy valve function on echocardiography. This case highlights that in those of risk of multiple valve pathology, such as in rheumatic valve disease, an Ozaki procedure using autologous pericardium is a viable surgical option for paediatric aortic valve repair with good outcomes. Take-home message In cases of systemic conditions affecting the heart valves where there is multiple valve pathology and risk of autograft failure, such as rheumatic valve disease, the use of autologous pericardium to replace these valves has shown to be a viable option in this paediatric case.

Evaluation and diagnostic approach for heart murmurs in children

Heart murmurs are common in children. Most of them are innocent murmurs with normal heart anatomy and function, and only a few are pathologic murmurs with congenital heart anomaly or abnormal heart function. However, a heart murmur may be the sole symptom of serious heart disease. Therefore, careful evaluation of heart murmurs for distinguishing pathologic murmurs from innocent murmurs is important. Heart murmurs are described by their intensity, timing in the cardiac cycle, location, transmission, and quality. Murmurs, such as a holosystolic or diastolic murmur, of grade 3 or higher intensity, harsh quality, an abnormal S2, a systolic click, or increased intensity when the patient stands are more likely to be pathologic murmurs. Innocent murmurs are more likely to be systolic murmurs, with soft sounds, short duration, low pitch, and varying intensity with phases of respiration and posture (disappears with standing). Not only auscultation but also physical examination findings are important to evaluate heart murmurs. The gold standard test for the evaluation of any potentially pathologic murmur is echocardiography. For the appropriate use of echocardiography, close physical examination, including auscultation, is essential and requires considerable practice.

Dermatologic Conundrum: A Cardiac Condition Masqueraded as a Dermatologic Distraction

A 38-year-old male presented to the emergency department (ED) complaining of extreme pain and a petechial rash on the left ankle for two weeks associated with generalized fatigue, intermittent fevers, and weight loss. He was discharged home from the ED on pain medications. He returned a few days later with a progressive rash that involved the entire left lower extremity to the level of the knee. He was diagnosed with herpes zoster (shingles) and was prescribed acyclovir and steroids. After several days, the patient presented for the third time to the ED. He developed a right lower extremity discomfort this time. The pain in bilateral lower extremities had become unbearable. His cardiac examination revealed a systolic murmur at the apex and a faint diastolic murmur at the left sternal border. Ultimately, he had an echocardiogram that demonstrated both a bicuspid aortic valve and large vegetation on the anterior leaflet of the mitral valve, and his blood culture grew Streptococcus mitis and Streptococcus oralis. The patient was subsequently diagnosed with subacute bacterial endocarditis thought to be sourced from his poor dentition. The diagnosis of infective endocarditis is often delayed due to its nonspecific clinical presentations. Our case displays an unusual skin manifestation of IE that may be present in the absence of other signs and symptoms of the disease.